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2025014350 | Page 1 of 1 | Recorded in GREENE COUNTY, OH 09/12/2025 10:50 AM
CERTIFICATE OF AMOUNT OF PREMIUM DUE
(LIEN ON REAL ESTATE AND PERSONAL PROPERTY. SECT. 4123.78 REVISED CODE )
ISSUE DATE: 09/04/2025
RECORDER OF GREENE COUNTY, OHIO
STATE OF OHIO : GREENE COUNTY RECORDER
BUREAU OF WORKERS’ COMPENSATION . 69 GREENE ST
. XENIA, OH 45385
Plaintiff .
Vs . TAX TYPE: STATE INSURANCE FUND
° PREMIUM
ANTIOCH COLLEGE CONTINUATION CORP . Risk No.: 01590656
ANTIOCH COLLEGE . Account No.: 301515734
1 MORGAN PL .
YELLOW SPGS, OH 453871683
Defendant
The aforementioned premium assessment has become final by operation of law for the purposes of
having a lien filed against the real and personal property of the above employer
TO THE COUNTY RECORDER:
Please file lien against the real and personal property of the above employer and return to the office of
the Attorney General.
LIEN RECORDED ON: |
,
MORTGAGE RECORD r >
VOL. NO.: PAGE NO.: ~ _ “le ) NT: $228.40
CHATTEL RECORD Lav
VOL. NO.: PAGE NO.: ¢ 4 ~,*
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action of the Bureau of Workers’
Bobbie J. Doneghy —
Supervisor of Accounts Receivable
Bureau of Workers’ Compensation
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