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01/04/2005 16:26 FAX 14024714429 NEBRASKA 200500150 IM002 /004 ELLISON I Filed: 01 3 Pao: 1 2005 02:03 PM STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR NDOL Office of Legal Counsel P.O. Box 94600 X ORIGINAL Lincoln, NE 68509 -4600 Telephone - (402) 471 -9912 FAX - (402) 471 -9917 Employer Name: Tom Ellison f/d/b /a Ellison Enterprises _ Address: 311 West 15'h Street Grand Island NE 68801 NDOL Serial No.: I LAB -0002 -2005 To be filed with the Register of Deeds in the following Counties: INDOL Employer Acet. No.: 0280444007 Hall Federal ID No. / SSA No.: 47- 0802022 This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Slat. §48 -657) or payments in lieu of contributions (Neb. Rev. Stat. §48- 660.01) pursuant to the Uniform State Tax Lien Registration & Enforcement Act (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. Combined Tax Or Payment In Lieu ! Qtr. I Yr. Date Assessed i Penalty Interest ' Through Subtotal Of Contributions Due i 1 12/23/2004 4/2000 12/8/2004 I $229.73 $0.00 { $161.05 $ 390.78 1/2001 12/8/2004 $479.25 $25.00 $314.95 ; $ 819.20 2/2001 12/8/2004 i $229.81 $25.00 $140.60 1 $ 395.41 3/2001 ? 12/8/2004 $34.35 1 $25.00 $19.46 $ 78.81 4/2001 12/8/2004 $26.88 1 $25.00 $14.01 i $ 65.89 1/2002 , 12/8/2004 $15.40 $25.00 $7.35 i $ 47.75 2/2002 12/8/2004 $30.80 ; $25.00 i $13.30 i $ 69.10 3/2002 j 12/8/2004 $2.84 $25.00 1 $1.10 t $ 28.94 4/2002 12/8/2004 $35.82 $25.00 $12.22 ; $ 73.04 1/2003 12/8/2004 $78.89 $25.00 $23.45 $ 127.34 2/2003 1218/2004 $2.68 _ $25.00 ; $0.68 ; $ 28.36 $ 0.00 TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): i $2,124.62 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, miss' n r o Date: January 3, 2005 G�HN�H. L -or- THOMAS A. UKINSKI gency Legal ounsel Legal Counsel r RETURN FILED COPIES TO: Nebr. Dept of Labor - LEGAL ?MR. DEPT. OF LABOR P.O. Box 94600 CHARGE ACCT. #14765 Lincoln, NE 685094600 I