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i <br /> Exhibit " C " TO THE JOBS GRANT AGREEMENT <br /> BETWEEN INDIAN RIVER COUNTY & NEXT LEVEL SECURITY SYSTEMS ., INC . <br /> Uaebiaokink. Erarr IeA- Handwritten ExaIeB + T d Florida Department of Revenue Employer's Quarterly Report <br /> Errol are required to lile:quarterl j tulwage reports regardless of enploymett activity or whether atytwas'n due <br /> t © � � y L ❑L3 3'nMWIO UGT� <br /> Use Black Ink to Complete This FdrmT 8. 03/12 <br /> QUARTERENDIN3 DUE CATS PENALTY AFTER'DATE TmWE: UTADCDUNTNUMBS <br /> Do not make any changes Hyou do nothatre xv account rwmber you <br /> to the pre-printed ate required AD mo'ster(aee instrmtoreJ. <br /> 11111111111Illllllllllllllllllllll p " E <br /> °eEPacaoQco [1ao <br /> ChangeForm (UCS'S)• FOR OFROIALWEONLY POBTMABKDO <br /> Reverse Side Must be.Gompleted ❑ a 011 f Ll Ll H E <br /> Name <br /> Manln9 2 grass wages paid Itrta quarter n n n s <br /> (M <br /> Andress ust total,ail pages} f ) 4J <br /> ! � _ <br /> Gi�/SVZIp 3 <br /> Excess wagaspadthis quiter <br /> (See instructions) ❑ �� � ' . � � <br /> 4; Taxeblewages paid this quarter !� ■ J, <br /> Location (see Instruction's) El 10 11110 J] <br /> Address 5 Taxdue F1 ❑ �� � � '❑ FID <br /> O s o 19 <br /> CUy/SVZIP (Muldp Y Line by Tax Raj !J <br /> L, Penalty, due ! n <br /> 1 . Enter the total, number (�( (See instrucdonaj. ❑ ❑ IF].i_J 0 ❑ ■ El F1 <br /> cof ovetwtimeand ed workers whome ist Month F1 Ela l� FJ T: (See intdue 0.F1 � Q [1 L1 E] nit ■ 0 I i <br /> perfanned seMiees during ❑ Ell <br /> l ' ❑ I ❑ (See mswcu4nsJ' r� l _ J _ LJ �1 u <br /> oireceivedpayforthe 2nd 8. .Installmentfee (;�� <br /> payrd(period induc4ng the (See instructions) a ■ LJ El <br /> 121h of the month. 3rd .Month ❑ F1 0 F1 El El 8a: Totatamoorddue ❑ F] 0 �❑ 1111 !❑ a ■ a <br /> (See instructions) <br /> Check it final return: <br /> ILJDate operailons:ceased. 00 / I—io / ❑ ❑ LJ (Seeinstru ) ❑ 'Qo '�J ❑ L 1 ■ oLJ . <br /> r Check ifyou had.:outof-state wages. Attach Employer's <br /> Quarterly Report for (ut-of-State Taxable Wages (UCT-BNF). '�'» d are, filing as a sate proprietor, is ly7 fou <br /> domesvtic (household) <br /> hold) employment only? }�} YesNo <br /> Under penef tes of perjury, I dedare that I have read this return and ther facts stated in it are true Nections 443.171(5) and 443,14104, Florida Statutes), <br /> Title <br /> 7herePhone ; . Faxy Preparercheck Pnrperer's <br /> Paidsignature Ifsalf-errpbYed ❑. SSN ar P'T1N <br /> preparers FirnYsnarre (or:yours Date FEIN only If self-er oyeN P eperer s <br /> and address ZP <br /> . . phone nurrbarr C ) <br /> -- - ` - - -�- - - - - -- ' ---- - -^ "- DO NOT . _ __ __-- - - `-- - <br /> DETACH <br /> Rule soaszi 7 Employer's::Quarterly Report Payment Coupon UCTd <br /> Florida Administrattire Code - Re 03t12 <br /> Florida Departmentof Revenue COMPLETE and MAIL with your FEPORf/PAYMENT, DOR USE ONLY <br /> lease writeyour LIT <br /> T Pt,Aa�check payatile to R rid U CUFund ER on check... � ❑ J ❑ <br /> UT ACCOUNT NO. [I a_C] a [i ... <br /> Use Dollars CenLs <br /> F.E.I. NUMBER - L�} ❑ ❑.❑ (From Li WAGES <br /> bove:) !L ] E ❑ :[] 0 F! ■ E <br /> AMOUNT ENCLOSED Q 1 1 ❑ D E ❑ it `r ,J I I ; . 1111 <br /> (From Line 9b above:) � L—j I� (�! <br /> Nume <br /> EQNG MM/YY UARTER [1 11 W- F1 <br /> Mailing <br /> Address Check here it you are electing to Check here if you transmitted <br /> ; I pay tax due in installments. funds electronically. <br /> L <br /> 9 .100 0 99999999 00680' 54031 7 5009'999999 0000 4 <br />