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07/15/2011 F1tt 15:26 FAX 4Q2 471 4424 UCC SECRETARY OF 5TATE -�y-� Hall <br />r!� <br />20�.�.05224 <br />STATE TAX LIEN o NEBRASKA DEPARTMENT OF LABOR <br />� An�TnMElvz' <br />�1ooalao3 <br />NDOL Office of Legal Counsel <br />P.O. Bog 94600 <br />Lincoln, l'�E 68549-4600 <br />Telephone - (402) 471-9912 <br />FA,X - (4UZ) 471-9917 <br />Employer or <br />L iable Person• Triple C 1Yansport Inc. <br />� Address: 147 E. Roberts St Gramd Island NE 68803-2159 <br />NDOL Acc� No.: 0335068000 <br />Federal ID No. / SSA P3o.: 27-20I4592 <br />This is an AMENDMENT of an existit►g lien and serves to amend/correct and continue the lien and pnonty of th� Nebraska Department of Labor on the <br />�ecte,d properiy of this employer or persoa This amendment is filed pur�ant to Neb. Rev. Star. §§48-657, 48- 660.01, 48-654, and the Uniform State <br />Tax Lien Registration & Enforoement Act (Neb. Rex Stat. §77-3901, et seq.). Nodce is given that combined tax� s or payments in lieu of coatribudoas, <br />interest (computed at 1.5% per month), and penalties are due from this employer or person and retnain unpaid ai ter demand. These combined taxes or <br />payments in lieu of contnbutions constitute a Gen for any and aTl persona] properiy and� real progerty in tho ca unty/countles named, belonging to �e <br />employer or pecson, whether now owned or heaeafter acquued, This State Titt Lien amends the Nebraska D�spattment ofLabor's intet�esd in the <br />a, fj`'ected prop of th employer. <br />LIEN TO BE AMENDED: <br />NDOL Serial No. LAB-0139-2011 Hall Couniy Document No. .2011050 <br />State Tax Lien Document N. 9911665907-5 �ex Filing Information: Amended to correct name from Tripie C <br />Transport LLC to Triple C Transporf Inc. <br />� ' Combined Tax or � � Intere,st <br />Payment Ia Lieu Of Contributions � �, [ through Subtotal <br />Qtr. / Yr. S Date Assessed Dae ° E <br />3/2010 6/14/11 <br />4/2010 6/10/11 <br />$10,571.38 $0.00 <br />$9,089.89 $0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />11,80655 <br />$9,739.68 <br />$2 <br />TOTAL Combined Tas or Payment in Lieu of Contributions Due (under this lien only): <br />I certify that the Nebraska Department of Labor has complied wit6 t6e Employment 5ecnrity Law of the State of Nebraska in the <br />determination of the amount dne, and the employer or person has failed to pay the amount due after demand. <br />Date: July 15, 2011 <br />T:IDOCUM��TfS1FORMSiLiens�Amendmentdoc <br />CATHERINE D. LANG <br />Com ' 'oner of Labor <br />Sy: � <br />H. ALBIN, Agency Legal Coansel <br />THOMAS A. UKINSKI, Legal Counsel <br />RETURN FILED COPIES TO: Nebr. Dept. of La.6or - LEGAL <br />P.O. Box 94600 <br />Lfncoln,lVE 68504-4600 <br />1235.17 <br />$649.79 <br />$0.00 <br />NEBR DEPT. OF LABOR <br />CHARGE ACCT #14765 <br />� <br />