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O1/18/?O11 TU� 14222 FAX 402 471 4429 UCC SECRETARY OF STATE ��� Hdll <br />� � <br />�alioo4�� <br />NE L�F C� S4aka Jnhn A 6.Ir - �C[ STL <br />9911648503-8 p9s: 1 <br />JG&J INC. <br />Filad: 01/18/2011 09:45 AM <br />�ooa�oos <br />NDOL O:f�ce of �egal Counsel <br />STATE T��►X LIEN C1 NEBRASKA DEPARTM�NT OF LABUR P.O. Box 94b00 <br />Lincoln, NE 68509 <br />� ORi�nvni. Telephone - (40Z) 471-9912 <br />FAX - (402) 471-991.'� <br />Employer or <br />Liable Person: 7 G& J Inc, d/b!a Bullwinkle Bar & Grill <br />Address: 2118 N. Webb Road Grand Island NE 68803 � <br />NDOL Serial No.: LA$-0015-2011 Ta be �ted with t he Re ister af peeds in the followin Counties: <br />NDOL Acct. No.: 0242960U49 Ha11 � <br />Federal ID No. / SSA No.: 47-0756101 <br />This Stats Tax Lien is issued for unpaid combined taxts (Neb. Rev Swr. §§48fi57 end 48�i64) or payments in lieu of coniributions (Neb. Rev. Star. §48-66Q01) pu�suant <br />to the Un'sform State T"ax Lien Ftegistration 8c Bnforcement Act (Neb. Rev. Stae. §77-3901, er seq.). Notice is given that combined Cayces or payments in lieu of <br />contri6utivns, interest (computed at 1.5% per month), and penalties are due from this employer or person and remain unpaid afl.et demand: 'I'hese combined taxes or <br />payments in lieu af contribukions constitute a lien far 8u�y and aJl personal property and real property in the county/counties named, belan$ing to the employer nr person, <br />wh�thcr now owncd or hereafter acquired. <br />Qfr. / Yr. <br />1/2010 <br />2/201 Q <br />3/2010 <br />Date Assessed <br />12/22/2010 <br />l2/22l2010 <br />12/22/2010 <br />$656.18 <br />$917.75 <br />$1,075.59 <br />TOTAL Combined Tax ar Payment io Lieu of Contributions Due (under this lien only): <br />Interest <br />Penalty Tdroagh Subtotal <br />1/14/2011 . <br />�p.00 <br />$29.33 <br />$37.54 <br />$83.79 <br />$7S_56 <br />$39.77 <br />$ 739.97 <br />$l ,oza.�a <br />$1,152.90 <br />$ 0.00 <br />$ 0.00 <br />�$ 0.00 <br />�$ 0.00 <br />� $ 0.00 <br />� $ 0.00 <br />$ 0.00 <br />$ Q.QQ <br />$ O.QO <br />$2,915.51 <br />I certify that the Nebrasicn Department of Labor has �omplied with the �mplayment Security Law of tb�e State of Nebraska in the <br />determinatian of the �mount due, and the emptayer or persan has failed to pay the amount dne after dernat�d. <br />CATHERINE D�G <br />Date: January 1 S, 2011 <br />T:�D�C1JM�:NT'S\FORMS�L.iens\Orip,in�l lien.docx <br />By: <br />RETURN FILED COPXES TU: Nebr. Dept. of L�bor �- L�GAL <br />P.O. Box 946D0 <br />Linwin, NE 6$509a►600 <br />Combined Tax Or Payment �n Lien <br />Of Contributions Due <br />�$IN, Agency Legal Caunsel <br />A. UKCNSKi, Legal Connsel <br />NEBR. DEFT. U�' LABO <br />CHARGE ACCT. #147GS <br />