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'fa(Gfifomia STATE OF CALIFORNIAKCAU Int KCVtKJC alL)C IStr�KC I.VMI'LCIIIVV IRIJ FLr%Jr1. <br /> AB--REPORT OF WAGES., A. CHECK ONE OF THE BOXES BELL, jO INDICATE THE TYPE OF SUBJECT WAGES <br /> iSE TYPE ALL INFORMATION YOU ARE REPORTING ON THIS PAM. (SEE INSTRUCTIONS FOR ITEM A.) <br /> B. EMPLOYER ACCOUNT NUMBER <br /> 243'672n a 1. ?� UNEMPLOYMENT INSURANCE (UI) AND DISABILITY INSURANCE (DD WAGES <br /> '�1'Jz�1 f1I'IO'.IP 2. Cl UI WAGES ONLY(RELIGIOUS EXEMPT, SOLE STOCKHOLDER, PUBLIC ENTITIES) <br /> Sylvia :`(arlowe <br /> `3r1DTlG' ?ZO7e? ytC'S -3. CJ DI WAGES ONLY (SOLE STOCKHOLDER, ELECTIVE COVERAGE, DOMESTIC SERVICES) <br /> . 0. Bos 159211 <br /> :� iTl +'3i 1L'Z, CA 94915-0211 <br /> 4. 0 UI AND VOLUNTARY PLAN.DI WAGES <br /> ENTER GRAND TOTALS ON PAGE 1 ONLY E ij1JUP LQO <br /> �U � <br /> Fr,a, in the above spore !Im enptaya. name cM businm address exactly as J. Tosal pop"of the .Pa„ K. Grw4 Tots—Aft Papa c 0 If'M <br /> I{ <br /> shown on Form DE 3 kj"�"o th6 p'p'-w Wags Paid The Q"w <br /> my oonlir-Kom pep". <br /> { DATE 27,111.25 <br /> QUARTER <br /> ENDED December 31, 1700 <br /> )EPT, E. SOCIAL SECURITY F. EMPLOYEE NAME G. No.of H. TOTAL WAGES PAID <br /> USE ACCOUNT NUMBER first wtid i0a Name Wks. THIS QUARTER <br /> 5>j?--45--1112' T,. Fenner 13 3350 23 <br /> 331-09-71019 16. �'rav -lu 2 255 <br /> 553_94--5139 3.?1e 1iz; 13 2-896 �1 <br /> J. Ga110wav 13 2225 31 <br /> 56`'•-5.:3-7360 S. Oallowa7 2 150 50 <br /> 506--02-2342 A. Orn*a 13 1509 35 <br /> 53i-3Q-5�c` 5 - iron 13 U724 50 <br /> 511-71 5552 T.-in_i'1 13 1320 4 <br /> 555-00--7232 .J. 'Iarl.gue 13 80Q5 -37 <br /> 572-310--.3531 T <br /> 31-25-> 57 i 3 c?.Lir 13 337 35 <br /> � <br /> 'i-32-5795 7 i1cl air 13 19 <br /> :i5—i+9-11=;n 710iso 1 13 391 23 <br /> i <br /> k <br /> I. Total of this page only. (ry <br /> i <br /> t DE 36.Rev.23(1-M Poge No. <br />