sora. ETADCC8CO 24 8.02 BONE. SEQUCUOARLe ( es Oxford Verification Form Pleade complete and provide the following document along with the Certification Form and tax documentation requested, Please submit all documents through IDEA and do not submit such documents directly to Risk Management unless you receive communication requesting additional information. oo aac lwweles bres Email Address: ‘Phone Number: a | Employer Identification Number Ball zrien| Ofartenctndigysaor1asse | (es 2917 7; Boss the business have any fulldime eligible Smployees other than the owner and overs D-Yes 7. is your group a Professional Employer Organization (PEO), Employee Leasing Company (ELC), [C Yes* ‘or other such entity that is a co-employer, with your client(s), of cllent-site employees? “If yes, then | 0 No by signing this form, you agree with the following certification: | hereby certify that my company is a PEO, ELC, or other such entty and that only those employees that are the corporate employees of my company, ‘and not my co-ernployees, are permitted to enrol in this group policy. | understand that UnitecHealtheare vill not cover the co-employees under this group pal Common Ownership Please list all companies thal are eligible to be Included as part of a consolidated federal tax retum (even if they don't consolidated federal tax retum) or who are part of a controlled group as defined under the Internal Revenue Code. Business Name Federal Tax 1D # of Full time Employees On this Polley es No 2 tno Yes/No 4 Yes No 7 ‘check one of the following: | certify iat my business applying for coverage with UnitedHealthcare is not part of a controlled group (commonly owned or affiliates) as defined under the Internal Revenue Gode. or CL centity that my business(es) applying for coverage with UnitedHealthoare (1) is eligible to file a consolidated federal tax return or (2) meets the IRS test for being a controlled group under common contro. | further cortity there are no other afiated entities, other than the ong listed above, who are part of the controlled group that includes my business. | represen tha, fo the best of my knowledge, th information Ihave provided is accurate and truth. | agre to notiy LntedHeatncae inthe event of@ change in eny ofthe information thet isthe subject ofthis certification. | understand that any msrepreseniaton or fraudulent stalement may result in rescission ofthe group policy, termination of coverage, 8ninrease npromiums ettoactive othe poly date, o ober consequences.g8pesmited by lav. _ iccretorkia 3 A 97.2 ‘Glis\\e le be LO80Z6ELSZ9O L 7% "sova Wa €%:ZT g9tOZ ET “desNYS-45 Quarterly Combined Withholding, Home Pibacy — Secvriy' a Dleclalenae . Wage Reporting, and Unemployment Insuran,.. Page 1 of 2 Help NYS-45 Quarterly Combined Withholding, Wage Reporting, and Unemployment Insurance Return es ‘Transaction Confirmation “Tha Yor Sala Ta Doprtmin reeled pou tonestion * Salo Pinta pts contrat gaye for your rca Taxpayer Nowe’ BELUIZEI ENTERPRISES INC. + Slat View/Post Far a savor pint cy af the arm yu lad fr your eco Confirmation Confiaton nme Teensitondate/tina Quanee Employer egisation rumba, Par toe etn Por Boa wit 8) Pare taal wones Unemployment Insurance (UN payment details Paya mata Buk: ukroutngvumbee ‘sank acount poe ‘Accomnt Account hoi eam ees ue ate Payne meu et Payer sun BEBOPELELS VW TUMHowGatevay ve t “gov ormaraiauis o7raerore 12:08 94701-09730, 208 Ness 95.95008 2 23,725.00 tam.se 23,725.00 Pay from Ban Aerount ‘THE MAHOPAC NATIONAL BANK ontstis9e voxxxs289 Busines ceding Belize Enterprises ne THE MRMOPAC NATIONAL BANK XXXK8299, seyor/2016 oeyor/2016 85,00 25.00 