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Exhibin't 6699 <br /> Use rYWk Ink Example A - Nenawnrten E(emple B • T ed Flo a ® �ll i LL ant of Revenue E p e ft ate Re rR <br /> IXam A ,�p ,� , g P"'Employers are required to file qua0efly to Mge repots regaidiess of empicyrnent activity of wt�hei any taxes are <br />due. <br /> C�7EM [JIMMOM ❑ NPAMSMU11 UCT-S <br /> R . 01/08 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> ❑ ❑ � ❑ ❑ � ❑ ❑ ❑ ❑ I L- [110011110 - 11 <br /> Do not make arty changes N yon do not have an account number you <br /> to the pre-pdrrted are required to register (see lnaf tions). <br /> Ird ormallon on lids <br /> III I III II I �� ( III III It rmWesitaand ommptote form. <br /> F.E. I. NUMBER <br /> 9100049999999006BOS403tr80099999990f�04 anFoerAccount ❑ _ n [ill <br /> ( l ❑ 11 L111CAange Change form (UC8r1}. J (� <br /> FOR OFFICIAL USE ONLY POSMARK DATE <br /> [10 / 1111 / <br /> I <br /> US Donors Cetus <br /> 2. Gross wages paid ) quarter 11 ❑ ❑ 9 ❑ ❑ ❑ 9 ❑ 11 ❑ ❑ <br /> -- <br /> (Must taalan pages) <br /> El <br /> 31 Wates paid 7,0 quarter in h $MVI of 57.000. ❑ ❑ , ❑ ❑ ❑ 9 ❑ ❑ ❑ e ❑ <br /> (Only Iha <br /> firer $7,006 paid to each a roloyea Dar <br /> t . i Calerdaryearissubjecttoflvrimlbtmrployllm T. <br /> n ❑� <br /> 4. Taxable wages forthi <br /> 3) quarter 11 <br /> I ❑ � 9 ❑ ' FIRE <br /> 111111 � 1111 <br /> L_ <br /> (Lme 2 minus Line 3) <br /> -- 5. Tax due ❑ ❑ ❑ 9 ❑ ❑ ❑ 9 ❑ ❑ ❑ o ❑ E <br /> 1 . Enter th o total number of full-time and part-time covered workers who performed (Multiply Lure 4 by Tax Rate) <br /> services during or received pay for the payroll period including the 12th of the month. 6. Penalty due <br /> let Month {See Instructions) <br /> 2nd Month ❑ ❑ ❑ 9 ❑ ❑ ❑ 7. (See <br /> (Sins <br /> ee rretructions) 1111 [TO ❑ [19 ❑ ❑ ❑ ' [1 ❑ <br /> {S <br /> ❑ ❑ ❑ 9 ❑ ❑ ❑ 6. TotalMake em®mddue <br /> eto. RoLmLino 7) ❑ ❑ ❑ 9 ❑ ❑ ❑ 9 ❑ � ❑ � ❑ ❑ <br /> 3rd Month Make check payable to: Ronda U.C.UC. Fund <br /> If you are fling as a sole proprietor. is this for domestic (household) employment ordy9 ❑ Yes ❑ No <br /> Under penalties of perjury, I declare that I have read this return and the fads stated in 0 are true (sections 443. 171 (5) and 443.141 (2) Florida <br /> Statutes). <br /> Title <br /> Sign here <br /> signauire of officer bate Phone Fax) ( ) <br /> Freparer's Preparer chKkproper erg <br /> Pard signature if Self-employed ❑ $814 ,31 PTIN <br /> preparers Fem 'a name (or yours Date FEIN <br /> only itself-employem <br /> and atldress ZIP praparer'3 <br /> DhmtenumDsr ( ) <br /> 00 NOT <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - -- - - - - - - - - - - - - <br />- - D�TT1LIt- - - - - - - - - - - - - - - - - - - - <br /> Employer's Quarterly Report Payment Coupon R oC6 <br /> o <br /> Florida Department of Revenue 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 /> UT ACCOUNT NO. L= <br /> ❑ — No number/ PdSTMARt( OA HAND.DELIVERY DATE <br /> 11110 111 1 11 (800 InshueHomr) <br /> F. E.I. NUMBER - ❑ ❑ ❑ ❑ US. Dollars Cents l <br /> AMOUNTED ❑ ❑ ❑ 9 ❑ ❑ ❑ 2000 ' 11 ❑ <br /> (if lase than $1 .001 .00 <br /> no remittance is necessary)t <br /> PAYMENT FOR OTR/YR — ❑ <br /> ❑ Cheri( here if you transmitted funds <br /> electronically. <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />