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Exhibit " C " <br /> Use black ink. Example A - Handwritten Example B - ed Florida Department of Revenue Employer's Quarterly Report <br /> TY <br /> En•ptoyers are required to [lie crirartErty taxhvage rcixxis regardless Of enrbyntenR actnsil or svttClPkr any ;axes are due. <br /> 000 "M13000 0190 8 § o UCT-6 <br /> R . 01 /11 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER <br /> 00 � 00 � 000 ❑ _._. 0 ❑ aa0 ❑ � <br /> Do not make any changes It you do not have an account number, you <br /> IIII1I1 to the pre-printed are required to register (see instructions). <br /> ( I ( II � I II � IIII III I III I 11chngesarnteesform. FELNU>r1QER <br /> rl changes are needed, ❑ ❑ ❑ ❑ r—� ❑ ❑ <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 n ❑ / 1111 / F T U 11 <br /> Name <br /> 7. Gross wages pa9 this quarter Mailing ❑ a 90 09� 0 n . ❑ a <br /> Mailing must !mal all pages) <br /> Address i� <br /> City/BUZIP 3. Excess traces paid ;his qua to [I0 0 90 ❑ 1 1 911 [1 ❑ ❑ ❑ <br /> (See instructions! <br /> u, (See instructions) <br /> paid this quarter [ 1 0 9E ❑ � 90 0 0 • 0 0 <br /> Location fSee instructions)Address S. Tax due 0 0 0 a 0 0 a a o . 0 a <br /> City/SUZIP (Multiply Line a by Teti Rate) 9 9 <br /> 5. (Penalty See <br /> 000900El900 ❑ aE <br /> I . Enver the total number (See instructions) <br /> o; Sidled w and parttime t st Month 11 ❑ ❑ ❑ i, Interest due a o 0 0 0 ❑ 0 a a • a 0 <br /> covered +voC;zrs who <br /> (Ste inS3NCli0n5) <br /> Geriormed services during 2nd Month 1111119111111 9 9 9 <br /> or received pay ,or the B. Instalment fee • n <br /> payroll period including inz (See insuuctions) E <br /> 2tn o; the month. 3rd Month ❑ 11 9 ❑ 9 ❑ g� • t__l <br /> t11•�II 1+t-1II ga. Total amount duo <br /> (J a � a � UAmount <br /> Endo ted <br /> Check if limo return: / / 90. AmeentEructio a 0 9❑ 9❑ a ❑ ❑ <br /> Date operations ceased. <br /> {See inssructions) <br /> Check if you had out-of-state wages. Attach Employer's Ifou are ficin as a sole proprietor, is this for I� <br /> Quarterly Report for Out-of-State Taxable Wages (UCT•6NF). i y g u <br /> : .: domestic (household) employment of yes No <br /> under penalties of Floury, I declare that I have mad this return and the !acts stated in it Bra true (sections <br /> 443.171(6) and 443.141(2)1 Florida Statutes!. <br /> Title <br /> Sign here <br /> s. nsture of officer Dole Phone ( ) Fax ( ) <br /> Preparer's Preparer check Preparer's <br /> signature it self-employed SS 40 <br /> PTIN <br /> Paid <br /> preparers Fumy namefor yours Da1e FEibd <br /> 0111 <br /> if Seli-ernplo ILI <br /> y and atldresS ZIP Prepa2r'S <br /> phone number ( ) <br /> - .. - - - - _ .. - - - - - - - - - - - - - - - - - - - - - - - _ - - - - - - - - ' - - - - - - - - - - - - - - - <br />. _ _ _ _ _ - - - - - - - - - - - - _ - _- _ - -- - - - - - _ _ I - NOT - _- _ _ ., .- _ _ - .. _ - - - - - - - <br /> DETACH <br /> Rule 6OBB-2.037 Employer's Quarterly Report Payment Coupon UCT--6 <br /> Florida Administrative Code R . 01 /11 <br /> Florida Department of Revenue COMPLETE and MAIL with your REPORT/PAYMENT DDR USE ONLY <br /> Please vrrite your UT ACCOUNT NUMBER on check . ❑ / na / � ❑ <br /> Friake check payable to: FloridaU.C. Fund POSTMARK OR HANO•DELNERY OATS <br /> ❑ a00a0 ❑ _ <br /> UT ACCOUNT NO. _.r <br /> Fn--- U .S. Dollars InCents <br /> F.E . I . NUMBER ❑ ❑ ❑ il ❑ ❑ ❑ ❑ ❑ (FomLi WAGES <br /> abu e.) (�{ ❑ � y❑ 0090 ❑ ❑ • 11 <br /> AMOUNT ENCLOSED ❑ ❑ ❑ 9❑ ❑ oy❑ ❑ ❑ • ❑ n <br /> (From line 9b above.) L1 <br /> Name PAYMENT FOR QUARTER o [I _ ❑ ❑ <br /> ENDING MM/YY U <br /> Mailing <br /> AddressF1Check here if you are electing to 11Check here if you transmitted <br /> City/St/ZIP pay tax due in installments. funds electronically. <br /> 91100 0 99999999 0068054031 7 5D09999999 0000 4 <br /> - 12 - <br />