7/26/2016 g9t0z-eT “desCOPY ge 241 for 2016: Employer's QUARTERLY Federal Tax Return savy (aay soe Eepeen Yee ony eto van te 8 1 erro n6| enorme 14 )~ 1 GIGIGIGIDIE te now eluate [BELLIZZ ENTERPRISES, ING Di tevewany Feoesiveren | | ewermepioy [Do] | | Ba ete f = Cl arcu, Anat, September a sccm [792 ROUTE 82 Cl eroceses rowenta, cncombur ff — = TEESE | | rooms menervestopsee (hopeweu junction } Cie] Ciesnacsey ]| [Saati dt He wy_| Lvs a on { ] | ood Teepe — ear Fed tha separate nsbuctons store you compile Ferm 941 Type o rin win the Boe, © " 8 > You MUST eamplte both pagms of Form 941 and SIGN ‘Aisa those questions foF this quarter. umber of smplayeos whe recelved wages ts, ér other compensation fer the pay period Including: Mor. 12 (Quarter) lume 12 (Quarter), Spt. 12 (Quartr 3 or Dee €2 (Quarter) 4 2 L___ 25,725 «_ 00) ages, tad ote compenaaon 2 Fed nen x tied rm wage, an ar comotndon a ais ne wagas, tise, and other compensation are aubject te ceclal security or Medicare tox —_L_] Chock and go torine 6. cohen Gobo Tenable seal securty wages . . [27S « 10] toe [294199] Thmale sec pouty toe. De Ov 26 c.00 Tenable tao wage ape. [Base 0] x 200» 8 Tonal wages 8 euletto [aston edere Yering 2] x ; ‘Add Column 2 trom lines 6a, Bb, Be, ard 6 tee i ‘Section 9121(6) Notiog and Demane—Tax dus on unreported pe ese nections) ‘Total taxes before acustments. Ad hes 3,80, 6d 8. (Currant quarter's dustment for fraotions of cents “ adjustmentfor sick pay . ‘Currant quarter ‘Gurent quartr’s adjustments for ipa ane group-term fe Iaurance . ‘Total taxen ater adjustments, Combine Ene 6 theeugh & Total deposits for this quarter, Including everpeyment spped from a prior quarter anc cveipaments apled from Form 84% Bt PA Hn oF BHA (5) en Ihe urrent quarter. oe al 5700. 3] ‘aiance due. If line YO%s more than Ine "1, enter the diference end see ineewevors .. , 12 a} ‘Ovarosrrent in #1 fe more than ne 1 enter the eerence T+ Oi}checkons: Clansrtominan, C1] seaarane ForPavacyAstand Paparuork Reduetion Act Hoi, seethe back ofhePaymart Vouchor. Cato tnt? Fem OAT ie. 207) 6680Z6LS79 “spva Ra pZ:2T gtozet'dos L iessozLy aT ap TESTON ADS TENT BELLIZZ1 ENTERPRISES, INC. et 839217, ‘Toll us about your deposit schedule and tox lal for thle quarter. you wre unvure about whet you are & monthly calorie dpeator ara semweoily ached of Pub jpsalior, ooo suction TT 1 chock one: (J. Ln 10m hs tus ie me 52500 neon rate the or quran an $450, You ot aa 8 'S¥00f05 exp Seaut abaaten ding tw srr ae rr maar an 0 ae Den teat & Sco mum Ju rst moc ¢ oe you won iny you moray anda, ete os Shae beeb yu ve snioeay tose tar ach sabwave 8 nf) So"OF es EE] You were a monthty sctculo depositor forthe entre quarter Enter your tax hey foreach moh an toa tally forthe quarter, thea goto Pat Textiailty: Month + 2m. 1 Month 2 li. 3d Month 3 1778430] “otal ably for arta 5,780 + 13) Total must qual line 10. 1 youwern » semiwoekly schedule deooster for any pat ef tls quarter. Complete Soheske 8 (Frm 841), Fepor of Tax Labi for Sersieoky Sohacule Depostlos and ateeh to Form 91 “Tallus about your bushoss fa question dogs NOT apply t you butnooe eave i blank. 