UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter 11 Debtor / DEBTOR'S NOTICE OF FILING PAYROLL AND SALES TAX REPORTS ______________________, Debtor-in-Possession, ("Debtor") pursuant to Local Rule 2081-1(A), having filed its Chapter 11 Petition on ____________, (the "Filing Date") files its Payroll and Sales Tax Reports as follows: PAYROLL TAXES: I. Payroll taxes accrued for 1st month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ II. Payroll taxes accrued for 2nd month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ III. Payroll taxes accrued for 3rd month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ IV. Payroll taxes accrued for 4th month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ V. Payroll taxes accrued for 5th month prior to filing Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ VI. Payroll taxes accrued for 6th month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ ________________ VII. VIII. Amount still due and owing for six month period preceding filing:________________ Amount still due and owing for earlier periods: ________________ LF-78 (rev. 12/01/09) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SALES TAXES: I. Gross Sales subject to Sales Tax for 1st month prior to filing: ________________ Sales taxes accrued for 1st month prior to filing: __________ Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ II. Gross Sales subject to Sales Tax for 2nd month prior to filing:________________ ________________ Sales taxes accrued for 2nd month prior to filing: Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ III. Gross Sales subject to Sales Tax for 3rd month prior to filing:________________ Sales taxes accrued for 3rd month prior to filing: ________________ Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ IV. Gross Sales subject to Sales Tax for 4th month prior to filing:________________ Sales taxes accrued for 4th month prior to filing: ________________ Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ V. Gross Sales subject to Sales Tax for 5th month prior to filing:________________ Sales taxes accrued for 5th month prior to filing ________________ Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ VI. Gross Sales subject to Sales Tax for 6th month prior to filing:________________ Sales taxes accrued for 6th month prior to filing: ________________ Date Paid: ____________ Amount Paid____________ Place of Payment:__________________________________ VII. VIII. Amount still due and owing for six month period preceding filing:________________ Amount still due and owing for earlier periods: ________________ Attached are copies of proof of all payments made for payroll taxes and sales taxes for the 6 months preceding the filing date. I, ______________________, president of ___________________________ declare under penalty of perjury that the foregoing information is true and correct to the best of my knowledge, information and belief. Date____________________________ By____________________________ ______________________________ print name of individual signing A certificate of service complying with Local Rules 2002-1(F) and 2081-1(A)(3) reflecting service on the U.S. Trustee, the Internal Revenue Service, the Florida Department of Revenue and any other taxing authority named in the report must accompany the filing of this document. LF-78 (rev. 12/01/09) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2