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Exhibit " C " <br /> Florida Department of Revenue Employer's Ouarterly Report <br /> Use Jar;rciiv, t,, �ur:dar� Handwnta - E;, ----- Type) , . <br /> - art - 0 330 a � _ � Ernploy?isarereQulledtofilequaileilylaxlwageiepoltsledaldlessdempliclyr �.ntactivityorwh�ihelant .S erg due. <br /> 0 _A � 7819' �J U1 /08 <br /> ( <br /> -. R . 01 /08 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> - F_ l - _ -- <br /> Do not make any changes 11 you do not have an account number you <br /> to the pre-printed are required to register (see instructions). <br /> III lol IIII II � I II II IIIII I I � IIII II requesInformation dcomplete <br /> It changes are needed . F.E. I. NUMBER request and complete <br /> 9r 00u9699A9990n6gp54p317500U999'3996Ci0pq <br /> an Employer Account r <br /> Change Form ( UCS-3 ). <br /> FOR OFFICIAL USE ONLY POSTMARK DATE <br /> El LE Erl <br /> �— — U5 Dollars j Cents <br /> 2. Gross wages staid this quarter <br /> (Must total all pages) � <br /> 3. Wages paid this quarter in excess of $7,000. F7, <br /> (� <br /> [ Qnlvthe trr l $7,600 pale to each envioyes Der l <br /> calendar year Is surijpci io Flotilla Unernfit oyrneril Tax .) <br /> 4 Taxable ssfor this quarter <br /> (Line 2 minus <br /> tin <br /> ll FF <br /> 1 . Enter the total number of full-time and part-time covered workers vvho performed 5. Tax due 9 <br /> services during or received pay for the payroll period including the 12th of the month. (Multiply Line 4 by Tax Rate) l l <br /> 9 . ........ ... . <br /> 6. Penaltydue ( l <br /> L.. ... .r , i. l ..i ' 1 t e .... . <br /> 1st Month i (Sea instructions) <br /> I <br /> 9 7. Interest due <br /> 2nd Month I ( L . . . . .1 (See instructions) — _:.Ll — 9 . .. .... ' 1 . <br /> I <br /> 9 S. Total amount due ( Line 5 + Lina 6 + Lina 7) L. <br /> rMale check payable to: Florida U.C. Fund l <br /> 3rd Month 9 _l Ci <br /> If you are filing as a sole proprietor, is this for domestic ( household ) employment only? .— Yes No <br /> Linder penaltiae Gf perjury, I declare that I have read this return and the Lads stated in it are true ( sections 443. 17115) and 443. 141 (2] <br /> Florida Statutes}. <br /> Title. <br /> Sign here — <br /> Phone Fax p, <br /> Signature crr iy -rlrDate ( ) ( ) <br /> a <br /> ......_ I r�reparar s Fraparer check i .. Prapdrei s <br /> gn r Lire itself-employe l S91J ,r PrIPJ <br /> Pai d ...... ..... <br /> .. ------- <br /> preparers FEN <br /> IJ <br /> Firm 's Herne (or yours Cate <br /> Only if self-empluyeU) — — `----- <br /> and adclross SIF j Preparer's <br /> phone number ( ) <br /> DO NOT <br /> TA_ CH .__ _ _ _ _ _ _ _ _ _ M _ _ _ _ _ _ - - <br /> DE <br /> Employer 's Quarterly Report Payment Coupon UCT-6 <br /> R . 01 /O8 <br /> Florida Oepartrylent of Revenue COMPLETE and MAIL with your REPORT/ PAYMENT. <br /> Please write your ACCOUNT NUMBER on check . <br /> Be sure to SIGN YOUR CHECK. fr DOR USE ONLY <br /> Make check payable to : Florida U .C . Fill — <br /> No number? POlSTMARKR N <br /> OAND QELIVERY DATE <br /> — <br /> UT ACCOUNT NO . i� C C n — a (See instructions.) <br /> —E -- <br /> F. E . I . NUMBER j, f . .....I f J l U .S. Dollars Cents j <br /> AMOUNT ENCLOSED 9 l [ _ 9 �_ _-_� --- <br /> (if less than $1 . 00 -- — <br /> no remittance is necessary ) <br /> PAYMENT FOR OTR/YR ❑ — — Cl <br /> Check here if you transmitted funds <br /> electronically. <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />