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Exhibit "C" <br /> Use black in k.Exam IeA Randwnttea EXam_le8_T ed Florida Department of Revenue Employer's Quarterly Report <br /> _....._.._.____..____._._._e_....._r...__.__._:...:_.._..__._....�..__�e.....__ <br /> CnEmployers ers are required to file quarterly taVwa e reports regardless of <br /> employment activity or whether any axes are due.�nmiRi�nnr <br /> oroip_MOrni u7) UCT-6 <br /> R.01/11 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE - - -- UT ACCOUNT NUMBER <br /> I EI <br /> Do not make any changes If you do not have an account number,you <br /> III IIII III I II III II II IIIII I II IIII II tothe <br /> mationpre-printed this <br /> are required foregister(see instrucfions). <br /> information on this form, F.E.I.NUMBER <br /> If changes are needed, 7 <br /> request and complete an <br /> _.1 J <br /> Employer Account F1'[ <br /> -�L.- il <br /> --1 -- (..._. _._ ....._ <br /> Change Form(UCS-3). FOR OFRCIALUSE ONLY POSTWXDATE <br /> Reverse Side Must be Completed 11 I9/l.__.._I�--_.-� 11L.__..1 L_I <br /> Name <br /> 2. Gross wages paid this quarterMailing f ' I I i __ f..... ,_...._ <br /> Address (Must total all pages) 1:11111'L L I'll]J � <br /> City/St/ZIP 3, Excess wages paid this quarter Ii ! <br /> (See instructions) I-._.. I.___1 _._ 1I _.__. _.._: L.. _ I ___1 t.._....J <br /> 4. Taxable wages paid this quarter I <br /> (See instructions) [........ F1j ._..._) I [I[I. <br /> Location I- - - --- <br /> Address 5. Tax due <br /> � I I I j <br /> City/St/ZIP (Multiply Line 4 by Tax Rate) ' I ;7 i <br /> 6. Penalty due <br /> I Entertnalot alnumbe 1 r....._........... ........1._..._ r._..... (See :structiorl I ; j I ,; <br /> of fuU-time and art-time 1st Month i <br /> i — �' <br /> P i i �l 7. Interest due <br /> covered workers who I <br /> performed services during ❑ (See instructions) , L <br /> or received pay for the 2nd Month <br /> 8. (neeinstntfee <br /> ) �1. ;- <br /> payroll period including the � r ; , Sae instructions) u <br /> 12th of the month. 3rd Month ❑ ] - '-- '-- <br /> 9a. Total amount due 1111. <br /> j <br /> 7 <br /> (See instructions <br /> Check if final return: <br /> El <br /> Date operations ceased. 9b. AnwuntFndosed �j n n.�n <br /> I_._.) (See in n J CJ'L-J 1__71._ 17t-__-.i f___J t__.l. !_...J!__.....1 <br /> Check if you had out-of-state wages.Attach Employer's : If you are filing as a sole proprietor,is this for <br /> Quarterly Report for Cut-of-State Taxable Wages(UCT-6NF). M? I <br /> w. _.' i. domestic(household)employment only? i. Yes L.._...No <br /> \n. <br /> Under penalties of perjury,I declare that I have read this return and the facts stated in it are true(sections 443.1710 and 443.14112),Florida Statutes). <br /> Title <br /> Signhere __._.._.__.._._.....__...._..........-........__._..._.____...._._.___......_._.__._. <br /> ---__._ ._signature of officer ---- --- ---_..._. Date --�- Phon@ { )--- Fax ( ) <br /> Pr"Preparer's Preparer check Preparer's <br /> if self-employed❑ SSN or's <br /> Paid <br /> prnN <br /> eparers Firm's name(or yours Date FEIN <br /> only if self-employed) ..._........---...............................---............__..__..............._..........._........__.......—_............ <br /> and address ZIP._.........._.._._._....__. <br /> Preparers <br /> phone number { ) <br /> -----------------------------..____-______»___-___-__--_--_--___-__-____---__-____..___-_______-AQN4T_---__-_ <br /> DETACH _______ __-- <br /> Rule 6068-2.037 Employer's Quarterly Report Payment Coupon UCT-6 <br /> Florida Administrative Code <br /> R.01111 <br /> Florida Department of RevenueCOMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY \1 <br /> T Please write your UT ACCOUNT NUMBER on check. <br /> Make check payable to: Florida U.C.Fund F/a ZPF] <br /> P Y POMARK OR rfAND-DYERY DATE <br /> UT ACCOUNT NO. , R__f '� `- I U.S.Dollars I Cents I <br /> GROSS WAGES <br /> !i <br /> F.E.I.NUMBER <br /> :- !1 �I <br /> l ' <br /> : <br /> J - (From Line 2 above.) <br /> AMOUNT ENCLOSED <br /> (From Line 9b above.) ] <br /> Name PAYMENT FOR QUARTER I I <br /> ENDING MMM L L_ U <br /> Mailing <br /> Address F__ Check here if you are electing to Check here if you transmitted <br /> City/SVZIP (...__ pay tax due in installments. _.__':. funds electronically. <br /> L <br /> 9100 0 99999999 0068054031. 7 5009999999 0000 4 <br /> 201 <br />