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III IILII IIIIII IIII IIID II II L parse (Odtofkq�111E�flt UEmployer's� Quarterly Report <br /> R. 011/3 <br /> IIIIIIII <br /> Use Black Ink to Complete This Form <br /> QUARTER EIOINQ DAPLOYEPI'S NAME RT AMOUNT NUMBER <br /> ❑ ❑ � ❑ ❑ � ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ ❑ <br /> 1p EMPLOYEE'S =Klin SECURr Y NUMBER + + EMS NAME � pdtd fat r«dre elrnah s d MM rune rid W 128, EMPLt1YEE'S WAOM Pito flag OUAMM <br /> ehreelre drat n e ;n 12b. 8APIf)1r 1 UYABi1 wA= PAD Tics oIiMRTER <br /> ono Heim seam pili m..an «Yr>ya. arorwdr yur r teeetir. <br /> 1111 ❑ - 1111 - 1111 ❑ ❑ La" 1100 ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ 12a. 1111 ❑ ,❑ ❑ ❑ ,❑ [ ❑ . 00 <br /> a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Midje F] � <br /> , 1111 ,❑ ❑ l- W • 4 _ _ i <br /> 1111 ❑ - 1111 - 1111 ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12.. ❑ ❑ ❑ ,❑ ❑ ❑ ,❑ ❑ ❑ . 1111 <br /> La� 1111 ❑ ❑ ❑ ❑ ❑ " ❑ 121. 11011 ,❑ ❑ 0 L 1 ' <br /> 111111 DOM Fie ❑ ❑ ❑ 00 ❑ ❑ ❑ ❑ 0 ❑ ❑ 121. 1111 ❑ ,❑ ❑ ❑ ,❑ ❑ ❑ . 111 <br /> Name 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 4titisl e ❑ 121. ❑ 11 ,11 ❑ ❑ . �I <br /> 0110 — 1111 — ❑ ❑ 1111 a ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ ❑ ❑ 12L 0011911 ❑ 901111 a F1a <br /> Num 11 kvuale 11 12R 11111111Ea l <br /> LJ <br /> 000 00 nOO ❑ Lam <br /> Narne 1111 ❑ ❑ ❑ ❑ ❑ 11171 112a. 1111 ❑ ,❑ 'F] <br /> ❑ ❑ . 1111 <br /> Name ❑ ❑ 110 ❑ 0011 ln e 1112 � ❑ 1111 ❑ . � ':_ <br /> 1111 ❑ - 1111 - 1111 ❑ 11 Lam <br /> Name 1111 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1111 ❑ 12a. 1111 ❑ ,❑ ❑ 11 ,❑ ❑ ❑ . ❑ ❑ <br /> e 7 [I1111 ❑ ❑ 1111 kAruliel e [I12tf_ ❑ __f ,❑ l ` ❑ . <br /> ❑ 11 ❑ - 1111 - 1111 ❑ ❑ Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12� 00119❑ ❑ ❑ ,❑ ❑ � . ❑ � <br /> Name ❑ 01111 ❑ ❑ 1111 M,," F] <br /> ❑ 121 1111 ❑ E, ❑ . L.1 <br /> ❑ ❑ 11 - ❑ ❑ - 1111 ❑ ❑ Lasl <br /> Name ❑ 1111 ❑ ❑ ❑ [I ❑ ❑ ❑ 111112L 11 ❑ ❑ ,❑ 11 ❑ 2111111 . 1111 <br /> Marne ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ hi e ❑ 121' 0 t__i 9F] ❑ L? . :1 — <br /> 13e. Totsl Camas Wagto {add Linea 12s only). Total this only. 11 F] 11 YO 1111 , ❑ 1111 . 1111 <br /> Include this and totals from additional pegea in line 2 2 oo n page 1 . <br /> L 13b- Total Taxable Wages {add Linea 12b onty}. Total this page ordy0 ❑ , 110 F1 . 11 0 <br /> ktclude this and totals from additional pegem in Lina b on page 1 _ <br /> DO NOT <br /> DETACH -- - - - - - - - - - -- - - - - - - - -- - -- - -- - - - - -- - -- -- - -- - -- - -- - -- - - - - -- - <br /> Mail Reply To: Social security numbers (SSNs) are used by the Florida Department of Revenue as urrque <br /> Reernployment Tax identifiers for the administration of Florida's taxes. SSNs obtained for tax administration <br /> Florida Department of Revenue purposes are confidential tinder sections 213.053 and 119.071 , Flodda Statutes, and not <br /> 5060 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 tntemet site at Wwrnyflorida.com/dor and select ONvacy <br /> Notice' for more information regarding the state and federal law governing the collection, <br /> use, or release of SSNs, including authorized exceptions_ <br /> Please save your instructions! <br /> Gjarterly RepDrt instructions (RTIWRT" are only mailed <br /> with new accounts or when there are changes. K you misplace <br /> your instructions, you can download them from <br /> www myflorida.corWdor <br />