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Exhibit " CCq <br /> Use black ink. Example A - Handwritten Example B -led Florida - Department of Revenue Employees Quarterly Report <br /> i _lr �lI !1Example A - - -- Exem 'a2 Employers are required to file quarterly tax/Wage reports regardless of employment activity or <br />whether any taxes are due. <br /> !=1 (MFI <br /> rl .1ELJ oLJtYLJ � a� ❑ <br /> — _. .. - - - - ---- -- UCT 6 <br /> T R. 01 /08 <br /> QUARTER ENDING _ DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> II IIII Il nn �� II �� ��LJ II ff u11 <br /> -� --f L. _.I L �J_� i� �J l._ � -- --- ----- �� �J a - <br /> Do not make any changes 11 you do not have an account number you <br /> to the pre-printed are required to register (see Instructions). <br /> III � �� IIII I II SII it II III ' I II VIII II It changes re this loan . <br /> 11 It changes are needed , <br /> request and complete F. E. I . NUMBER <br /> 910009999999906680540377500999999900004 an ounl <br /> Change Form ( UCS-3) . ruFOR OFFICIAL USE <br /> u ONLu(Y�POSTMARK DATE <br /> y _ O / 00 [10 <br /> i-- US Dollars I Cents <br /> 2 . Gross wages paid this quarter 11 E 11 <br /> ( Must total all pages) Il— LJI IL` <br /> 3 , Wa es paid this quarter in excess of $7,000 <br /> (on <br /> calendthe fIrstyear i subject <br /> ct to H each Une. . . a per I� ❑ U ❑ ❑ E !� <br /> alentlaryearissubfedtoFioridaUnemDloymentTax ) _ t—J > > ■ u <br /> 4 . Taxable wages for this quarter <br /> (Line 2 minus Line 3 ) <br /> 7 7 <br /> Enter the total number of lull-time and part lime covered workers who performed 5. (ax duey y ) n ( El <br /> ' <br /> (Multiply Line 4 b Tax Rate i ..._. Il—I I II' <br /> ' oil period including the 12th of the month . t_._J <br /> services wring or received pay for the payr p udln <br /> _ - <br /> � G. Penally due <br /> r— � r- <br /> 1st Month ' (See instructions ) <br /> 7 . Interest due r — LJ! <br /> it' �i I—I ❑ .2nd Month ( - ) ( See instructions) I_ll <br /> II <br /> 1 - 8 Total amount due (Line 5 + Line s + rine 7) r- _I <br /> 3rd Month t Make check payable to. Florida U C. Fund LJ _—' t__.) 7 11 E, Cl , -� E <br /> If you are filing as a sole proprietor, is ( his for domestic ( household ) employment only? �_._.1 Yes ____ No <br /> Cn^ :, par:a !ti2s of pe wry, aeclnie that have read ( his return and the facts statad in it ora true (sections 443. 171 ( ii) <br />and 445 . 141 ( 2) Florida Statutes) , <br /> Title <br /> 7Sign <br /> siyna,� ure a orrioei Date Phone Fax <br /> Preparers Preparer check Preparer s <br /> signature ' if self-employed SSN or PT1N '— <br /> Paid -- — — — — — — — — <br /> preparers Firmm <br /> 's nae (or yours Data FEIN <br /> only ifsalt-employed) — ._..----and address ZIP preparer's <br /> phone number i ) <br /> - - - - - - _ _ .. _ ._ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DO <br /> NOT <br /> Employer's Quarterly Report Payment Coupon UCT 6 <br /> R. 01 /08 <br /> Flonda Department of R.avenueCOMPLETE and MAIL with your REPORT/ PAYMENT. <br /> T Please write your ACCOUNT NUMBER on check . — <br /> Be sure to SIGN YOUR CHECK . DOR USE ONLY <br /> Make check payable to: Florida U . C . Fund ❑ ❑ / � �� / ��� <br /> I f c Nnamber7 Seelnstruct <br /> UT ACCOUNT NO . I ! I lons.) POSTMARK OR HAND DELIVERY DATE <br /> -- --------------- <br /> F. E . I . NUMBER <br /> ! I I — U .S. Dollars { I Cents I <br /> AMOUNT ENCLOSED I ! <br /> ( it less than $ 100 i._J I___� �__ -_J ? I_ _J _ _ ■ �� <br /> no remittance is necessary) <br /> PAYMENT FOR QTR/YR ❑ — ❑ ❑ <br /> s <br /> Check here if you transmitted funds <br /> electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />