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<br />12/29/2008 MON 8:03 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121002/006 <br /> <br />Ofb <br /> <br />200810441 <br /> <br /> <br />~TL <br /> <br />P9ll: 1 <br /> <br />STATE TAX LIEN. NEBRASKA DEPARTMENT OF LABOR <br /> <br />NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />Ljnco~,NE 68509~4600 <br />Telephone ~ (402) 471~9912 <br />FAX- (402) 471-9917 <br /> <br />~ ORIGINAL <br /> <br />Employer or <br />Liable Person: Michelle Cervantes dba Speedy Roof!.!!.tL_._ <br /> <br />Address: 116 E. Hwy 30 Grand Island NE 68801 <br /> <br />NDOL Serial No.: LAB~02~~:-2008 ______ To be tiled With=+=he Re ister of Deeds in the following Counties: <br /> <br />NDOL Acct. No.: i~~1!79437649~: ,__ Hall_________ ____ ,- ______~__ <br />Federal ill No.1 SSA No.: ~-r-- <br /> <br />This Slllte Tax lien is i55ued for Wlpaid combined taxe5 (Neb. Rev. Still. ~~48-657 and 48-(64) or payments in lieu of contribution5 (Neb. Rev. Stat. ~48.660.01) pUf5uant to the <br />Unifonn Slate Tax lien Registration & Enforcement Act (Neb. Rev. Stilt. i77-390 I, el seq.). Notice is given that combined tlIltell or payments in lieu of contributions, interest <br />(computed at I.S%.per month), and penalties are due from this employer or person and remain unpaid after demand. These combined taxes or paymenlS in lieu of contributions <br />constitute a lien for any and all personal property and real property in the county/counties named, belonging to the employer or person, whether now owned or hereafter acquired. <br /> <br />1/2007 11/10/2008 $810.00 <br />2/200~1I1072008-l-- ----- $1,387.21 <br />312007 1111012008 t- _ $2,847.61 <br />4/2007 11/10/2008 $474.39 <br />1/2008 11/10/2008 $866.65 <br />. <br />_ 212008 _ _1111012008, _ $~512.00 <br /> <br /> <br />~ - -=i----=-- - ~ --' <br /> <br />I I --J $ 0.00 <br />l I -I $ 0.00 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): i $9,431.56 <br /> <br />I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of Nebraska in the <br />determination of the amount due, and the employer or person has failed to pay the amount due after demand. <br />FERNANDO LEC <br />Commissioner. abor <br /> <br />$25.00 <br />$25.69 <br />$52.73 <br />$25.00 <br />$25.00 <br />$25.00 <br /> <br />Interest <br />Through <br />11/25/2008 <br /> <br />$229.61 <br />$330.32 <br />$548.9(1 <br />~~ <br />$89.30 <br />$87.21 <br /> <br />! <br /> <br />Subtotal <br /> <br />Qtr./Yr. <br /> <br />Date Assessed <br /> <br />Combined Tax Or Payment [n Lieu <br />Of Contributions Due <br /> <br />Penalty <br /> <br />$1,064.61 <br />$1,743.22 <br />$3,449.25 <br />$ 569.32 <br />$ 980.95 <br />$1,624.21 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br /> <br />Date: December 24, 2008 <br /> <br />By: <br /> <br /> <br />, Agency Legal Counsel <br />A. UKlNSKI, Legal Counsel <br /> <br />T:\DOCUMENTS\FORMS\Liens\Original.doc <br /> <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor ~ LEGAL <br />P.O. 801 94600 <br />Uncoln, NE 68509-4600 <br /> <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #1476& <br />