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Exhibit " C " <br /> Florida Department of Revenue Employer's Quarterly Report <br /> r <br /> �rilO!l)}��, lt' Ir.',QIP •. dd (O � I� r iJ it ldl k iN � VFlel eGt ! lo lr,Q (jl I ! � : e.11er( lli � lflll i'll. =ar <br /> (I 11 tv 014VrIrl �1 �I dCij+ ( � . . , %Jf r-, (jUB. <br /> III <br /> 0123+456789 UCT-6 <br /> R . 01 /08 <br /> QUARTER, ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> Do not make any changes 11 you do not have an account number you <br /> to the pre-printed are required to register (see instructions). <br /> III III IIII I II III II II III II I II III I II information on this term . <br /> It changes are needed . FE I. NUMBER <br /> request and complete <br /> , , , L „�L� . dOD; an Employer Account <br /> r . ,. On_i <br /> Change Form ( UCSm3). <br /> FOR OFFICIAL USE ONLY POSTMARK DATE <br /> --- US Dollars - -- Cents <br /> ?. Gross wages Laid this quarter <br /> (Must total all pages) <br /> 3. Wages paid this quarter in excess of $7,000. <br /> iOnlJ � iui1' w i I a;laitloy � ' � � . <br /> ;'�nani 111P3nr, sill J h� I t"11I , Uiu� ra> nhnen lax ) y • -. <br /> 4 . Taxable wages for this quarter <br /> � . <br /> (Line 2 minus Line „ f <br /> 5 <br /> 1 Enter the total number of full-time and part-time coffered workers who performed . Tax due <br /> (Multiply Line 4 by Tar Rate) <br /> services during or receiced 1!r for the loll period including the 12th of the month - <br /> - P fay <br /> 6. Penalty due <br /> 1 st Mrnth (See instructionF' ) <br /> I <br /> ■ <br /> 7 ? <br /> 7 7 . Interest due <br /> 2nd Artrnith (See instructions) <br /> e ' ! 7 <br /> E. Total amount due ,( iia l + L �, r r Low 71 <br /> Make check payable to: Florida U. C . Fund <br /> 3rd Month 7 <br /> S <br /> If you are filing as a sole proprietor, is this for domestic (household ) employment only ? _ Yes No <br /> iexl Chis Iietum ani the fit L ,t,aed m It ara tnie Lrtiuns 43171 ( 3) and 443 14h2 ) Florida Statutes ). <br /> Title <br /> Sign here <br /> Phorl Fax <br /> 1 11 IF ji <br /> i ,: ri r lar cre 1: Fi dI r a <br /> it ^cIt carie .Ir Pr IfJ <br /> Paid _. <br /> preparers - ,� ij � a F- IN <br /> Only -- <br /> a _ rirs 31F' <br /> phua n .un`, , r 1 i <br /> DC NOT <br /> DETACH . <br /> Employer 's Quarterly Report Payment Coupon UCT-s <br /> R . 01 /08 <br /> n s .; pritru n . t � ? nu COMPLETE and MAIL with your REPORTJPAYMENT. <br /> T Please write your ACCOUNT NUMBER on check . <br /> Be sure to SIGN YOUR CHECK . - DORT USE ONLY <br /> ke check payable to Florida U C ._j and <br /> No uFF051 MA� <br /> r <br /> + a number? RK OR tiANY) fiECtVEftY DATE <br /> UT ACCOUNT NO . — (See instructions) <br /> F. E . I . NUMBER <br /> .... -- - U .S. Dollars ---- - --- Cents <br /> AMOUNT ENCLOSED <br /> (if less than $1 . 00 <br /> no remittance is necessity } <br /> PAYMENT FOR QTRNR — <br /> Check here if you transmitted funds <br /> electronically . <br /> L <br /> 9100 0 99999999 0068054 031 7 5009999999 0000 4 <br />