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Exhibit "C" <br /> Florida Department of Revenue Employer's Quarterly Report <br /> Pie Use black ink- Example A-Flartdavrilten Example B Typed Employers are required to ge quarterly taxM'a a reports regard of employment activi or whedfer an taxes are due. <br /> 0 1 2 3 4�[51�!7 S 9! �'�r"—'_ g Y 9 Pa 9ry Y <br /> 1111❑CL 1^l ❑L, ❑®1Z34567$D❑ RT-6 <br /> Use Black Ink to Complete This Form R.01/15 <br /> QUARTER ENDING DUE DATE PENALTY TAX RATE RT ACCCUNT NUMBER <br /> ❑❑/❑❑/❑❑❑❑ F I ❑1111❑❑1111 <br /> III II IIIII I II IIS II II IIIII I II IIII II Dobe pre-printed <br /> Byou donot have ater(sw number you <br /> to the pre-prirded are requBed to register(see mstructfone} <br /> information on this forth. F.E.I.NUMBER <br /> It changes are needed, <br /> EmptoyerAccountan 11110[11:111110❑ <br /> Change Form(RFS-3). FOR OFRCUiL USE ONLY PO.SFA M DATE <br /> Reverse Side Must be Completed ❑❑/❑❑/11 ❑❑ <br /> Narne <br /> AMailingddress 2. Gross wages paid this quarter 11 <br /> 1191111 91111❑9❑❑❑ ❑-- <br /> (Must total all pages) 11 <br /> City/StlZIP 3. (See instructions Sews wages paid this quarter 11 11 119111111 911 1111■ 11 1 <br /> 4 Taxable wages paid this quarter -11110,,[] <br /> �❑❑9❑❑1:1. ❑Location ( s) 1111 <br /> El <br /> Address 5. Tax due ❑❑❑91111119❑❑�■ ❑� <br /> Ci !StlZIP (Multiply Line 4 by Tax Rate) LJ <br /> 6. Penaltydue ) 111111 9111111 9111111■ ❑(- <br /> 1 Enter the total number (See instructions IIL�—II!! <br /> of full-time and part-time 1st Month 111111, <br /> I❑❑'I I I I❑ / oto �e n <br /> covered workerswhod 2nd Month __I I—I LLLJJJ 111111 9 ❑❑9111111 ❑ <br /> performed services during � (See st ductions) El <br /> or received pay for the ❑❑❑! 11 11❑ 8. Installment fee <br /> payroll period including the 110(�7 E I J❑j� (See instructions) ❑ ❑ <br /> 12th of the month. 3rd Month I 1 1 9a. low amorNdue LLLf-1 LCheck it final return: (See instructions) 0 D[I 0❑C ❑❑11■ 0 El <br /> Date operations ceased. 9b. Amount Enclosed00/00/Mill] l <br /> (Seeinstructions) 11 9 ,9 1111■ 11 El <br /> Check it you had oul-of-state wages.Attach Employer's <br /> Quarterly Report for Outof-State Taxable Wages(RT-6NF). RT-6 domestic <br /> are filingestic(househ a sae proprietor,is this for <br /> ddd)employment only? Yes ! No <br /> Under penaine_s of p 1tuy,I dxiare that I have read this return and the facts Gated in it are!rue(sectrons 443 17•(7,Florida Statutes). <br /> Title <br /> Sign here <br /> :ayrasue of officer Date Phone ( ) Fax t ) <br /> Preparer% Prepare'check Prepaer's <br /> Paid signature if sett-employed I SSN or Fr <br /> IN <br /> preparers FwWa name(a you s Date FEIN <br /> only ifseif-employz <br /> and address ZIP Preparer's <br /> phone number ( ) <br /> DO NOT <br /> ------------------------------------------------------------------------------------------------- ------- <br /> TC <br /> Rule 7311-10.037 Employer's Quarterly Report Payment Coupon RT-6 <br /> Florida Administrative Code R.01/15 <br /> Effective Date 11/14 <br /> Florida Department of Revenue COMPLETE and MAIL with your REPORT/PAYMENT DOR USE ONLY <br /> T Please write your RT ACCOUNT NUMBER on check <br /> Make check payable to: Fl rkla I.I.C.Fund ❑ /Ell] <br /> / ❑ <br /> POSTMARK"ORHAND-DELIVERY DATE <br /> RT ACCOUNT NO. ❑❑❑❑❑❑❑ RT-6 <br /> U.S.Dollars Cents <br /> F.E.I.NUMBER 1111-1111❑❑❑❑❑ (From LiSe2above.) ❑1111'011119111111■ 1111 <br /> AMOUNT�N�O) 11111191111❑911❑❑■ 1111 <br /> Name PAYMENT FOR QUARTER ❑❑_❑❑ <br /> ENDING MM/YY <br /> Mailing <br /> Address Check here if you are electing to Check here if you transmitted <br /> City/St/ZIP ❑ pay tax due in installments. funds electronically <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />