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Exhibit "C" <br />P126 <br />Florida Department of Revenue Employer's Quarterly Report <br />UsA Mick ink. Eympl;,A - Klin0writtion Lxarnf:A�, 13 - 1yPCKI <br />E <br />Emplr-yets are teWred to fi:e quarterly taylivae repctts regvdless of erriWlioy.-ient acWty v Whether any taxes are due, <br />lbumlleA E�m fie B <br />U -9RT-6 <br />01 2 3 4 5 6 7 8 9 012-34, <br />Black Ink Foroi <br />R. 01/15 <br />T <br />C:JART-L P [W -NIG ULC DA:rE <br />pflll!.;FY Af I -LF*. LWE RLT[' RT ALr,,X1N1 NUVEJ[P.lIl <br />Do nal make any cliangetz ffyoudo nothave allaccourritnumbar you <br />Il <br />I'll' <br />II <br />Ill <br />Il <br />�� <br />1iIII <br />l <br />I <br />lli <br />) <br />to thp pre-prhtled are mquiried to nagister (see lrtstructiilns} <br />infainaiion m, the loam. Ft !, IdL".4C�f <br />It changes am nailed, <br />FXXIMM aid C0111I)WO An <br />Employor Account <br />ChangeForm(RTS-3). r0A0FF1CXUSE6XLy"5TK4jK6jfE <br />0 - <br />di <br />ci', ?SWI P <br />1�eo if, F U <br />Tzx it <br />tn, -4 by.t'al'l a <br />En;o <br />1% <br />ps; f R, Isl Minith <br />wv f-" ho <br />Peefurow %,HV,4,5 <br />211d Month <br />11 rmvwed (0.ffor Vic <br />12 in of th" Montt, Std Month <br />Va. ictal filmouril de^ <br />I h <br />Check if final return: <br />Oate <br />U.. Amount Efidilled <br />opeialims coased. <br />Chick if you had out -of -slat,, wages.. Attach Ftrpbyor's <br />Ifyl firing ll <br />rXi al as 2 �;ole ploprioor' is fill!; fix <br />Quattcy,�, Rr1w)rl fur Out -of Shite In-xibA, ilVarx-s (141-61NIF). <br />doirneMic (hivisehold) ein0ayinent only? <br />Yoz No <br />Sign here <br />Phone Fax <br />t <br />Paid <br />preparers Rw'zlomw lor ywm <br />WN <br />only ItteA-erriplowc.) <br />DO NOT <br />- - - - - - - - -_-^•_-_.-._...._---- - - - - - - - - - - - - - - - <br />- - - - - ------------------- - - D'r;TArR - - - - - - - - - - - - - - - - - - - - <br />TcRule 732-10.037 Employer's <br />Quarterly Report Payment Coupon RT -6 <br />Florida Adrillidatrafive Code <br />R. 01/15 <br />Efflictive Data 11114 <br />COMPLETE and MAJLv.ith <br />your REPORTiPAYLIEW <br />7 <br />Please -,%rrite your FIT ACCCUNI NUMBER on check <br />dr, <br />14ahe diepayable to: Rmida.VC fund <br />L <br />FIT ACCOUNT NO. <br />Cents <br />F.E.I. NUMBER <br />GROSS WAGES <br />(Ft(xn Line abovu.) <br />AMOUNT ENCLOSED <br />(From line 91.) above.) <br />PAYMENT FOR QUARTER <br />ENDING MM/YY <br />Check here if you are electing to Check here if you transmitted <br />pay tax due in instaliments. funds electronically. <br />91,00 0 99999999 COL8OS4031 7 5009999999 0000 4 <br />P126 <br />