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III II VIII I II III II II VIII I II IIII II III II L Florida Department of Revenue Employer's Quarterly Report R.o 15 Employers are required to 61e quarterly taxAvage reports regardless of employment actNity or whether any taxes are due. Use Black Ink to Complete This Form QUARTER ENDING EMPLOYERS NAME HT ACCOUNT NUMBER 111/011/11111-111111/011/11111-111 !—I TA❑❑❑❑❑❑ 10.EMPLOYEE'S SOCIALSECURITYNUMBER 11.EMPLOYEE'S NAME tpteasepriafrstiw&ecteractersoflast name and first 12a. EMPLOYEE'S GROSS WAGES PAIDTMSQUARTER eight characters of fust narne in boxes) 12b. EMPLOYEE'S TAXABLE WAGES PAID THS QUARTER Only the 1119$7 000 paid to each employree per alrndar year is tax ble. 1111❑—1111—1111❑❑ Nam ❑❑❑❑❑❑❑❑❑❑Middle❑❑ 12a. 01109111111 11E.11■ 1111 Name ❑❑❑❑❑❑❑❑ Initial ❑ 12b. 11114❑00. ❑❑ 1111❑-1111-1111❑❑ Fame ❑❑❑❑❑❑❑❑❑❑cid❑❑ 12a. E. 1111❑9❑❑❑9❑ ❑■ 1111 Name ❑❑❑❑❑❑❑❑r�qMiIniwil ❑ 12b. 1111'❑C❑■ 1111 1111❑-1111-1111❑❑ S,- 1111❑❑❑❑❑❑111100 12a. ❑❑❑4 Ilij I . 1111 Mane ❑❑❑❑❑❑❑❑ Inital Middle 0 12b. ❑❑4110,❑■ 1111 1111❑-1111-1111❑❑ Last Name ❑❑❑❑❑❑❑❑❑�❑❑ 12a.Middl1111❑4❑❑04❑f )11.11❑ Name ❑❑❑❑❑❑❑❑ Inift�e 11 12b. ❑014❑[❑■ 0101 1111❑-1111—❑❑1111 LastName ❑❑❑❑❑❑❑❑❑❑❑❑ 12a. ❑❑❑40009011F,r ❑■ ❑❑ Nai ❑❑❑❑❑❑❑❑ Middle Name ❑ ❑114❑❑❑ 1111 Initial 12b. I � ❑❑❑-00-11011❑ are [111111111101101111 12a. ❑❑119❑❑❑4❑❑❑■ 1111" 1731 i e , .uHlae11 ❑❑4DC❑■ 1111 1111❑-1111-1111❑❑ Name 00000000-0001] 12a. 1111❑9❑❑,❑4❑I f❑.❑❑ Name 1111❑❑❑ IINtilt. ie ❑ 12b. ❑❑4❑C El. 1111 1111❑-1111-11❑❑❑ Last Name [1000❑1111❑❑❑1111 12a. 11110911111111011. 1111 e 1111❑❑❑ MaNar» Middle ❑ 12b. ❑09001"11. 0 E 13a. Total Gross Wages(add Lines 12a only). Total this page only. Li 11❑9111111 911❑{�I■ 1111 Include this and totals from additional pages in Line 2 on page 1 L 13b.Total Taxable Wages(add Lines 1 only). Total this page 1111911(-11■ 110 Include this and totals from additional pages in Line 4 on page 1 �! DO NOT -----------------DETQCR----------------------------------------------------------------------------------- Mail Reply To. Social security numbers(SSNs)are used by the Florida Department of Revenue as unique Reemployment Tax identifiers for the administration of Florida's taxes. SSNs obtained for tax administration Florida Department of Revenue purposes are confidential under sections 213.053 and 119.071,Florida Statutes,and not 5050 W Tennessee St Bldg L subject to disclosure as public records. Collection of your SSN is authorized under state Tallahassee FL 32399-0180 and federal law. Visit our website at www.myflarida.com/dor and select`Privacy Notice' for more information regarding the state and federal law governing the collection,use,or release of SSNs,including authorized exceptions. Please save your instructions! Quarterly Report instructions(FTHNIRTS-3)are only mailed With new accounts or when there are changes.R you misplace your instructions,you can download them from www.myflorida.com/dor