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Exhibit " C" <br /> ,Use'dackink .Exempla-A-- Handwritten EicempleB - Typed Florida Departiment .of Revenue Employeft Quarterly Report <br /> i r,mm , A .gym 9B Employers areiequ116d, :file quart erlytax/wagefeportsregardlessofempleymentactivityorwhetheranyfaxesaretlue. <br /> Dal� � o Nora ❑ gPMMUD UCT 6 <br /> T <br /> . R . 01/08 <br /> QUARTER ENDING' DUE DATE PENALTY AFTER DATE TAX RATE UIT ACCOUNT NUMBER <br /> ❑❑ / ❑ ❑ Jo❑ o❑ T -7 ❑ T ❑ ❑ ❑ T ❑ <br /> Do not make any iihanges !I you do,nof have an account number you <br /> '10 the'preytdided are required to moiste►(see Instructions). <br /> III III IIII I II IILI) II IIID I II III) II <br /> Information.n onlids lortn. . <br /> N changes are needed. <br /> request.and complete T.E. I. NUMBER <br /> 910009999999900680540317,500999999900004' %an Ene'Forra (VC .4 ❑_.❑ — ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Change;form (UG33). <br /> FOR'OFRCIAL USE ONLY POSTMARK DATE <br /> tr , ❑. ❑❑ ❑ ❑ ❑ ❑ <br /> fx� letVr� � G ;1. � � <br /> 11 <br /> USDollars Cents <br /> G itp, cr is { <br /> 1I 2. Gross wages psi e ) quarter ❑ '� ' ❑ ❑ � ' ❑ ❑ ❑ . ❑' D <br /> (Must total all paggess)' <br /> 3. Wages paid this quarter in excess of$1,OOD. ❑ ❑ a ' 9 ❑ ❑ <br /> oc.>rit�rt (Only the tir,t$r p00 paid io each <br /> errployee per ' <br /> +w�d� sus calendaryear.is subject to Florida Uneirploymerii Tari.) <br /> fir; x `f a s. Taxab21 Fnin es fm this'quarter ❑ ❑ ❑ ' ❑ ❑ � ' ❑ n . ❑ ❑ <br /> Line.,21 mints Line 3) I� <br /> 1 . Enter the total number of full-time and part-time covered, workers who performed 5: Tax due ❑ ❑ ❑ ' ❑ a' ! ❑ ❑ <br /> services during or received' pay.for the payroll period including the 12th of the month (Multiply"' Liiie '4 by Tim Rate) U <br /> 6. Penalty due , <br /> 1 st,Mortth ❑ ❑ . ❑ ❑ ❑ (See instructions),7. Interest due <br /> . <br /> 2nd Mottfti ❑ ❑ � ❑ ❑ ❑ (See instructions) u <br /> 7 B. Tote4 clikk.d due elos S + Lina BCUnn d ❑ ❑ 119 _❑,❑ ❑ , ❑ ❑ ❑ . 110 <br /> 3rd :Moidh ❑ ❑ ❑ ' 1111 . 11 <br /> Makeisieckpayableto: Ronda UC. Fund. <br /> if you are filingas a sole'proprista; is this for domestic (household) einployment only? ❑ Yes ❑ No <br /> t, PL�W <br /> Under,penMEMEN alties o(perjury, Ideclarethat f have read this return and.the.facts stated`in it are true (sections 443.17.1 (5) and 443:141 (2) RoridA <br /> Statutes). <br /> Title, <br /> Sign here <br /> Signature of officer Date; hfigl9 ( ) Fax ( ) <br /> 'rteparer's Preparei check Pieoerer�s <br /> signature - ' ifself-employed ❑ SSN' orPTIN <br /> Paid <br /> preparers Firm` deme (or, yourDate: <br /> FEItJ <br /> only itself-emplOYecfy ate: <br /> end address ZiP P eparers <br /> 00hen6mber ( ) <br /> _ . <br /> DONOT _ <br /> Employer's �Quarterly iReport Payment Coupon UCT 6 <br /> R : 01108 , <br /> Florida Department of Revenue COMPLETE and MAIL with your REPORTLPAYMENT <br /> Please write:your ACCOUNT 'NUMBER on. check, <br /> T Be sure 4o SIGN YOUR CHECK. DOR USE ONLY <br /> Make checKpayable to; Florida U .C. Fund <br /> ❑ P E <br /> UT ACCOUNT NO. POSTEaARKOHnA►ao; Fly <br /> r uve 'DATE' <br /> No nrunbe/! <br /> (See InstiucHor) <br /> F. E.I . "NUMBER 1111 <br /> ❑ – ❑ 1❑ ❑ ❑ A❑ ❑ ❑� <br /> us. ;oollars –j I Cenft <br /> AMOUNT 1' SED <br /> (if tesT1 ❑ 111100 <br /> ❑0 ❑ ,[ ❑ F1 F1 F1ti dian �i`.tl0. <br /> no remittance is, necessary) <br /> t�stxta <br /> ttiei,lrg PAYMENT FOR 0TRnFR '❑ — ❑ ❑ <br /> c ass' rr "' l ❑ Check, here if ou transmitted funds <br /> - t< electronically, <br /> 9100' :0 9999999'9 00680:54031 7 50.09999999 0000 4 <br />