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11111111111111111111111 <br />'WJARTER ENDIN3 <br />1 <br />1111II <br />LFlorida Department of Revenue Employer's Quarterly Report R. o is <br />Ein lbt+srb are tapirtd to fit quarls11y ttixtritags rep tr1a re tires of empiorrelatlhtly a whelleir m1 teaos WV dun,. <br />Use Black Ink to Complete This Form <br />EMri.OYER'S NAME <br />1 U EMPLOYE'S SQOw1AL $ECUR4TY NUMBER. <br />n <br />L <br />DO NOT <br />DETACH <br />Mail Reply To: <br />Reemployment Tax <br />Horida Department of Revenue <br />5050 W Tennessee St Bldg L <br />Tallahassee FL 32399-0180 <br />11. EMPLOYE'S NAM` rpleeae prim fret twe+xb the le : d I ri renin rni <br />tett chattier: of bet rra—tr it boom) <br />Lasi <br />Wane <br />Fest <br />Name <br />Lasi <br />Nan_ <br />Fst <br />Name <br />Lad <br />N3 ne <br />Fri <br />Name <br />Lasa <br />Nane <br />Fr<t <br />Nan <br />Lad <br />Nam <br />F� st <br />Nene <br />Lasi <br />Nam=_ <br />F.st <br />Wane <br />Last <br />Name <br />Nane <br />Last <br />Nane <br />Fast <br />Name <br />n <br />n <br />n <br />Midas <br />in -L31 <br />Mitts <br />In`isl <br />Mid; e <br />In: isl <br />r,9ibe <br />In:i31 <br />tn'isl <br />12a. <br />12b. <br />12a. <br />126 <br />12a <br />12b. <br />12a <br />12b. <br />12a. <br />1213. <br />12a. <br />1213. <br />12a. <br />12b. <br />12a. <br />126. <br />RTAXCUNTtsumstm <br />12a. EMPLOYEE'S GROSS WAGES P O THIS 0:.1 015% <br />12b. EMPLOYEE'S TAXABLE WAGES PAJb THIS QUARTER <br />Onljthe frsll.=rr-i1 eeatieipb?tretow wieder yeastub e. <br />13a. Total Goss Wages {add Lines 12a onI}). Total :We page only. <br />1 ;dada this .and totals from additional page in Line 2 on page 1. <br />13b. Total Taxable Wags (add Linea 12b o sly'I. Total this page prey. <br />nolude this and to:ala from additional pages in Line 4 an page 1_ <br />r <br />5 <br />5 <br />7 <br />5 <br />7 <br />I <br />L• <br />l <br />I <br />:nr <br />• <br />I <br />• <br />Socia security numbers (SSNs) are used tyy the Florida Department of Revenue as unique <br />identifiers for the administration of Rori la's taxes. SSNs obtained for tax administration <br />purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not <br />subject to disclosure as public records. Collection of your SSN is authorized under state <br />and federa' taw_ Visit our Internet site at www.myflorida.00m/dor and select `Privacy <br />Notice` for more information regarding the state and federal law governing the collection, <br />use, o- release of SSNs, including authorized exceptions. <br />Please save your instructions! <br />©.iarteryy Report instructions (RT-6h+RTS-3) are only mailed <br />with new accoints or when there are changes. If you rnsplace <br />your instructions. you can download them from <br />www.myflorida.corn/dor <br />86 <br />