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Exhibit " C " <br /> U e .>la I. n h ,_,,,aintilr i1 I lapdm -- -yn L. arnr IN d Typed Lia erg <br /> Florida Department of Revenue Employer% yj Report <br /> i E urs e > _ n�+luE� — IfflplCyP,fSafAfrJ � Ull � f (4� file QllBfC�Il' <br /> 0 -- <br /> C', <br /> i 6 7 Iii laxAdAge feporkS le�7alTe� iS 01 etilplbyrrre,0 111 !`•/ I � 0[ wheulel anv loxes Orf' due. <br /> L �. ...._ � � 02�3�496 ?�89JL j <br /> ... UCT 6 <br /> QUARTER ENDINGR . 01 /08 <br /> '- CCOUNT NUMBER <br /> UE DATE PENALTY AFTER DATE TAX RATE UT A <br /> -- - <br /> _ _ <br /> Do not make any changes 11you do not have an account number you <br /> III III II i II I III I III I to the pre-printed are required to register (see instructions). <br /> information on this form <br /> If changes are needed , <br /> request and complete <br /> NUMBER <br /> 9i00Ulu A9r;' 990i)58p „ 0:3175009a99 990000•r -- ... ...... <br /> an fmployerAccount 1 <br /> Change form ( UCS 3). LI I . 1 1..._ , ....... 1 I .....-,I <br /> FOR OFFICIAL USE ONLY POSTMARK DATE <br /> Fj `1 � <br /> US Dollars —I Cents <br /> 2. Gross wages laid this quarter r" r <br /> (Must total all pages ) 1 <br /> 3. Wages paid this quarter in excess of $1,000 .. <br /> OnIV the 1IM1 ,171300fafC to each ernplo JaB per <br /> I _ <br /> C"28fIdAl' fYdr 15 fiUliPt,t 10 -�0 rido Lli ien'IpUytnrrl lax ), <br /> I -, 9 <br /> 4. Taxable wages for this cIuarter II l 1 <br /> (Line 2 minus Line 3 <br /> p 5. Tax due ) i.. .. I_ 1 I p <br /> _ . 9 I <br /> 1 . Enter the total number of full-time and part-time covered workers who erformed — f �I (� l �-� <br /> services Burin or received a for fhe (Multiply Line 4 by Tax Rate) 1 <br /> 9 pay payroll period including the 12th of the month. IJ El <br /> � —( 6. Penalty due . . ... .. 9 <br /> 1st Month �i � - 1 �� . (See instructions ) � ....... I I I e .. I <br /> 9 .._i 7. Interest due ) a 7 <br /> 2nd Month S. Totalamountdue ( Line 5 + rine Er + Line 7) . . . <br /> 1 . I <br /> 3rd Month 1 �, Ivl Make check payable to: Florida U. C. Fund 7 <br /> I <br /> Ifyou are filing as a sole proprietor, is this for domestic ( household) employment only? '_ Yes No <br /> Linder penalties of perjury, I declare that I have read this return and the huts stated in it are true (sections 443A ill ( 5) and 443, 141 (2) Florida <br /> Statutes ) mom. <br /> 1 <br /> Sign here Fax <br /> ; Title <br /> Qign,ions:Lir t ^er Phone `, ( 1 <br /> ° n Date <br /> .. <br /> Poe avers �+y, Fraparer11 .. <br /> ar els check Piap <br /> Paid _ ifsolt-ernploye SSN PrIN L I <br /> V <br /> Only if self <br /> prpreparerseYS � Fnm 7a, ne for yours i FE <br /> mplcye<,rDare-----.'-- —_ ... �. <br /> and address - <br /> ZIF ' r <br /> Owe n .imnar } <br /> _ ._ _ _ _ _ _ _ _ ._ _ _ _ _ _. _ _ _ _ _ __ _ _ _ _ _ _ _ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ DO NOT <br /> _ - -- DETACH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . <br /> Employer 's Quarterly Report Payment Coupon UCT- 6 <br /> R . 01 /O8 <br /> Florida Departryreni of Revenue COMPLETE and MAIL with your REPORT/ PAYMENT. <br /> Please write your ACCOUNT NUMBER on check . <br /> TBe sure to SIGN YOUR CHECK. <br /> — <br /> Make check payable to: Florida U . C . Ftmd j —�I i ---- D%R- USE- ONLY <br /> _ No number? <br /> UT ACCOUNT NO . POSTMARK OR riAND DELIVERY DATE <br /> '— _..!� �. !— - -� (See instructions.) ---- <br /> L.F. E . I . NUMBER { <br /> U .S. Dollars Cents I <br /> — -- <br /> AMOUNT ENCLOSED I — <br /> (if less than $1 . 00 <br /> J <br /> no remittance is necessary ) <br /> PAYMENT FOR OTR/YREl <br /> -- <br /> f 1 Check here if you transmitted funds <br /> u electronically . <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />