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Exhibit " C " o UCT-6 Form <br /> Florida Department of Revenue Employer's Quarterly Report <br /> o E sA a 0 �HBe `, EmpIoyersare required tofile quarterltaK/wagerepels regardless ofemployment arNiyorwhetherany taxes are due. <br /> L 103-3, F� 3 lernn_'D -6t;MWI� it � UCT-6 <br /> ink Example L man P Yoe <br /> R. 01/07 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> Do not make any changes dyou do not have me second number you <br /> to the pre-piloted are required to register (see Instructions). <br /> IIIIII I III I II III II II VIII I II IIII II Ifchang s re ee loan. <br /> If changes are needed, <br /> request and complete FIE I. NUMBER <br /> an fmPlaYerAccoun! l � ] d <br /> ChanDe Form (UCS-S) I <br /> FOR OFFICIAL USE ONLY POSTMARK DATE <br /> US Dollars Cents <br /> 2. Gross wages paid this quarter �l (— I� ( <br /> (Muss total wages <br /> pages)aid This <br /> IL Ill <br /> 3. Wages paid this quarter in excess of $71000 1 <br /> " (Oak to first $7000 pat to each employee par <br /> _ <br /> weakerY®r is su bleat to Ronda unempiWt Te <br /> menx ) . ( f <br /> 4, Taxablewages for this quarter i <br /> (Line 2 minus Line 3) <br /> 1. Enter the total number of full-time and centime covered workers who performed 5 Tax d(Multiply Line 4 by Tae Rete) <br /> (— <br /> sernces during or received pay for the payroll period Including the 12th of the month. Il <br /> � I 6. Penalty due 1 — y - — <br /> 1 ;IMonth 7 1_ (See instructions- , 7CC , ICC . � <br /> - - - � � L7. Interest due - - <br /> 2nd Month (See instructions) <br /> 8 Total amount due (Lim s . Line 6 . Line 7) - - <br /> Make check Paya <br /> 3rd Month <br /> If you are filing as a sole proprietor, isthis for domestic (household) employment only , J Yes I No <br /> Un 1_1 pinnitc,. .. _- jury _Izzl ha4 I eru h,., 7r , . , P. 1 . 11.> ! 7 1 r alk ^ 1 1 F ri=1 4 <br /> Sign here ITitle <br /> S21 � c o (Fsr _ Date Phone Fax - <br /> Prepaner's Praparercheck ( Preparers <br /> Paid signature if self-employed SSN or PTIN <br /> preparers Firms name (or yours ' FEIN - <br /> only it soff-employed) _ _. -.. Date -...... <br /> and address _ . . _.... _ _ - ........ - - . -. ..._ _..... <br /> Zip Preparers <br /> Phone number <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ ._ _ _ _ _ _ - . DO NOT <br /> Employer's Quarterly Report Payment Coupon UCT-6 <br /> R. 01/07 <br /> PtondaDc-p anent of R�venue COMPLETE and MAIL with your REPORT/PAYMENT. <br /> a� Please write your ACCOUNT NUMBER on check. <br /> Be sure to SIGN YOUR CHECK. Y <br /> Make check payable to'. floridaU-C Fund <br /> Fund 11 -11 / I �E� --- �) <br /> ._It— <br /> UTACCOUNT NO ) - -I Nonumber7 ERY DAM � <br /> 111 111 (See fnstrucflons.J <br /> F.E.I. NUMBER I I I 1 <br /> LJ J —I ._I i U.S. Dollars Cents <br /> AMOUNT OENCLOSED <br /> (iL , J J E <br /> ' LJ . <br /> no remittance Is necessary) LJ <br /> -j "nxF I PAYMENT FOR OTR/YR <br /> s= <br /> „a <br /> 1 Check here if you transmitted funds <br /> Lelectronically. <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />