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Exhibit " C " <br /> Use black Ink Example A - Handwritten Example B---Typed Florida .Department of Revenue Employer's Quarterly Report <br /> EXan pie A - Exen,Pla a Employers are required to lite quarterly tax/wage reports regardless of employment activity or whether any <br /> taxes are due . <br /> 4 01:0 AS IU8 P1 Ll <br /> R . 01 /08 <br /> QUARTER ENDINd DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> .......... <br /> Do not make any changes /r you do not have an account number you <br /> to the pre-printed are required to register (see Instructions). <br /> III III IIII I II 111118OS4037 <br /> IIVIIIIIIIII information an Employer Account term . <br /> If changes are needed ,crequest and complplthiete FE. I NUMBER Jr I If990061500999999900004 <br /> Ll - Ll L.] L i � - i <br /> Change Form UI I CS-3 . L��JJJ ��ll <br /> FOR OFFICIAL USE ONLY POSTMARK DATE <br /> US Dollars Cents <br /> 2_ Gross wages paid this quarter ' <br /> (Must total all pages ) I <br /> 3. 01 ndarages pest $s ,000paidtoeach <br /> Floriaid this quarter in da <br /> lopeeper oyment � l r � IL I7lir � � <br /> 4 Taxable wages f quarter <br /> ( Line 2 minus Line 3 ) ; l <br /> 5 Tax due , r <br /> 7 7 <br /> Entei Ine total number of full -time and part-time covered workers who performed ( Multiply Line 4 by Tax Rate) <br /> 9 y 12th of the month - <br /> servi �es Bunn or received pay for the pa roll period including the <br /> J <br /> 7f <br /> 6 Penalty due <br /> st 1111 ( ( See instructions ) <br /> 7 7 7 Interest due <br /> - 7? [Id Month 8 Total amoun '� ons ) <br /> y See instruct 7 <br /> t due ( Line 5 . Line 6 a Line 7j - <br /> i I <br /> SrJ E� aitf Make checkpayableto Florida U C Fund <br /> If ou attr. tiling as a sole pruprielor, is this for domeslio (huusehold ) employment only IYes -_ 1 No <br /> fat 1 I t i Int - I inrl th ( _ 1s tf rr �t �t, ar I I . , r:-ir � 17i 111 d4 1 <br />Lt Floc 1� Sta ` ure <br /> si <br /> ' Title <br /> I Sign here <br /> � x <br /> I :. Phone Fa <br /> Prepnr_re <br /> Preparercheck Preparers r <br /> siynnture if self-employed � S6N or Pl1N <br /> Paid _ — - <br /> pl-epareYSFirm's name (or yours Date FEIN I <br /> 1 it Belt employed) - - - - - -- - -�-�- <br /> Only and address ZIP Preparer's — <br /> phone number <br /> DO NOT <br /> - - .- .. _ _ .. _ .. L, - - - - - - - - - - - - - - - - - - - - - - - - - - DEIrAdF <br /> Employer's Quarterly Report Payment Coupon UCT s <br /> R. 01 /08 <br /> COMPLETE and MAIL with your REPORT/ PAYMENT. <br /> 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 /> y il <br /> 'I No number? I\� POSTMARK OR HAND DELIVERY DATE <br /> UT ACCOUNT NO . I i — (See instructions.) -- ----- — <br /> F. E . I . NUMBER U .S . Dollars i Cents <br /> ff Iff , � <br /> AMOUNT ENCLOSED I l I <br /> ( If less than $ 100 <br /> no remittance is necessary) <br /> PAYMENT FOR QTR/YR � ) <br /> Check here if you transmitted funds <br /> electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />