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Exhibit " C " <br /> Florida Department of Revenue Employer's Quarterly Report <br /> 012345 £ 789 UCT- 6 <br /> R . 01 / 11 <br /> _- <br /> i <br /> Do not snake any c0anges It ym de not hire an aecmmi number, you <br /> to the pre-prinled are required to re0lsfer (sec rnetruc Nons; <br /> Inionnation on this form FF I NU'41KIP <br /> . <br /> IF changes are Wedded <br /> regu" I and complete an <br /> Ernpin ycr Account <br /> Change Form IUCS- 3i . FOROFFICIALDSEONLf pORI41d. VATE <br /> Reverse Side Mast be COHIPICted <br /> Name <br /> Nil a,Dnu <br /> ety st;� iea <br /> � Y <br /> ,TqtFI,FpIm IFFF III - <br /> Location <br /> Arica rcys la. ; -�e <br /> Gtlyr!';L'Zlla � . 1 7 <br /> SI=. <br /> IF <br /> IF <br /> r 3rT ?'c • .� telae an�unt tlur <br /> n Arnc�nt CndazM <br /> F . a. . U I .;�a ' P ri .-, AFtfjuIilr �. Fo > el'` It .n� r rna,. � if .,r„i. •?LJ• u, rh� sfoV <br /> 7 , .r. Lru . Ar ar, : . . ,<) , ) A. 1 ai?4t-}. - t „ ,;c; , I sihc; r '. T". r r rr• <br /> j � ..if:S : No <br /> . . . . . .,. <br /> J. <br /> rt i �r:re I <br /> PhoneF nx� r <br /> I <br /> Rmd .. <br /> IV N <br /> t111y ..._ . . . . .. . . . I ' <br /> J.( <br /> �t 1• <br /> DO NOT <br /> - DETACH <br /> Auk 60HH - 2.037 Employer's Quarterly Report Payment Coupon UCT-s <br /> Honda naministraGvu Cada R . 01 /11 <br /> Oji,?PLCTE i1idHIL I�h rot FEPr RT'eMrb1ENT. DOR USE ONLY <br /> F,41 VIFIFF ,. . � f e, CSFs tlh o%.r UT xi XON1 N (JIMAiLk nl ChRgts. <br /> I <br /> tllake OFPcft, rx% yable t0 flot{da U.C. FUnd t*OSTMIARK 0R HAt*'O OELtVERy 0ATE 11 <br /> UT ACCOUNT NO. - --- U.S. Doliars - Cents <br /> F. E . I . NUMBER GROSS WAGES <br /> AMOUNT ENCLOSED - - <br /> IFTzzwitrn[- 9n m :r,. f L � 5 <br /> IF PAYMENT FOR QUARTER <br /> LNDING A1tA4. YY <br /> M9ilinp <br /> Addra �s Check h „ re � f you al:�t tnlq tc Cheek Y; �re rt yc:,t tralrsanittO:J <br /> C dy7St: ZIP ' Pa _7lax dar<_. :n irsta '. Hants . funds ele�tranlc ailq <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br /> - 12 - <br />