Latil. (: Lfyourbusineeshasclssedoryaustoppsdpayingwrgoe I
Latil. (: Lfyourbusineeshasclssedoryaustoppsdpayingwrgoe I
Latil. (: Lfyourbusineeshasclssedoryaustoppsdpayingwrgoe I
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
Month 2
Month 3
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
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
Preparer's sigrlature
Address
":.**: i{t},.te]l{i g<1 J:9-HV<-a<
Fhone