18 lfyourbusinees ha closed or you stopped paving wouye Tor neo, ans starve final dateyoupais wages [27 +16 t1you aoa zeanonal employe and you de nothave ofl areumfor every quarter otthexear , . (") chee PEED re oe wth our rp ese? carr coma toe wx oD FW a OTT SAT [El ves. Desisnse's nee and phone number [GAROI. ANN MCMURDY,BA ( gosasz-a0u5 sacs ScigtPesona tortteaion unin fit oues wentaangtomnems. (HS) EL) On. Siri Va Tsong a pn oP om o B Under ets pf, cece Dit Pave aremined tha oy, ous tcorpanying aches bd aaa Soe Dat omy Mrvlecn ntl tl becom, and conpit Osc of rope tea espyed esas ona ronan ot wh Popa Pasty trea, re your Sign your J, ramenere [JAMES BELLIZZL Pint your ranwrere | Skint SE" sia mw ‘est caytme phone 845-297-8550 Fal Preparer Use Only ‘Seeck Tyo0 we warplanes w Prmweterane [CAROL ANN MOMURDY, BA, ea ponseaa03 rranesioate eal Glia Yee Vd EE) ome (7a ger) hen name (yur Seytameg" [CAROL ANNMGWURDY,ga dn ates 1938 NEW HACKENSACK ROAD Prone ACIS ony POUGHKEEPSIE, } sate LAY] a cove 12603) ie fa Fam BF fa OT, 006026LS79 L ie “sova Wa 0z:2T gtoz-Et-desDLN: oge27 114116 Employee Wage and Withholding ala aaa a eee eset i {Showing +2012 empotyous) Guarterty omployenipayae wage reporting bntormation a wage and sun total ate ds mite trannies Bas Pavet TO60Z6LS79 4 /3 “aove Wd SZ:ZT 9toz‘et dos£47] Ne Vx it Deparment of Tran and Farce Quarterly Combined Withholding, Wage Reporting, And Unemployment Insurance Return DUN: e4s27tid116 NYS-45 WEB Reference these numbers inal corrnepondence Lledo reat tee OE aBAGE ane wancer “164882017 Employer tagat nar BELLIZZ| ENTER?RISES INC, um of mpi Enter tha nunbac offal ara perch he ect ora ot ove poy fone sk at nde hoa do ofeach mosh Part A Unemployment inguranee (ul) information 4 Total emerson patti guar 2. Renner gal this quater Irexcass fe Ul go base a loge JBRuEY fens ‘ 3. Yges exec fo cotton [eobist ina romne 1) 41528. 5 Ro-anplormet serves ting (ieee 3 Soe) 5a, nBBLON RDU yn $5. Uproar ideas in Interest 7 tle 4,860 ai 4. Esler Ul peasy overpale ® Total ut amounts gua (ing 7 a [spasiotian tne 8 bole atorsice) 10. Teil Uovrpad ff ne Be avotar ‘han ine 7, te citer * An overpayment of either tax cannot be ui covered eroayees 23.728.00), 185.00] 208, Apely to outstanding atk an Xi ony one bot nate te quart (a sapere tetra mut becopsee Yor oben gunna and se 8 os Wants c= aprte =. day te Oat erst Meso 7) Bebo Riek 1 2 3 4 oyou ole dependent host surance bones 6 any amplayee? .... Yes fy No! mark an Xin the box 8 Fal onik | (8 Second marth [hire Secon er at 2 isaetor eit Part B-Withholding tax (WT) information 12, Now York State tax witibeld i‘ 1.281.584 43, Now York Gly tax withnsls g ai09} 14 Yorker ex wannons 48, Total tanita i: (Si ines 7,13, 0814) 46. WT geet fom prvious z : {Maron a S00 AEE) san bo #7, etm NYS-4 payments ‘erate 18, Toll aeyments (oa oe Bane 17) 18. Total We amounts cue fine 1516 - rete han no 8, ete roo) | 0.00) 20, Tol WT overpai tfna 19 8 {punter han ina 14 nme eros pene ‘ove snemark an Xin 200 oF 20 © 28. Credo nex ater ies andra ‘set ae 24. Tata payment toe eateeetesnsc a 605 to offeet the amount duo on the other tax. Part G=Wage Reporting Summary © Testu ot romunerabonigroes ROU Bl 8 GUA er Hi 1 Tle gross wages or dstbuton os | _ error 23:08:48: ZOGOZELSZO L /9 ‘a9va ai.r2h.: Toa number a employees : : i iE Taaltan tints "Si ne Tile als) (Ssupr. Wa Sz?@t stoz-eT*Sep.13.2016 12:26 PM ee : DLN: 84927114116 ions number ,F4AB3z2i7 ” Port D-Form NYS~1 corrections/adaltions Wed fled rot applicable Part E=Chango of businose information 24. yeu pormanontiy eo eying wages, enter tho date ODYY| of hes pepo 2% Du you tet ortanstir ao patatyourbuehess? “Yea ano Wee ndeate sl orcansawae in olor Pat “rips YD (e49)402.2946 it sof anloyad CHAMPION ACCOUNTING ‘Unemployment insurance (Ul) payment data ‘avon ete a : - jowovzots sicnai ~ aiaeee : i ou aie? + {THE MAHOPAG NATIONAL BANK oot91 396 ' asebiathai”— ae eee eee saben 200018299 } “pane aM eee 7. ! ‘Withholding tax (WT) payment details (Pecoone saved) Pay a [Ae 7 neo i oe ~ i ou er {wy ‘0.00, Transaction dotalls ‘catia sain eavarenaiie | sums 6F "CRROL ANN MCMURDY