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08/17/2005 09:22 FAX 14024714429 NEBRASKA UCC IM003 /004 Dg 200508022 NE Sm. of Slaim - flee STL 99 06408146 -7 Pps: 2 AVILA DOUGLAS Filed: 08 /16/2005 10 :44 AM STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR NDOL Office of Legal Counsel P.Q. Box 94600 X OWGINA1L Lincoln, NE 68509 -4600 Telephone - (402) 471 -9912 FAX - (402) 471-9917 Employer Name: Douglas Avila d/b /a Taller Mecanico Centro Mexico Address: 603 West 4a` Street Grand Island NE 68801 NDOL Serial No.: LAB -0112 -2005 To be filed with the Register of Deeds in the following Counties: NDOL Employer Acct. No.: 0287965006 Hall - Federal ID No. / SSA No.: 47- 0836131 i This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat. §48 -657) or payments in lieu of contributions (Neb. Rev. Stat. §48- 660.01) pursuant to the Uniform State Tax Lien Registration 8t EnforcementAct (Neb. Rev. Stat. §77 -3901, et seq.). Notice is given that combined taxes or payments in lieu of contributions, interest (computed at 1.5% per month), and penalties are due from this employer and remain unpaid after demand These combined taxes or payments in lieu of contributions constitute a lien for any and all personal property and real property in the county /counties named,, belonging to the employer, whether now owned or hereafter acquired_ Qtr. / Yr. I Date Assessed Combined Tax Or Payment In Lieu Penalty Interest Through + Subtotal Of Contributions Due I I 6/15/05 2/2001 - 5/31/05 .. -_T� $70._00�'_ -_ -- $25.00 j $48.83 - $ 143.83 3/2001 5/31/05 $70.00 $25.00 $45-66 140.66 _ 4/2001 5/31/(5 -_ -� -� $70.00 $25.00 $42.48 $ 137.48_ 1/22 ��5/3 00 1/05 $70.00 $25.00 $39.41 2/2002 - 5/31/05 $70.00- - -� - $25.00__ -- $36 -24 _ $ 131.24 -- 3/2002 - - - - -- 5/31/05-_ $70.00----- $25.00 i $33.06 $ 128.06__ _ 5/31/05 - __$70.00 ~� $25.00 $29:89_ $_124.8_9- _ _ 1/2003 5/31105___.__ $70.00 j $25.00 $26.81 _. ,__- $ 121.8_1 -- 2/2003 5/31/05W___ $70.00 $25.001 $23.64 _ $118.64 3/2003 - j _ 5/31/05 _ $70.00- - $25.00- $20.46 T^Y E $ 115.46 4/2003 t�_ 5 /31/05 $70.00 _ $25.00 1 $17.29 $ 112.29 5/31/05 � $70-00 -- j 1 $14.18 _._ w $ 109.18_ 2/2004 5/31/05 $70.00 $25.00 $11.01 $ 106.01 3/2004- 4/2004 -'_' _ .. TS/31/05 5/31 /O5�- _ _. $70A0 -- -._.._.._ ----- - - ---� - $70.0 $25.00 $25.00 $4.66_ $ 102.83 $ 99.66- __ _ 1/2005 _ _ 5/31/051 $70A _.� $25.00 I $1.59 Y -$ 96.59 - - _ � I _ _ $ 0.00 TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): $1,923.04 I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of Nebraska in the determination of the amount due, and the employer has failed to pay the amount due after demand. FERNANDO LECUONA, III Commissioner of Labor, Pagel of 2) SEE ATTACHMENTS RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL P.O. Box 94600 i Snrnli_ WF 6Rfi09 -46(10 NEBR. DEPT. OF LABOR CHARGE ACCT. #14765