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Exhibit "C"
<br /> Florida Department of Revenue Employer's Quarterly Report
<br /> Use black ink Exampla A-Handwritten Example D vTyped Em3lcyers are required to file quarterly taxtivage reports regardless of emaloymant activity or whether any taxes are due
<br /> �EXMn iN E
<br /> ,0 1 2.3 4 5' 6 7 8 9i U1E 56"1E�? RT-6
<br /> ise Black Ink ` ( ia:„ T? i,Y P" i`' ° R.01/15
<br /> QUTARTEREFIrING DUE PENAL.-YAFTER DAl' T.�".hW;iL 'AGCCUidiMUML'ER
<br /> III II VIII I II III II II VIII I II IIII II trot make any changes you do not have an account number,you
<br /> to !f
<br /> to the pre-printed are raquimd to ragisfer(sea instructionsA
<br /> intormatimtoil this lorm. FE.I NUNg0_-R
<br /> II changes are needed, -
<br /> request and complete an
<br /> Employer Account -
<br /> p Change Form(RTS-3). FOR OFFICIAL USUSE ONLY POSTMARK DATE
<br /> Nara-2 Cine wages pard this ouai ter --
<br /> Addy£ (Musttoti':all pages)
<br /> If
<br /> �: ■
<br /> 3. Fxeess wages paid this gaa!tet
<br /> S?e in sh ur.hJnsj _. _.
<br /> 4 Taxabie wages p ini lhu gjarter
<br /> See mrtruchors
<br /> 5. Tax due
<br /> (MuNIA!Line 4 by`Ax Rate, ■
<br /> w 6 Prt€ 6;due
<br /> I Ente:the tctalnumt, (Se !nstrcchoral
<br /> r , e
<br /> ollul'',4near:dparbtlrre list Month 7 Interos-du,
<br /> cweredw,:�k�rs.vho
<br /> perlVnrol ser:res curing (Oee insuwliws,
<br /> or ie-nerved pay lortl:e 2nd Month 6 Installrr,erl're
<br /> pdyrulipenudincluding One --- --- - - --- (Seen>puohans;
<br /> t2th of the month, Std Month9a TNalamnmddue ----—_ __. _. _ _
<br /> (See invtrucli,ns; ?
<br /> Check if final rettlm: , j
<br /> Date operation ceased. / 9h. Amountbdesetl
<br /> (See in struohons" ,
<br /> Check it you had out-of-state wages.Attach Employer's . tt you are filing as a sole proprietor,is this far
<br /> Quarterly Report for Out-of--State Taxable 4Nages(RT-t;Nf--). » domestic(household)employment only')
<br /> - Yes No
<br /> L>
<br /> Title
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<br /> Phone,
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<br /> PhoneFax, ,
<br /> p - Cate i.'"
<br /> Pr,)a-er'c Pieparer check Prepay,'a ,
<br /> Paid slgnaru:e irsau-ernP!c;;ed xwu wird
<br /> i
<br /> FEIN
<br /> preparers Fnrr's Warne,�r yor, Cate f
<br /> only asell-emolcyadY I" ..
<br /> ,, skid address ZIP Properar's
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<br /> DO NOTTC
<br /> »
<br /> Rule 736-10.037 Employer's Quarterly Report Payment Coupon RT-6
<br /> Florida Administrative Code R.01/15
<br /> Effective Date 11114
<br /> COMPLETE and MAIL with,your REPORT/PAYMENT
<br /> Please write your RT ACCOUNT NUMBER on check.
<br /> T Make check payable to Fbrida U.C.Fund ! /
<br /> RT ACCOUNT NO
<br /> —U.S.Dollars Cents
<br /> F.E.I.NUMBER GROSS WAGES
<br /> (from I_inr.2 abovv.l
<br /> AMOUNT ENCLOSED
<br /> r (From Line 9b above) •
<br /> PAYMENT FOR QUARTER
<br /> ENDING MM/YY
<br /> Check here if you are electing to Check here if you transmitted
<br /> ;rx.tif, pay tax due in installments. funds electronically
<br /> 9100 0 99999999 0068054011 7 5009999999 0000 4
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