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Exhibit CA TRUE COPY " " ' CERTIFICATION ON LAST PAGE J . K . BARTON , CLERK Florida Department of Revenue Employer's Quarterly Report Ji use dlac ink Example,A Handwrl jen Exampie_8 Typed Employers are required to file quarterly tax/wage reports regardless of employment activity or whether any taxes are due. Plop� I—1 �,a�m�le�, CJa � LJUI� Jc t❑ J ccl' pf t �18 � ❑) UCT-6 .. .. R . 01 /11 QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER T F117 / 11EI / Ell ED 1111 Ell 11 E E Do not make any changes ff you do not have an account number, you to the pre-printed are required toregister (see instrucfions). information on this form. F.E.I . NUMBER If changes are needed, P (�! j j request and complete an I I I I Employer Account ��- �� 1 I Change Form (UCS-3). FOR OFFICIAL USE ONLY POSTMARK DATE Reverse Side Must be Completed C Name 2. Gross wages paid this quarter 1111 ' 9a 1111 9 'r] 11 1111 11 Mailing J Address (Must total all pages) City/St/ZIP 3. Excess wages paid this quarter a 9 � ! 9 f . ❑ (See instructions) I 4. Taxable wages paid this quarter (See instructions) Location _ .... .. -..- I . 11 [1 [1 � J 00 Address 5. Tax due CitylSt/ZIP (Multiply Line 4 by Tax Rate) 9 9 ,E 11 nn 6. Penalty due E 11 � n 11 ] 1111 ' 11 11 1 . Enter the total number � (See instructions) �,I i of full-time and part-time 1 si Month C. C 9 9 F1 F a 111 covered workers who 7. Interest due 1111 , 1111 � I � � performed services during 9 � (See instructions) or received pay for the 2nd Month Ci 11 J Ell E g, Installment fee � . payroll period including the ( - 9 --' � - -� (See instructions) 12th of the month. 3rd Month 9 11 . ( 9a. Total amount dueChe9 � 9 ❑ (See instructions) El 1111 E 11 11 Date op final return : / / : 9b. Amount Enclosed , 1 n 9 � 91� Date operations ceased. i . I� R 11 1 . (See instructions Check if you had out-of-state wages , .Attach Employer's " h If you are filing as a sole proprietor, is this for Quarterly Report for Out-of-State Taxable Wages (UCT-6NF). domestic (household) employment only? Yes No Under penalties of pe jury. I declare that I have read this return and the facts stated in it are true (sections 443. 171 (5) and 443. 141 (2), Florida Statutes), I Title Sign7Siqnl=j! 0. i Phone Fax of officer Date 1 ) ( ) Preparer's Preparer check Preparer's signature if self-em Paid ployed j SSN or PTIN preparers Firm's name (or yours Date FEIN only if self-employed) and address ZIP I Preparer's phone number ( ) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DO NOT - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DETACH Rule 60BB-2.037 Employer's Quarterly Report Payment Coupon UCT-6 Florida Administrative Code R . 01 /11 Florida Department of Revenue COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY Please write your UT ACCOUNT NUMBER on check. EE / ❑ ❑ / ❑ ❑ Make check payable to: Florida U .C. Fund POSTMARK OR HAND-DELIVERY DATE I � UT ACCOUNT NO. j U .S. Dollars I Cents I F. E. I . NUMBER ] � L 1 Ell F1 11 F E,I GR(FromSSW m Line 2 above.) E E E II] C C yCi 1111 . 1111 AMOUNT ENCLOSED ' I (From Line 9b above.) �_. ... F ... .. -. 9F E ..... 19 Name PAYMENT FOR QUARTER I� I _ ENDING MMM Mailing Address I� Check here if you are electing to Check here if you transmitted City/St/ZIP pay tax due in installments . funds electronically. L 9100 0 99999999 0068054031 7 5009999999 0000 4 - 12 -