EIN Name Control Business Name 1 Business Name 2 Address 1 Address 2 City State Zip Code Agent Name Agent Title Contact Name Contact Title Phone Number e-Mail Address Signature Name Signature Date Account Type Routing Number Account Number End of Period Employees Total Wages Total Tax Withheld Wages not Subject to SS/Medicare Taxable SS Wages Taxable SS Tips Taxable Medicare Wages Current Quarter's Fractions of Cents Current Quarter's Sick Pay Current Quarter's Adjustment for tips and Group-Term Life Insurance Current Year's Income Tax Withholding (941C) Prior Quarter's Social Security and Medicare Taxes (941C) Special Additions to Federal Income Tax Special additions to Social Security and Medicare Advanced EIC Total Deposits Deposit State Seasonal Date of Final Return Monthly or Semi-Weekly First Month Liability Second Month Liability Third Month Liability Refund or Apply to Next Return ( for Overpayment Only ) SBM1D1 SBM1D2 SBM1D3 SBM1D4 SBM1D5 SBM1D6 SBM1D7 SBM1D8 SBM1D9 SBM1D10 SBM1D11 SBM1D12 SBM1D13 SBM1D14 SBM1D15 SBM1D16 SBM1D17 SBM1D18 SBM1D19 SBM1D20 SBM1D21 SBM1D22 SBM1D23 SBM1D24 SBM1D25 SBM1D26 SBM1D27 SBM1D28 SBM1D29 SBM1D30 SBM1D31 SBM2D1 SBM2D2 SBM2D3 SBM2D4 SBM2D5 SBM2D6 SBM2D7 SBM2D8 SBM2D9 SBM2D10 SBM2D11 SBMD12 SBM2D13 SBM2D14 SBM2D15 SBM2D16 SBM2D17 SBM2D18 SBM2D19 SBM2D20 SBM2D21 SBM2D22 SBM2D23 SBM2D24 SBM2D25 SBM2D26 SBM2D27 SBM2D28 SBM2D29 SBM2D30 SBM2D31 SBM3D1 SBM3D2 SBM3D3 SBM3D4 SBM3D5 SBM3D6 SBM3D7 SBM3D8 SBM3D9 SBM3D10 SBM3D11 SBM3D12 SBM3D13 SBM3D14 SBM3D15 SBM3D16 SBM3D17 SBM3D18 SBM3D19 SBM3D20 SBM3D21 SBM3D22 SBM3D23 SBM3D24 SBM3D25 SBM3D26 SBM3D27 SBM3D28 SBM3D29 SBM3D30 SBM3D31 777777777 TEST Testing Corporation Storage Solutions 223 Misdemeanor Ave Suite B Rockville MD 20654 Kenneth Sims President Brenda Willis Financial Secretary 2402224544 bw@lswonline.com Brenda Willis 3/1/2007 Checking 255071981 333333333 09/30/2007 240 "$20,000.00 " $0.00 0 "$20,000.00 " "$20,000.00 " "$20,000.00 " $3.29 ($39.00) $0.00 $0.00 "$5,000.00 " MD 1 M "$2,500.00 " "$2,500.00 " $504.29 R 888888888 HENN Henning Systems 393 Florida Ave Silver Spring MD 20601 Cynthia Henning Owner Sandra Bullock Bookeeper 3018393209 sb@lswonline.com Cynthia Henning 4/12/2007 09/30/2007 22 "$30,393.39 " $23.00 0 "$30,000.00 " "$30,000.00 " "$30,000.00 " $39.39 ($3.30) $0.00 $22.00 "$10,000.00 " MD 0 S A "$1,000.00 " "$1,000.00 " "$1,000.00 " "$1,000.00 " $347.09 "$1,000.00 " "$2,000.00 " "$1,000.00 " $0.00 555555555 JOHN Johnson Plumbing Roto Rooter 21 History Road Springdale MD 20774 James Johnson Owner Jenny Wilson Bookeeper 3013244929 jj@lswonline.com James Johnson 3/15/2007 09/30/2007 3000 "$769,505.49 " "$22,302.00 " 1 "$765,594.39 " "$765,594.39 " "$765,594.39 " "$2,382.29 " ($0.39) $0.00 $0.00 "$250,000.00 " NJ 0 S A $0.00 "$3,000.00 " "$50,000.00 " "$50,000.00 " "$50,000.00 " "$50,000.00 " "$3,000.00 " "$30,753.54 " $0.00 666666666 ELEC Electric Corporation Test International 242 Elm St. Suite Z Annapolis Junction MD 20701 Tim Welch Accountant Tina Welch Bookeeper 3015551212 tw@lswonline.com Tim Welsh 4/1/2007 09/30/2007 229 "$100,290.00 " $33.00 0 "$100,290.00 " "$100,290.00 " "$100,290.00 " -$232.00 $0.00 $0.00 $0.00 "$15,000.00 " 0 M "$10,000.00 " "$10,000.00 " "$7,581.33 " R