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Exhibit " C "
<br /> P ..r. Florida Department of Revenue Employer's Quarterly Report
<br /> 0123956789
<br /> U TI
<br /> 1 / 11
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<br /> Do not intake any changes 11 you do not have err account ❑umber; you
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<br /> information on this form
<br /> If chat es are needed ,
<br /> rCones I and complete an
<br /> Employer Account -- - --
<br /> Change Form ('DCS-3), FOR OFFICIAL USEONIY POSTlAARH DATE
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<br /> IN I 1 11
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<br /> Paid � U , , n,r . . + v41
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<br /> DO NOT
<br /> DETACH
<br /> Pule bosa .a.os'
<br /> Flooda nrmnss, r „,.11 teas Employer's er's Quarter) y Report Payment Coupon UCT- 6
<br /> R . 01 /11
<br /> GOSiPCETE erJ tdAh : dh pour REPORT PAVAENT. f" O , U .. ! t� i1CY
<br /> T Pica a OrAstff t 7 ;r t T ACf,Ol1NT NUh4REf4 an checi
<br /> 'Jakh r r, : pay., bafog. Florida U.C. fu(TQa , titscr=;
<br /> ., COP _ I i7O,Tt
<br /> UT ACCOUNT NO.
<br /> U . S. Dollars __ Cents
<br /> F. E . I. NUMBER GROSS WAGES
<br /> AMOUNT ENCLOSED
<br /> N , ) l N1, PAYE%IENT FOR ODARTER
<br /> it . „ n , ENDING PAtvt,YY
<br /> } Check here if you are, electing to (heck h2rc: if you Ironsn, ltted
<br /> 1aP pay tax data on nStahrnents . funds olGctronicaily.
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<br /> 9100 0 99999999 006805E+ 031 7 5009999999 0000 4
<br /> - 14 -
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