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Exhibit "C" <br /> r Use black ink. ExarnpleA-Hanciwrillen ExanpleB-Typed Florida Department of Revenue Employer's Quarterly Report <br /> Fxampe a Gzunpe e, Employers are required to fide quarterly taxAvage reports regardless of employment activity or whether any taxes are due. <br /> (0�1P02 3�1 5'©MNi9f ❑[0.11�345678!D❑ RT-6 <br /> .Use Black Ink to Complete This Form R.01/15 <br /> OUARTERENDNG DUE DATE PENALTY AFTER DATE TAX RATE RTACCCUNTNUMBtER <br /> FIFIFI ooa❑ oaaa000 <br /> III II II IA I II I II II II VI I I I II III I II to he matte any changes B you do not have Wor("eit nuuctio you <br /> to the pre-prirded are required to register see instructions} <br /> irdrnrnatioa an this form. F.E.I.NUMBER <br /> II dtmrgeare needed,, ❑ -❑[J ❑ <br /> request and <br /> d re head e <br /> Employer Account <br /> Change Forth(R7S-3). FOR OFRC14 USE ONLY POSTIAM WE <br /> Reverse Side Must be Completed a/1 D❑R <br /> .Name <br /> 2. Gross wages paid quarter <br /> iftiling <br /> Address ❑❑090009000' [1[1 <br /> (Must total all pages) <br /> ) <br /> City/St/ZIP 3. Excess wages paid this quarte (—!111 <br /> I 17 ❑ 9� ❑ <br /> (See instructions) IL_l1 — <br /> Location 4. Taxable wages paid this quarter ❑ 90(j 9(�❑ a <br /> (See instructions) II_ll JI <br /> AAdress 5. Tax due �❑❑7nn❑7[100. o0 <br /> City/St21 P (Multiply Line 4 by Tax Rate) <br /> 6. ISeeinydue 0090 0,9000■ D� <br /> 1 Enter thetotal number � (See instructions) <br /> of full-time and part-tune 1st Month 1 I❑ ❑❑❑ <br /> perf rormedservices during I—i T Interest due ❑❑❑ ❑❑❑ ❑❑■ f l <br /> Month 4, (S�instructions) <br /> e 9 9 JJ ILJ! <br /> or received 2nd Mth 11❑❑ 111111 <br /> 11 8. <br /> for the Installment fee . <br /> payroll theincluding the ❑ ❑^ (Seeinstructions)• _ <br /> 12th m of the month. 3rd Month I JI <br /> 7 9a. ictal amoral due {u' <br /> (See instructions) <br /> Check 6final return: 7 9 <br /> Date operatiorts ceased. 00/00/0000 gb. ((ce instructions) ❑0 9111111 n■ 1111 <br /> Check it you had out-of-state wages.Attach Employer's If you are filing as a sole proprietor,is this for <br /> Quarterly Report for Out-of-State Tarmbfe Wages(RT-6NF). RT_ <br /> domestic(hokttehold)employmerd only? Yes No <br /> U oder penalties of peryksy.I declare that I have read the return and the tats stated in it are true(sections 4d3-t ti(5),Florida StatF�� utes). <br /> Title <br /> Sign here <br /> Siy,awre of officer Date Phone ( ) Fax ( ), <br /> Preparer's- Prepaur cheek Preparer's i <br /> Paid signature if self-employed SSN or PTI. <br /> preparers Firm's name(a yours Date FEIN <br /> only it self-employed) -Preparer's <br /> - <br /> and address ZIP phone <br /> phone nunber •{ ) <br /> f DO NOT <br /> -------------------------------------------------------------------------------------------------MAOR-------------------- <br /> Rule73B-10.037 Employer's Quarterly Report Payment Coupon RT-6 <br /> Florlda Administrative Code R.01/15 <br /> Eff■ctiv■Data 11/14 <br /> Florida Department of Revenue COMPLETE and MAIL vriftt your REPORTMAYMENT DOR USE ONLY <br /> Please vrrite.your RT ACCOUNT NUMBER on check 1111/r�❑/ J <br /> T Make check payable toe ROM U C.Fwd PCDsrnnARK OIR�H IAIVD-DEtJV DL <br /> RT ACCOUNT NO. ❑[I a❑❑❑F1 RT-6 U.&Dopers Cents <br /> F.E.I.NUMBER011-❑ 11111100 (GROSSAGES <br /> From Line2above.) 007❑0�9❑❑�• ❑� <br /> AMOUNT ENCLOSED DF1� ❑❑� 0❑a■ [I[I(From Line 9b dhoti.) 9 9 <br /> Name PAYMENT FOR QUARTER ❑❑_[111MM/YY <br /> Mailing ENDING <br /> g/ess, Check here if you are electing to 11funds <br /> here if you ansmitted <br /> St/ZIP pay tax due in installments. funds electronically <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 00011 4 <br />