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� o <br /> IIB IIIB IIB II BBI II IB BIIIB I BB BIII II BBI B L EmplFloaPdrequired to file quarterly a Department ofyRev�en 9e Empardless of <br />loyer's Quarterly'Repony taxes rtd e R 01 j6 <br /> , ,J <br /> QUARTER ENDING EMPLOYERS NAME _ _ _ _ _ _ UT ACCOUNT NUMBER <br /> ] Fr / ] ] / CC ! <br /> 10 EMPLOYEE'S SOCIAL SECURITY NUMBER 11 . EMPLOYEE'S NAME (please print first twelve characters of last name and fi;st j 12a. EMPLOYEE'S GROSS WAGES PAID <br />THIS QUARTER <br /> _ _ _ eight characters of (ust name in boxes) ! 12b. EMPLOYEE'S TAXABLE WAGES PAID THIS QUARTER <br /> i� I� ILII I�' i� Ii i fOn�ly ithle first $7,000 paid totolleach employee per calendar lyear is taxable. <br /> C E:1 L_I LJ 11 Name ❑ � o I— L�I ❑ � ❑ IJ 12a I_ . _J I_...._,� 91... I <br /> Nam111 <br /> Name 11 1111 ] 11InitiMidallP ] 12b.Last <br /> ] ] 9 ] I] ] � •�]� � <br /> Fill] - EF:11EE Nemo I11EIIEC ] 0 '1E0E 12a. 11 EllFirst <br /> Name L. I I I '.. ...-.-I t-.._...I l . .. t._....1 Initial n 12b. <br /> ] 7111 — EL.' I] ] ] E Noma 001110E 12a. <br /> Last <br /> 7171 ] ] ] yo 11 <br /> I I _ I Last LlLJIFirst � � �I � Meddle <br /> (n� nnI I ���',, Noma Inn IIrl�ti�Il nu 12b. �'� i� e <br /> ]I �] � IJL= Name —1L�1 �� lJI�1E � ❑ � I�1oo 12a. �� � LJ9 � � 9 1J � . � E <br /> First ❑ Middle i ] ! <br /> DC 12b 1111 E <br /> l t j I 111 InitialLu 12a 91�J L�I ,� j� 1:111 II <br /> U LJ E Ivt <br /> Nanta I�1I (� I� <br /> First <br /> Name _1 El] <br /> 12b <br /> IS�III I IIII �II III��.. I(�, � � � � ❑ � 12a. � � � � i� 9 � 1111a —J � <br /> LJ 71 C 11 ] LJ ] L� Name 1111111111 LJ ILII II I I II ISI <br /> (� <br /> Narst me ie LastnE I] ] 1E (11 (E 110 Initial Middle � 12b. "� n 9 I ...I �...-._.-.I 9 �� I� � . L... .. . 1 <br />L...._.1 <br /> ] ] l] — � ] � � � E lame EIDE I—II—_i � L—IE � ❑ O 12a. J11DIE � �19 �� !J � . � 11 <br /> ( f 1 Name (7171 ;] ] ] ] ] ] Initial <br /> la ] 12b. F. <br /> �� IJ IJ I..II Name lJ L.1 -11111 UFirst (�'� LJ [�1 Ll lJ lJ Ll 12a, . . . .... ! . . .. .. <br /> . I ....._... . ... <br /> I , ll 1 . 11 . 1 [ 1 <br /> Name 7171 ] ] 71171 ❑ Iniifi�ale 12b. 'J71 <br /> Include this and totals from additionalpages--in­ <br /> a es In Linen on a e 1 . <br /> _l I _ _ <br /> 13a Total Gross Wages (add Lines 12a only). g Total this page only. <br /> 9 `�' 9 `�' If��i <br /> L 3b. Include thital s and t totages ls fromlnes 12b additionnal pages in <br /> lthis page only.Line 4 on <br /> DO NOT <br /> - ' - - - - - - - - - - - - - - -' - - - - - - - - - - -- - - - - - - - - - - - - - ` - - ` - ` - - - - - - - - - - - - - - - - - - - - <br />- - - - - - - - - - - - - - - - - - - - - - - - - - ` - - - ` - - - - - - - - - - - - - - - - - - " - <br /> DETACH <br /> Mail Reply To : Social security numbers (SSNs) are used by the Florida Department of Revenue as unique <br /> Unemployment Tax identifiers for the administration of Florida's taxes. SSNs obtained for tax administration <br /> Florida Department of Revenue purposes are confidential under sections 213.053 and 119.071 , Florida Statutes, and not <br /> 5050 W Tennessee St Bldg L subject to disclosure as public records. Collection of your SSN is authorized under state <br /> Tallahassee FL 32399-0180 and federal law. Visit our Internet site at www.myflorida.com/dor and select " Privacy <br /> Notice" for more information regarding the state and federal law governing the collection, <br /> use, or release of SSNs, Including authorized exceptions. <br /> Tired of paperwork? We can help ! <br /> OTATE OF FW84113A r File and payYour Florida unemployment tax online.INDIAN RIVER.000l <br /> THIS IS TO CjRTlFYTHATTHIS. IS - = It 's fast, easy, accurate , and secure . <br /> A TRUE AND CORRECtCOPY,OF THIS <br /> THE ORI (a`INAL'ON FILETN Internet Address : www.myflorida.com/dor <br /> OFFICE <br /> SIE _ REY K. TON , CLERK <br /> B ur: �.� �...,. Dole. <br /> DATE - <br /> - 13 - <br />