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Exhibit "C" <br /> Florida Department of Revenue Employer's Quarterly Report <br /> Use black ink. Example A-Harldwntten Example B-Typed Employers are required to file quarterly taxAwage repots regardless of employment activity or whether any taxes are due. <br /> Example A Example B <br /> T <br /> 01 234 5678 .9 0123456789 RT-6 <br /> Os.....;, Black Ink Ike .;ci tplete 'Pols Tenttrt R.01/15 <br /> QUARTER ENDING DUE DATE PENALTY AFTER DATE TAX RATE RT ACCOUNT NUMBER <br /> / /, <br /> 1111111111111111111111111111111 <br /> Do not make any changes B you do not have an account number,you <br /> to the pre-printed are required to register(see enstructions) <br /> information an this farm. F.E.I.NUMBER <br /> II changes are needed, <br /> request and complete an _ <br /> Employer Account - - <br /> Change Farm(RTS-3). FOR OFFICIAL USE ONLY POSTMAN(DATE <br /> 1-1,.0vr'rf. Irnr 14 o a bf- i72.4-,InpliAteci / / <br /> 14,:aa <br /> ►�q niitry 2. Gross wages pad this quarter - - <br /> .Ackin- (Must total all pages) - 1 - 1 _- e <br /> rq.'�t.1it' 3. Excess wages paid this quarter <br /> (See Instructions) <br /> f w- - s <br /> 4. Taxable wages paid this quarter <br /> (See instructions) <br /> i` zl I <br /> D x e <br /> Ad=#ire« 5. Tax due <br /> 1,,,,::-. =,P (Multiply Line 4 by Tax Rate) * . <br /> y <br /> _ 6. Penalty due <br /> 1. Enter the total number (See instruchons) <br /> of full-bme and part-brie 1st Month S t! e <br /> covered workers who ' 7. Interest due <br /> performed services dunng (See instructions) 4 e e <br /> or received pay for the 2nd Month r 8. Installment fee <br /> payroll period including the (See Instun ons) e <br /> 12th of the month. 3rd Month k 9a. idol amount doe <br /> (See instructions) <br /> Check if final return: / / /' ` e <br /> Date operations ceased. Sb. Amount Encased <br /> (See instructions) <br /> I 1' e <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 Out-of-State Taxable Wages(RT-6NF). domestic(household)employment only? <br /> Yes No <br /> • <br /> Title <br /> Sign here - <br /> i Phone Fax <br /> 1 Date _ . . . <br /> 6 Preparer's Preparer check Preparers <br /> 1 signature0. if self-employed SSN or PTIN <br /> Paid <br /> preparers Fern's name yours . Date FEIN <br /> only if self-employed? <br /> and adctess ZIP Preparer's 110 <br /> phone number , <br /> DO NOT <br /> DETACH"- -- - .,. <br /> Rule 738.10.037 Employer's Quarterly Report Payment Coupon RT-6 <br /> Florida Administrative Code R.01/15 <br /> Effective Date 11/14 <br /> COMPLETE and MAIL with your REPORT/PAYMENT. i it. i h>';; ,;NI.Y <br /> T Please write your RT ACCOUNT NUMBER on check / / <br /> Make check payable to: Florida U.C.Fad :,:i mAiA ,i i.4:,l or_ yr-,JP•- L <br /> RT ACCOUNT NO. <br /> 1 U.S.Dollars l I Cents <br /> F.E.I.NUMBER _ GROSS WAGES <br /> (From Line 2 above.) s <br /> ti } <br /> AMOUNT ENCLOSED <br /> (From Line 9b above.) * a <br /> 14.10/.4PAYMENT FOR QUARTER <br /> ENDING MMNY <br /> h9:calx <br /> A.t,ir?,s, Check here if you are electing to Check here if you transmitted <br /> i..,tv,r.t.,ci' pay tax due in installments. funds electronically. <br /> L <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />