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Exhibit " C " <br /> Use bMk 4*. Exam 171e A . H 1:� Wl& B _ T� Florida Department of Revenue Employer's Quarterly Report <br /> �M STOWsrs are Irguitrd to No glarted Iaxlwage reports "Wdbn of wfly roam &**y a +�Aieeer any tnxee err due. <br /> � E] ❑ 3 4 5 6 DEE] ❑ � � RTS <br /> Use Black Ink to Complete This FormT R. 01/13 <br /> QUARTER 84AW DUE DATE PENALTY AFTER DATE TAX RATE RT AG�CCt1Nf wmBBt <br /> ❑ ❑ / ❑ ❑ / ❑ ❑ ❑ 0 1 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tlo an taake an dla"M If you do sot bene an avolru aom6er, you <br /> Loft rw:rd amlralrrdta ,syb�rlaeeMueracuoaAl <br /> ildertae kin ea fila Wim. F.EI NUMBER <br /> It ckanilies we owdec <br /> reilliwstandw <br /> EmpbyerAcoount ❑ ❑ - ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Change FwmlT-$ PO80FAtaALIItEO,r1F08tIW,( MTE <br /> Reverse Side Must be Completed 110 / ❑ ❑ / 11111111 <br /> Name <br /> AMailing 2, <br /> ddress #AW 1015111 Wl PapbeJ �rerter ❑ 11 '11 ❑ ❑ '� ❑ ❑ . ❑ ❑ <br /> City/SVZIP Sam houclionlIll <br /> 11 <br /> ❑ 1111 11 ❑ 11 '11 ❑ . ❑ <br /> 4. Taxable waQea Wd this 4uarier ❑ ❑ 11 '11 ❑ 11 '11 ❑ ❑ ❑ ❑ <br /> Location rose l+stllcforol <br /> Address <br /> tf S. Tau due [1011 ,011111111 ❑ . 1111 <br /> CnylSUnP Y 1�e4 � Tax Re/e4 <br /> 6, Penalty due 1111 ❑ a ❑ ❑ 1111 ❑ . ❑ ❑ <br /> ,. Enhrifielot# �rlber {See .0nitWorel <br /> cow w�r5 latMonth 1111 ❑ , ❑ ❑ ❑ 7. � ❑ ❑ ❑ '❑ ❑ ❑ '❑ ❑ ❑ . ❑ ❑ <br /> Wbil or mceww���ft 2nd Month ❑ ❑ ❑ a ❑ ❑ 8. Wiftentke 9111 <br /> 0 . 0 <br /> 12M1i d the ll"Ill . 3rd Month ❑ ❑ ❑ ' ❑ ❑ ❑ 9a. TAW assn dr <br /> Check R final earn: / / 9b ❑ ❑ �❑ ❑ 11 '11 ❑ ❑ ❑ ❑ <br /> Date operations ceased. ❑ 11111111111111 (See reftowo ❑ ❑ ❑ 5111111 911 ❑ ❑ . ❑ ❑ <br /> Check R you had out-of-slate wages. Ansch Employwl; 1 It you are filing as a sole proprietor, is this for <br /> Quartedy Report for Out-ci`4 to Taxab)s Wipes STT-GFS "r, r t domestic (household) employment only? ❑ Yea [] No <br /> lkuier penak+®s d pert try, I declare chat I titre read the return and the tact. lwtad +n h are true (sections 443. t 71 (5) .and 443. 141(2), Flonda <br /> Statutes}. <br /> Title <br /> Sign here <br /> Signarrre or CA LW Da" Phone <br /> ( ) Pax <br /> Proiwd < Pleperer dietk PMpner'e <br /> Paid agruturo N rer�exnVW"dd SSN or Pr1N <br /> PrOPWOrS Fern's arra W yixw Ona FEN <br /> only r .en errptoyedp <br /> aid addrees ZIP P"=erk <br /> -- - -- - - - - -- - - - - -- - -- - - - - -- - -- -- - -- - -- - -- - -- - -- - -- - - - - -- - -- - -- - - - -- - -- - - - - - - - - - - -- - -- - -- - -- <br />- -- . .. . .. . . . . .. . .. . .. <br /> DETACH <br /> ftle IAar.rrww�evr. ked. Employer's Quarterly Report Payment Coupon RT-6 <br /> Fkm R. 01/13 <br /> Florida Department a' RevenueCOMPLETE and MAIL with your REPORTIPAYMENT. DOR USE ONLY <br /> T Please write your RT ACCOUNT NUMBER w check. FIR / ❑ ❑ / [IF] <br /> AK D <br /> Make Check payable to: FWW B.C. Pond POUMAA NAND t LiVE1tY DATE <br /> �..- <br /> RT ACCOUNT NO. ❑ 11 ❑ ❑ F1 ❑ � r ._, i <br /> ❑ ❑ - ❑ ❑ ❑ ❑ ❑ ❑ U.S. Dollars I Cents <br /> FE.I. NUMBER GROSS WAGES 0 111 '11 1111 10 11111111 <br /> . <br /> (From Line 2 shove.) <br /> AMOUNT ENCLOSED <br /> ba e.) ❑ ❑ ❑ ❑ ❑ 11 '11 ❑ ❑ . ❑ ❑ <br /> (From Line Ob <br /> shwa_) <br /> Name PAYMENT FOR QUARTER 1111 _ 11 <br /> ENDING MM/YY u <br /> Mailing <br /> Address 0 Check here it you are electing to11Check here if you transmitted <br /> in <br /> City/StizIP pay tax duo in stallments. funds electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />