350el,q

your trade naml

FOUNN&?IOI.J FOF. LATil.[ A}'{JIRTCAX A}';T:{ROPOLC 23 -7 04E] 45
Palt 2: Tell us about your d*pssat scheduls *Ed tax liability for thie quartsr.
]f you are uil$ua? about whBther you ar a ffiorltfily schedule depositor or a semiwsekly achsdulG deFssitsr, ece xstlon {'l
af Pub. 15.

r::1
1 4 Check one: | -\ J Line 10 on th is Gturn is less th6n $2,50G or lirle | 0 on the retum for the prior quarter wa$ less than t2,500, and you
didnotincura$100,000noxt-daydepositobligetionduringthecurrefllc!uerler. lf li:rel0fortheprl*rquar\u',,ruaslesg
- thanS2-5lScutlnel.C ctihigre:urnisS.l00OCt$/fi\$e, you-rlusrprcvidearecordolyourfederal taxlrability. llyctar*
aoronflrlyscned.,jedeposrtlr conlpieternedBposrtscnedl.r,ebelc'ai: ;{y-ouateeremiv;eellyscheduledepcsillr attach
Schodule I tForr *41't t)c lc Part 3
j_ jVou*glssrnpnltrlyscheduledepositcrlortheentirequartsr. enle;'1*tt iariiafrlrll'irreacnrnottha,1dlOtal
ir*lrility f*r l*e quatler, tirer] gi* io psrt 3

T*x liability: Month 1

Month 2

Month 3

Total liahality for qualtsr Tetal must *qual llne 10.

You were a semiweekly schedule depositor for any part ot this guarte,.Con:p1ete Schedute B iFornr 941]
Report ';{ 'f ax Ltaf;ility li:r Serriweekly $cfiedriie Depo$itDr$ ard attach ri 1o Forry S.t1

Part 3: Tall us about your beEin*rE" lf a qu**ticn dqes hlST apply ta yq{rr buclnpss! lsavs it hlanki---_"r
t$ lfyourbusineEshasclssedoryaustoppsdpayingwrgoe I lCnecxhere.and

eBte{ li}e finai date yeu paid vrages

t6 lf ysu aiB a sea$onai Bmploysr and yo* do not havs to fils a rturn tor evBry q,uarter of tho yesr Cherk lrere.
Parl 4; May we speak wifr? yaur third.party designee?
Do yo* $ranl to alle$, En employee, a paid ta: prep*rel; or ancther person to digisu*s thi rsturil with the lR$? See ,nsiluctions for detarls

Yes De*ignee'$ *eme aftd ptrrsfl* r]limber i:.t)1.'l/ ?aFq"lL:'7 ; HlI.,DS 4:-9-893-337L
Sel*ct e 5-digit F*rsor'r*t 1{Ssntifi*arion Nuritrsr 1plN, tc rs.e !,/nen ti:l;.irg t* the tR$. tgsSc
[ **
Part 5: Sign here. You MUST complete both pages of Form g4'1 and SIGN it.
Under penallres oi perjury. I dec:arE thai I lavs exarriieC th,9 Igl*rn, rr:ciuding accuilpaiiyrng senedules and sleteff*nts ard lo the fiesl ol .n'y
knuwludgs ard t eiref, it z$ irre. ;orreci &ld co,nplel*. Dcclrr$tren *{ loiher thrr laxpay0.l it br$ed rln ill infn.mtliAn o{ srhich prflf}?rer
Das any knowlegge.
*rinl yot:r

> Srgn your {\av-\* {efU NrehEtas fu llno(h

name here Frinl your
tille hcre ?reo,Jr^l
a izlr Eest da,'tific pirc'fle t tq - 8 L3-1zt g

Paid Preparer Use Only Check ii you are sell-enrployed

Freparer's rame I,1a ri l. r*n ?g'q:m.b] y ?{JL3 6 012 0

r3l IN

Preparer's sigrlature

Firm's naRre (*r t$urs

if slf-employed) Xti*k., Y',,*rszzit*.h & !-li&ds :n.. ilN 1.4.".)O4ra.Q

Address
":.**: i{t},.te]l{i g<1 J:9-HV<-a<
Fhone

i!'ia ili:n* 4353"f *\622