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07/0612011 WED 14:51 FAX 402 471 4429 UCC SECRBTARX OF STATE -�-+y Hall <br />,' <br />201105 <br />�oos�oos <br />--� <br />STATE TA►X LIEl�T ❑ N�BRASKA DEPARTMENT OF LABOR �OL Office af Legal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509-4600 <br />� OittGnvA,1. Telephone - (402) 471-9912 <br />FAX - (40Z) 471-9917 <br />Employer or <br />Liable Person: Triple C Transport LLC <br />Address: 201 N.1� St. Doniphan NE 68832-1712 <br />NDOL Serial No.: LAB-0138-2011 To be fded with the R ister of Deeds in t6e followin Counties: <br />NDOL Acc� No.: 0315147000 Ha11 � <br />Federal YD No. / S5A No.: 20-4973399 <br />This State T�c Lieu is issued for unpaid combined texes (1Veb. Rev. Stcr� §§48-657 and 48-564} or payme�nm in lieu of contributions (Neb. Rev. S1at �45-660.01) pursuant <br />to the Uniform State Tex Lien Registretion & Enforcemcnt Act (Neb. Rev. Sta[ §77 3401, ee seq.). Notice is given that combined taxes ar payments in lieu of <br />contributions, inb�est (computed at 1.5°lo per moath), and penalticx ere due brom Wis employer or persoa and re�ain unpaid after demand Thesa com6ined t�ces or <br />payments in lieu of c�ntributia� eoastitute a lien for any and all personal property and real property in tha countyicounties named, belonging to the employer or person, <br />whether now owned or hereafter acquired. , <br />Qtr. / Yr. <br />4/2009 <br />1/2010 <br />2/2010 <br />Date Assessed <br />b/1012011 <br />6/10/2011 <br />6/10/2011 <br />$451.35 <br />i,138.73 <br />i.241.1'7 <br />TOTAL Combined Tau or Payment in Lieu of Contributions Due (under this lien oniy): <br />Interest <br />Penalty Thruugh 5ubtotal <br />6i2512011 <br />$0.00 <br />$113.48 <br />1,066.56 <br />1,498.89 <br />$ 564.83 <br />$6,2Q5.29 <br />$10,740.06 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />� 0.00 <br />$ 0.00 <br />S17,510.18 <br />I certify tLat the Nebras�ta Departmeat of Labor has complied with tl►e Employment Security Law of the State of Nebraska in the <br />determination of the amount due, �nd the employer or person has failed to pay the amoant due after demand. <br />CATHERWE D. ��] <br />Date: 7/6/2011 <br />T:IDOCUMENTSIFORMSU.iens\Original lien.docx <br />RETCTRN FXLED COPIES TO: Nebr. Dept. of Labar - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509-4600 <br />Combined Taz Or Payment In Lieu <br />Of Contribablons Dne <br />�'IN, Agency Legal Counsel <br />UKINSKI, I.�gal Couasel <br />n <br />NEBR DEPT. OF LABOR <br />CHARGE ACCT. #147G$ <br />