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Exhibit "C" <br /> Roridsvepartmnt of Revenue Employer's QuerteriyleW <br /> pyery �erequl�ediofileUuart�iYtaxh'!8gewaft reg dwo*VA" lorwhether " um a-mIda <br /> WWII <br /> QtWATER ENDING twE DATE PENALTY AFTER DATETAX RATE UT ACEAUNT NUMBEtT <br /> HCl / 00 / [ Cl __�__�__ _� ` DIEI <br /> Corwtmakearyahan� aye,idor� tmr!e� atoa+ntnunmeKtali <br /> . ` theme-prl?�ed arem ��egfieebr�+�n�. <br /> I� IIIIfil� lll �lllllllllillllll� ll - � � � � � � � <br /> Chsrag Fmmp Mw3S -fN AL0Vft <br /> �itpTE <br /> � �w�e e Mu b� Cbin- E � c� � <br /> Qui El 1111110, EID <br /> m0 <br /> Lot"" ''iD LJIf�T <br /> GNyl8tixiP 5, . LareabyTa><:Ratd ' Q � ,., o% QE1 � • oD <br /> Addoess- E <br /> t. EctiiterrihewetroMtNv�resanbe� ' 1st Month � �}���L.''##!(( � O 7&. ii5neetea�hutnlweMctuaas <br /> l y0 <br /> 0� 00C� QC <br /> pe6* 0 , 401rlEl0 EI <br /> [IDE Q0 <br /> aeedGNroforsd " 2nd Month n <br /> ; <br /> 121heof the <br /> peyromanlh,ftrft ingthe 3rdMotxh [10 ��,L � 8a : TaNAaa e i • �`'"� <br /> re <br /> t <br /> 0 <br /> Cheek°mooed. E1Fl/ o/E1EJ0 000 ,1111 . Don . o1 <br /> Check N you hed cus Wstate wages. ANaoh Empfoyer9 If you are.fating as a sole prnpdetor, is thtsfa <br /> (� [ <br /> ' (�uaRerfy RepoYt fa, Oitt-fl/-Sfax TdxpDfe bYegeg (t3GT 6t iE}• CT' .6 4ftn" o Qwus0mkQ ernpkmp d onWl LjYbs . Nc <br /> lJt p orPe a� td.Clerezh ltrmrireed brs rsiaMflh4t 9 leq kers tern"(9-- ILLa44 t1r 4s<3Ilt( . # afda <br /> Sign here <br /> orotTa�er <br /> Phane Pax <br /> Pnq>srer9 Preparecehadc , <br /> Slow <br /> Ns�lemWcYeOIwPTIN <br /> Palet <br /> preparers Ft m"s mm(or 7Nura: F tn1 . . . . <br /> only HsdremPwredl >aoparers <br /> end adOress ZP numtror s { l <br /> DETACH <br /> Employer's ttu�tdariy Report Payment coupon <br /> UCT-S <br /> A an.ecode R. Oi/11 <br /> FW*.Dep p qitt 0fAeWWI MMPWE"and MAIL with your REPORTA%YMENT i E DN{ yr <br /> Please write your UT ACCOUNT NUMBER on ched , <br /> Make ehem payable to �'Jt auuti c/ art Nt► Lnteltr`"(a+as <br /> U!GTUT ACCOUNT NO: �--`— --"— U S ITolFeea---i Corns { <br /> FE {. NUMBER; rt �O 81N e,l � � +� 00 . 011 <br /> AMOUNT "CLOSED: . <br /> E001" 1111C 0 <br /> (F'roln Bite 8b above.? � <br /> PAYMENT FOR QUARTER (' <br /> ENDING'MMM L J OIL <br /> mao* <br /> Address <br /> Q Check here N;you are etebtMgi. to Cheek here N you transmitted <br /> pay tax. due in instalimer>t ., El funds electronicaiy <br /> LL <br /> 9100 <br /> ' 0 999999 9 L0068054031 7' 50'09999999 0000 4 <br />