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Exhibit " C " <br /> Florida Department of Revenue Employer's Quarterly Report <br /> 05F11at_k ih Example A - Ha rtlxv lion rn lime 8 Typed <br /> rL. imazcu Ft Iwo- T III,,.: j tD ilf- Itp eirlr :;' !nr_ 1 1 9_„ asr• II i r Je„ Ii [ I ;n'. -t�a 1 , rl . ,nrdP.�r <br /> x i t. .rsrr= ci., <br /> C 11 i . 01121314 � 6It8J9 UCT-6 <br /> R , 01 /11 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER T <br /> Do not make any changes I7 you do not have an account number, you <br /> to the pre-printed are required to register (see instructions). <br /> III IIII III I II III II II VIII I II IIII II It changes <br /> It's form- FE NUMBER <br /> It changes are needed, <br /> request and complete an <br /> Employer Account - - - - <br /> Change Form (UCS-3). FOR OFFICIAL USE ONLY POSTMARK DATE <br /> Reverse Side Must be Completed <br /> Name <br /> Mailing 2 . Gross vrages pa this quarter <br /> Address (Must total aI paged <br /> City/Sl/ZIP <br /> 3 Excess wages paid the quarter <br /> (Se91nS!ructionS) I �' � • <br /> _ -- <br /> d_ Taxable wages paid Ihre quaver ! <br /> LoraLocation 'See i'lstructionsl <br /> Address 5. Tax die <br /> i <br /> GtyISUZIF (MudipP) Line a by Tar Ralei 1 <br /> I . Erner ;he total RiniP Pavony due <br /> See insvuctionsl <br /> J <br /> - I <br /> 7 . _ � . <br /> qi list-t.'ne and Part time 1st Month Interest due <br /> rover dxvor'aers �yho <br /> ' ,See nsiruchonsl <br /> F. dor med services during 2nd Month <br /> O <br /> reCO Pd pay fpf Ih9 j _ ' -. B . Insix inent fee <br /> payroll period :naluding Ina :;See iWructicnsi <br /> 12th a! the month . 3rd Month <br /> ' 4a. Total amount due <br /> ISeems! coons) <br /> Check if final rnturn : <br /> Date o eration s ceased. / / 9C Amount Fndosetl <br /> p <br /> 1Seei7structlonsi <br /> 71 � <br /> Check if you had out - of- state wages . Attach Employer 's If you are filing as a sole proprietor, is this for <br /> Quarterly Report for Out or State Taxable Wages (UCT-6NFf domestic (household) employment only? Yes ! No <br /> � . _ . t .. ;r ' iia , . —i act ; r1 n . 1 I 41 . . , : <br /> Title ' <br /> 7Signhere <br /> _ Phone Fax . <br /> r ' ; . . .. . .� Date I seri ren c chnyect PSN or PT <br /> .- ,_ _ �_� -_.,.__ <br /> si ni , <br /> Paid - <br /> Pepa ors Pep7rer e^k PP nrur � <br /> preparers FiTM s gar e log yor.rs FEIN <br /> sell-e'n play edl Date t <br /> only _ <br /> artl s]dress ZIP Pieparer's <br /> phone nlrmber <br /> DO NOT <br /> DETACH <br /> Rule 6OBB-2.037 Employer's Quarterly Report Payment Coupon UCT-6 <br /> Florida Administrativo Code <br /> R . 01 /11 <br /> �r ' r,n ;, i r;::;I ,,; I ' ; n nt c' P?.-; rr` uE COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY <br /> write Your UT <br /> UNT <br /> T Make check payable to . FIOon a U CUF dER on check . POSTMARK On HAND DELIVERY_ / ERY DATE <br /> UT ACCOUNT NO. <br /> - - - - - - U. S. Dollars 1 Cents <br /> EE . 1- NUMBER GROSS WAGES <br /> . - (From Line 2 above. ) <br /> AMOUNT ENCLOSED <br /> (From Line 9b above.) . _ . <br /> Name PAYMENT FOR QUARTER <br /> ENDING MM/YY <br /> Mailing <br /> Address 1 Check here if you are electing to Check here if you transmitted <br /> CityStizip 1 pay tax due in installments. funds electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br /> - 12 - <br />