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20h APP 24 PH 2• � I
- Hn'ErILA D COUNTY
PENNSYLVANIA
IN THE COURT OF COMMON PLEAS OF DOCKET NUMBER:
CUMBERLAND COUNTY, PENNSYLVANIA DATE ENTERED:
CERTIFIED COPY OF LIEN COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
TO THE USE OF THE
UNEMPLOYMENT COMPENSATION FUND
TO THE PROTHONOTARY OF SAID COURT: VS.
Pursuant to Section 308.1 of the •
Pennsylvania Unemployment COMPLETE FIELD SOLUTIONS LLC
Compensation Law, 43 P.S. § 788.1, MIKE JOHNSON 764 ALLENVIEW DR
this is a Certified Copy of Lien for MECHANICSBURG, PA 17055
unpaid unemployment compensation
contributions, interest and penalties to •
be entered of record by you and
indexed as judgments are indexed.
AD Number: 622122
CONTRIBUTIONS, INTEREST and /or LATE REPORT PENALTIES
QTR/ REPORT CONTRIBUTION CONTRIBUTION PAYMENTS/ BALANCE INTEREST r PENALTY TOTAL- `
YEAR STATUS TYPE DUE CREDITS DUE 03 / of * DUE DUE
03/07/2014
112011 Filed Employer $1.42 $1.4'2
2/2011 Filed Employer $598.631 $128.07 $470.56 $112.96 $583.52
TOTAL 1 $584.94
OTHER PENALTIES
DATE AMOUNT PAYMENTS/ BALANCE
ASSESSED TYPE ASSESSED CREDITS DUE
05/17/2012 CIVIL $1,000.00 $0.00 $1,000.0
TOTAL $1,000.0
'Unemployment compensation contributions bear interest at the rate of one - twelfth Grand Total $1,584.94
(1 /12) of the annual rate determined by the Secretary of Revenue under Section 806 $21.50
of the Fiscal Code, 72 P.S. § 806, or at the rate of three quarters of one per centum Filing Fee(s)
(0.75 %), whichever is greater, for each month or fraction of a month from the
date they are due through the date they are paid. Additional interest will accrue on the
above balance of unpaid contributions until they are paid.
The undersigned, Assistant Director, Office of Unemployment Compensation Tax Services, Department of Labor and Industry, certifies that
the above unemployment compensation contributions, interest and penalties are due and payable by the above named defendant under the
provisions of the Pennsylvania Unemployment Compensation Law. Pursuant to Section 308.1 of said Law, 43 P.S. § 788.1, the above
contributions, interest and penalties are a lien upon the franchises and property, both real and personal, including after acquired property, of
the above named defendant and attach thereto from the date of entry of this Certified Copy of Lien.
Department of Labor & Industry I Office of UC Tax Services 1 651 Boas Street I Harrisburg, PA 17121 -0750 1 www.dli.,,t
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Auxiliary aids and services are available upon request to individuals with disabilities. �� I _ 0 ggen ag 1
UC -728 REV 01 -14 (page 2) Equal Opportunity Employer /Program (
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SALLY L. RATAK
h Y7C1'I III
Assistant Director, Office of Unemployment Compensation Tax Service UC- 72820140318095452166823248696
Department of Labor & Industry Office of UC Tax Services 1 651 Boas Street I Harrisburg, PA 17121 -0750 AWWAli,state.pa.us
Auxiliary aids and services are available upon request to individuals with disabilities.
UC -728 REV 01 -14 (page 3) Equal Opportunity Employer /Program