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Exhibit " C " <br /> Use oiack n¢ E.an'p e A : Ha dwntten EwmP1a 8 Typed _ <br /> Florida Department of Revenue Employer's Quarterly Report <br /> vv W0.x <br /> Lr:a [w fl ta-Cu,frTsi { `y7urFrl rppole -110,1H*r '9a ,vagr K;f-r � '" >I tNt, '.fl Cf 1M' irrJ d P_ :e <br /> .,. P <br /> 042:3-41561819 uCT-s <br /> T R. 01 /11 <br /> OUARTEP ENDING DUE OATS _ PENALTY AFTER PATE TAX RATE UT ACCOUNT NUMBER <br /> 11111 Do not make any changes If you do not have an account number• you <br /> III ILII III I II III II II VIII I II III ) II <br /> to the e-pare <br /> reoved to regisferlase mstructoos). <br /> Informatkm on MIs form. Ft NUMBER <br /> It changes arom needed.eded. _-.. ._— <br /> request ami complete an <br /> Employer Account <br /> Change form (1JCS•3). FOR SIAL USE ONLY PMTMAFX DATE <br /> Reverse Side Must be Completed <br /> Name __ _: <br /> Mailing 2 . Gross wages paxi this quarvr <br /> Address Must total ail pages, <br /> CitytSVZ1P 3 Excess wages paclthis quarer <br /> (See ,nsfructionst <br /> d . Fumble w <br /> ages paid mss quaver - <br /> Location <br /> ;Ser. f1sliumonsi <br /> _ <br /> Address 5. Tax 2u8 <br /> city/ styz =Mottply Line 1 oy Tar Rate', <br /> 6. Penalty due <br /> Ex ter 'ne * )tai nuircer .. " - (See nshr %et%onsl <br /> nt 41Ii.il we r10Darr. tlme 1St Month <br /> Ne Interest 7ue - <br /> Dirft"ed :.erwices aur,rq 2nd Month See asirucuonsl <br /> p e ne B. Instattment fee <br /> payro•I erod �ncivamgme - :See :nswct%ans) <br /> 6H ,1i It•.e month 3rd Month • . <br /> 9a. Tall almint sue <br /> .- _. _. . . . %See nsuuctjonsi <br /> VatsLate o pf !into Tatum: / _. / .- - 90 Amort Er4osM <br /> operators ceased . <br /> Check f you tad out-of .state wages, Attach Employer 's I! you are filing as a sole proprietor, s this `or <br /> Ocarredy Report for Our of- State raxadie Wages iUCT-6NF), domestic (household) employment only? <br /> - .. .. . Yes - _. : No <br /> .n 5 ,.n ., 4 " a . ' �,^at ava ean ' ( Vin(( ^e 'htt5 ,:atao ! 3fr. ":;a .. x•id ::. 3 ' „ <br /> Title <br /> 7SignHere <br /> Phone Fax <br /> i.r-. .or Data <br /> gnm.,re <br /> Paid f sgpl wrWoyed SSN or oTN <br /> � _ . . . <br /> preparers r m, uICIMP Or woufs Dale FE N <br /> .. - . .... . <br /> Only - -. --. . <br /> 3i'•rl eodress zip P*I!pamr"5 <br /> L_ 0 re n6rnger <br /> DO, NOT <br /> DETACH <br /> Rule 60811 -2.037 Employer's Quarterly Report Payment Coupon UCT-s <br /> Florida Administrative Code R . 01 /11 <br /> mina 711 iCrne❑t if ?e `sore CCMPLETE aro MAIL with your REPORT/PAYMENT DOR USE ONLY <br /> Please write your UT ACCOUNT NUMBER on check <br /> T i L <br /> Make check payable to: Flgridn U. l�.-Fund. POSTMARK OR RANO DELIVERY DATE <br /> UT ACCOUNT NO <br /> -. __ i ---- U.S. Dollars Cells <br /> F.E. I . NUMBER GROSS WAGES <br /> . ... . . _. ' - _. ; (From Line 2 above. ) _.. : -.. ' .. . . .-. <br /> AMOUNT ENCLOSED <br /> (From Line gb above. ) <br /> Name PAYMENT FOR QUARTER <br /> Mailing ENDING MMNY _ <br /> Address ' Check here if you are electing to Check here it you transmitted <br /> C4ty1s1v21P — pay tax due In Installments. _".. funds electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br /> - 12 - <br />