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08/05/2010 THU 14:12 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall ~' STATE TAX LIEN 3 ORIGINAL 201005532 NEBRASKA DEPARTMENT OF LABOR X003/005 NE Sra a~ 5lHr John A 6~l• - 11CC STL 9910G338g7-0 P9s: 1 SUNNY'5 Filed: 08!05/2010 11:10 AM NDOL Office of Legal Counsel P.O. Box 94600 Lincoln, NE 68509-4600 Telephone - (40l) 471-9912 FAX - (402) 471-9917 Employer or ___~._ Liable Ferson:.__Shawn Derr d/b/a S__ unnYs _._.._.__.....__,.,._._-~.--- Address: 7221;. 7~Grand Island NE 68801 ~-'°"-""`---~~`---~-_.._._._.._______ ~___~_,,,,~-, __~~_ NDOL Serial No.: LAB-0_137-2010 -_ _ To_be filed with the Re inter of Deeds in the following~Counties: ._ _ _NDOL Acct. No.: 03324SIOD1 _ _ Hall - Federal ID No. /SSA No.: 80-0483877 ~ -...~._.-~~ - ~~~- __ ~--~~~-__-"~""F-~--------- -_____ This State Tax Lien is issued for unpaid combined taxes (Neb. Rer•. Slat. ~~4$-657 and 48-664) or payments in lieu of contributions (Neb. Rev. Sta[. X48-660.01) pursuant to the Unifnnn State Tax Lien Registration & Enforcement Act (Neb. Rev. Slat. X77-3901, 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 or person and remain unpaid after demand. These combined taxes or paytents in lieu of contributions constitute a lien for any and all personal property and real pmpeRy in the county/counties named, belonging to the employer or person, whether now owned or hereafter acquired. Interest Qtr. / Yr. Date Assessed ~ Combined Tax Or Payment In Lieu Penalty ! T)-ronl;h Subtotal I Of Contributions Due ~ 7/27/2010 ~ 4/2009 7/12/2010 $25.20 $25.00 $2.20 $ 52.40 1 10 7/12/2010 $12.50 $25.00 ~ $0.54 ' $ 38.04 ._.___._...- T.._ .,~.-._______.._..._ ___..,~.,...__.._._..~__.~__.__._._ _._._.____._----~-____..._.__,____--_-~--~..._.~. -.-_.______.___ --_.~.._..~_.____ _ _ __ _ _$ o.oo _ ~~ ~ ~~_ _ _ $ o.oo ...~.....~___,._,.... - ,_..-.._ _.~.. __._.....__-L ......M.._.._._C~ _W__~~...._.-..~ $ 0.00 ~ $ o.oo TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): $ 9p,44 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 or person has failed to pay the amount due after demand, CATHERINE D. LANG Commissioner of Labor Date: August 5, 2010 gy; OI3N 13. ALBIN, Agency Legal Counsel T:\DOCUMENTS\FORMS\Liens\Original lien.docx THOMAS A. UKiNSKI, Legal Counsel RETURN FILED COPIES TO: Nebr. Dept. of Labor -LEGAL NEBR. DEPT. OF LABOR P.o. sox 94600 CHARGE ACCT. #14'165 ' 4ineoln, NE 68509.4600