Name (as shoun on page I Semi-Weekly Deposit Schedule A. First Month of Quarter (Days of the Month) _t O 3 O _CO _LO 6 Et 13 O 20 27 0 Month 1 Liability: Enter total here and on Pan 2, line 81 Chad( a box only If you had a next-banking day withholding obligation. B. Second Month of Quarter (Days of the Month) 1 O B O 15 O 22 O 29 O 2 O 9 O 16 O 23 O 30 O 3 O 10 O 17 O 24 O 31 O 4 O ii O 18 O 25 O Check a box only if you had a next-banking day withholding obligation. 5 O 12 O 19 O 26 O 6 O 13 O 20 O 27 O 7 O 14 O 21 O 28 O Month 2 Liability: Enter total here and on Part 2, line 82 $ C. Third Month of Quarter (Days of the Month) 1 O 8 O 15 O 22 El 29 O 2 O 9 O 16 O 23 O 30 O 3 O 10 O 17 O 24 O 31 O 4 O ii O 18 O 25 O Check a box only if you had a next-banking day withholding obligation. 5 O 12 O 19 O 26 O 6 O 13 O 20 O 27 O 7 O 14 O 21 O 28 O Month 3 Liability: Enter total here and on Part 2, line 83 $ Part 5 Amended Form Al-QRT Return Information If you checked the box "Amended Return' in Part 1. explain why an amended Form Al-ORT is being filed (include additional sheets, if necessary): Part 6 Final Form AI-QRT If you checked the box "Final Return' in Pan 1. check the box that indicates why this is a final return: 1 ❑ Reorganization or change in business entity (example: from corporation to partnership). 2 0 Business sold. 3 0 Business stopped paying wages and will not have any employees in the future. 4 0 Business permanently closed. 5 0 Business has only leased or temporary agency employees. 6 0 Other (specify reason): 7 ❑ Check this box if records will be kept at a location different from the address shown in Part 1. Name: Number and Street: City: State: ZIP Code: 8 ❑ Check this box if there is a successor employer. Name: EIN: , Number and Street: City: State: ZIP Code: ADOR 10888 (17) AZ Form AVORT (2017) Page 2 of 2 EFTA01219703