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III IIIIIII I II III II II IIIII I II IIII II III II Florida Department of Revenue Employer's Quarterly Report I01 /11 <br /> i � p °T�nt act�nt• �� whether any taxes are d��e. R . 01 /11 <br /> En>uto}�rS ora rE�uued to file �uaner,r tae wage repots rug•.tdless a. gmp'cry. ; . • � i <br /> OUARTER ENDING EMPLOYER'S NAME UT .ACCOU14T NUMBER <br /> ❑ ❑ � ❑ ❑ � ❑ ❑ ❑ ❑ 0000 ❑ ❑ ❑ ❑_❑_ <br /> 10. EMPLOYEE'S SOCIAL SECURITY NUddeER 11 . EMPLOYEE'S NAME folease ryTn fiat twelve cbaactars of last name are first 72a. EMPLOYEE'S GROSS INAGES PALO THIS <br />QUARTER <br /> ayn• cnaracczr5 0: fast name m bo.esJ 12h. EMPLOYEE'S TAXABLE WAGES PAID THIS QUARTER <br /> 0n1ytan !m Si,00.^ naw teach er(.wyee (xr ca'en • vim' u :xtatda. <br /> 1111 ❑ - ❑ ❑ - 1111 ❑ ❑ fate 0000❑ 0 ❑ ❑ 11 12a ❑ ❑ ❑ 9❑ ❑ ❑ 9❑ ❑ ❑ . ❑�{ ❑ <br /> Name ❑ ❑ ❑ ❑ F] 0 ❑ ❑ Initial 126. ❑ ❑ 9❑ J(❑�� ❑ . L_._I ❑ <br /> 11110 — ❑ 11 - 1111 ❑ ❑ Nasme 0 ❑ ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ t2a. ❑ ❑ ❑ 9❑ ❑ ❑ 90 ❑ ❑ • ❑ ❑ <br /> First <br /> Name ❑ ❑ ❑ ❑ 0000 ❑ ❑ Ingle ❑ 125. ❑ ❑ 9❑ ❑ ❑ . 11 11 <br /> 0000 — ❑ - 0000 ❑ ❑ Last Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 72a ❑ ❑ 119❑ ❑ ❑ 9❑ 11 . 11 ❑ <br /> First <br /> Name 0000 ❑ ❑ ❑ ❑ nit�18 ❑ t2b. 11 ❑ 901111 ❑ <br /> • U ❑ <br /> 0000 ❑ — ❑ - 0000 ❑ tame ❑ ❑ ❑ ❑ 111100 ❑ ❑ ❑ ❑ t2a. ❑ ❑ ❑ 9❑ ❑ 1190 ❑ ❑ . 0000 <br /> First Name ❑ F1 11 11111111 Inittiiale ❑ 12b. ❑ ❑ 9110 ❑ • ❑ ❑ <br /> 0000 ❑ - 0000 - 0000 ❑ ❑ Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12a. 00119❑ ❑ ❑ 90L.111 . 00 <br /> First Old <br /> Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Initial"' <br /> ❑ 12b. ❑ 119❑ ❑ ❑ • ❑ ❑ <br /> 0000 ❑ - 0000 - 0000 ❑ ❑ Last Na" e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12a. 0000 ❑ 9❑ ❑ ❑ 9 ❑ Ir❑�I '�11II ❑ • ❑ ❑ <br /> First Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ In F] 12b. ❑ ❑ 9O LJ ❑ • 0000 <br /> 0000 ❑ — ❑ ❑ - 1111 ❑ ❑ Nme ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ ❑ ❑ 120. 0 ❑ 119❑ ❑ ❑ y❑ I(❑�1I (I11 <br /> 11 [1111 <br /> First Middle <br /> Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ddle ❑ 12b- <br /> Name ❑ ❑ 9111_! i-1 . L—I ❑ <br /> 0000 ❑ — ❑ - 0000 ❑ Last <br /> Name 0 ❑ ❑ ❑ ❑ ❑ 00 ❑ C11I ❑ 12a. ❑First ❑ ❑ 911011 :[111 <br /> ❑ ❑ • ❑ ❑ <br /> Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Initial ❑ 12b. t�T ❑ ❑ f1 ❑ . 1111 <br /> t3a. Total Gross Wages (add Lines 12a only). Total this page only. ❑ 0 11911 ❑ ❑ 91111 11 • ❑ ❑ <br /> Include this and totals from additional pages in Line 2 on page t . <br /> I 3b. Total Taxable Wages {acrd Lines 1 only}. Total this page only. F1 ❑ 9110 11 . 1111 <br /> include this and totals from additional <br /> al pages in Lune 4 on page T . <br /> 00 NOT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ' - - " - - - - - - � .. . - _ ... _ _ . - - _ _ . <br /> _ - _ _ <br /> _ _. ._ _ _ _ _ - _ _ _ _ _ _ ` - _ - - - <br /> bETACH <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.mytlorida.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 /> File and pay your Florida unemployment tax online. <br /> It's fast , easy, accurate , and secure . <br /> Internet Address: www.mytlorida.com/dor <br /> - 13 - <br />