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Exhibit "C" Use black ink. Example Florida Department of Revenue Employer's Quarterly -Report A - Handwritten Example B -Typed e ,mom 4 ,�,e.E a Errlplbyers are required to Ile quarterfy.ta Aage reports regardless of erriplcymEnt activity or whether any taxes are due. 1, LI'�I�JI,�1151�6��?�is�9' ❑rG;? r3 5M�fl 11 RT -6 Use Black Ink to Complete This Form R. 01/15 OJARTERENDNG DUE DATE � � � ± /� I''t.�� SIJ I- PE14ALTYAFTEP.DATE TAXRATE F.TA000UNTNUMBEF � �- �-----� i i ;,- -1�-- III II VIII I II III II II VIII I II IIII II to he ne-jpr nle �;� a you do not love a tor(s"nf number, y - to Ifre pre-printed are required Ai register(see instructions} information on tftis form. Ff 1: NUMBER 11 changes are needed, request and eompfele an EinployerAccaunf L Change Form (IRTS-3). FOR OFRpAL USE OYIY KSTWX DATE Reverse Side Must be Completed L Ll/LJ blame LJt_— Mailing Address 2. Gross wages paid this quarter — i j (Must total al pager•) n, , u� l " � F-� - i— j f I LI' EF] l City/sImp K Excess wades paid Oas quarte r-- j (: ee nStrUC OOM) I E-1 ,� 9 . ' i r ,—I BID I r ,�� moi_: .Lt -_ 1 I,B ICl Location 4. Taxable wages paid Ns quarter ^ (§eemsoucoorxj �� n11i Address City/St21p L_J — 5. Taxdue� � c (Multiply Line 4 by Tax Rate) LJ L�LI,L)L�LJL-ii_ I 3r—; L_ a L—i ■ �r ---1 r-- ,'--)fj�' ■ LJl 1 Enter the total number (� of full-time and part-time Ist tvlorrth I 6. Per alty due i — (See iistrucoons LJ EI r—I E— I I� } 1 J El 01 covered wwAers v6o ! _J10 ! ! ! � .I i i j performed sen der ng i �- -� �— 7 ht6est due i I r-� (� r - (See instructions) F L) �� u �t L_� 10 or or 2nd Month or recurved pay for the 0 J I 7 1H u • 6 Installment lee 9 payroll period inGud q1 the j� — -- .--� — 12 It. of the month. 3rd Month i I ! ! j f 7 l 1i (See instructions) I �i - L ■ t—,1 9a. idol - LJ LI L Chedd'ff final return: anoud due (see nstructions) ) j j l r I I I j L- -�`� i l� � -I ;+ � I I�I� Date operatiats ceased. J J/L;Li/l — y.—� , . 9b. Anant Endised fI Lj I ii 1) see ist uciions) E rI I Chedi if you had• out-of-siale wages. Attach Err9byer's 1 (?eiarterly,Report for Oritaf-State Taxable Wages (RT�NF). — y ` (�` If you are filing as a sole progietor, is this fa {( R," y tt domestic (household) employment only? 1`_ 1 Yes DIN. P,;;-.J:res N' pe:;tu;, 1 rkdzi; E lfot Ilia! i rFzd f h--s,,iw p. and the fzc; Sign here FA ---- ------------ - •`'.4pnFi,t;+a Or par^yf Da;e i Pr�.,arert - s gnat ne Paid L---� -------------- preparers 1 Firm's name only if self-empbyed) r and address m li a e V75 (szcStdnE'9r:..; 17 i Title -- iPhona Prepares ineck i Freperer's if self-vrtnptdryed . SSN or •PiIN �1__ FE114 ZIF' ® I Preparer's phone number t TC -------- Rule -" _ "Rule 7313-10. 037 Employer's Quarterly Report Payment Coupon Florldi Adrririitratiiri Code Effec6e Uatei.liild -- Florida be�artmcrnt of RevEniie COMPLETE and MAIL with your REPORT/PAYMENT /" DOR USE ONLY T Please write your RT ACCOUNT NUMBER on.chedt. +I r Make check payable to: hmida U.C. Fund POSTMAJ91. OR HAND-DELIVEP'f DATE RT ACCOUNT NO. II I (J�� I"r,4� F.E.LNUMBER LLl I Name Mailing Address CitylStJZIP L RT -6 R. 01/15 L r U.S. Dollars—I I cants j GROSSWAGES �` -1 ` �F Ir�Ell (From Line 2above.) 11 '�!i �i�g0L �Jt_ AMOUNT ENCLOSED i Hni (FranLine9b.above.) Uj )! I 11 !0 )1ULJLJa �J PAYMENT FOR QUARTER F] 5 s ENDING MM/YY it— - [I F7 I Check here if you are electing to - Check here if you transmitted Lpay_ tax due in installments. ; funds electronically 9100 0 99999999 0068054031 7 5009999999 0000 4 106