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Exhibit " C " <br /> Florida Department of Revenue Employer's Quarterly Report <br /> Use black ink Example A Ilandwrnttan Example 6 - Typed _ <br /> e w pI@ n E a ply ® Employers are requhed to file quarterly !a0vage reports regardless of employn>Ent adivily or whether <br /> any taxes are due. <br /> !J J � ` 111... L. J . ' , � _ 1101 3956 � 8j8 I <br /> t.Tt. UCT6 <br /> R. 01 /11 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> ...... r ._.. ._.....i , .... . <br /> Do not make any changes If you do not have an account number, you <br /> r to the pre-printed are required to register (see instructions). <br /> II IIII III I II III ( ) II IIIA I II IIII II <br /> information re this form F.E.I. NUMBER <br /> If changes are needed, <br /> request and complete an - <br /> EmployerAccount ( -- <br /> Change Form (UCS-3). FOR OFFICIAL USE ONLY POSTMARK DATE <br /> tee <br /> — I <br /> Reverse Side Must be Completed <br /> Name <br /> Meiling 2. Gross wages paid this quarter <br /> pages) <br /> Address Must total all <br /> City/St/ZIP 3. Excess wages paid this quarter <br /> (See instructions) releeel—I i,, 7 _.-_ , ( , 1... l • __,l I ,_ , <br /> 4 Taxable wages <br /> Dopa Id this quarter ' _ <br /> Location __ i , . _. . , .... . . _.. i.... <br /> Address 5. Tax due I66 .. ....I <br /> (Multiply Line 4 by Tax Rate) � i l____ ,� ! I <br /> CitylStlZIPeeA,e <br /> 6. Penalty due <br /> 1 Enter the total number -� ) l (Sea instructions) <br /> of full-time and part-time 1st Month ( ( ! - - <br /> covered workers who I • - 7. Interest due 999 t 1 <br /> or received ay for the g 8. Installment cf ons) i_ ) ' _J [ ( ,_ <br /> performed services during ' 1 _ . J <br /> P 2nd Month e — <br /> payroll period including the (See instructions) 1 <br /> 12th of the month. 3rd Month <br /> 9a. Total amount due ( - <br /> � , _ (See instructions) <br /> Check if final return . - ( - <br /> 9b. Amount Enclosed ' .. _.. . . J , ...... <br /> is —� , _a � , � _ _� � <br /> Date operations ceased <br /> (See instructions) -1 <br /> Check if you had out-of- state wages. Attach Employer's �---- <br /> Quarterly Report for Out-of-Stare 7axable Wages (UCT-6NF). If you are filing as a sole proprietor, is this for <br /> domestic (household) employment Yes ._.._.._ No <br /> jrt I;�. e.i1 ,.F (, ... 67. r , .,CI.. PihRi I '1c ., C;r.d 'i" S feM ( ri andTie fa✓.., _ tu, rPd rn it are ti l <br /> of,C?I. lin11 t ,.i) ai'd17 . 711 �' i , '' % of Y .. Su. 1 . <br /> Title <br /> Sign here _.__..__ 6 & ell <br /> Phone Fax <br /> ' ^7 '.a , offir4: e t 1 111 r <br /> „r Det •--_. <br /> Preparers Preparer check Preparer's <br /> signature_ if self-employed ( SSN or PTIN L...... . <br /> Paid _ .. _ <br /> preparers Firms name for yours FEIN <br /> Date <br /> Onlyif self-employed) _ <br /> i and address ZIP Preparer's <br /> I phone number f <br /> DO NOT .. . . <br /> DETACH <br /> Rule Employer's Quarterly Report Payment Coupon <br /> Floridaonda AAdministrative Code UCT s <br /> R, 01 /11 <br /> 1 / fie a Departr r r ,1 T COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY <br /> Please write your UT ACCOUNT NUMBER on check. <br /> T payable - _61 14 9 99 <br /> Make check a able f0 Florida U.C. Fund POSTMARK Ota HAND-DELIVERY DATE <br /> r , <br /> UT ACCOUNT NO. 1 <br /> l _ < < <br /> I , , _. _. _ i U.S. Cents <br /> F. E. I . NUMBER � i � - � � � GROSS WAGES � <br /> (From Linn 2 above.) <br /> AMOUNT ENCLOSED <br /> (From Line 9b above.) L (... . i , __ ( ._.. ( . , <br /> Nar se PAYMENT FOR QUARTER <br /> ENDING MM/YY <br /> Mailsrtg <br /> Address _ Check here if you are electing to Check here if you transmitted <br /> Cityfstr'zIP pay tax due in installments . 1 ( funds electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br /> - 13 - <br />