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Use black ink. Example A - NancAvrittvii Example B - lypc,,7 <br />E(arnrA A r rrti[5L <br />2`,3;4 51'6 7''8 9 <br />\.'.: <br />CIJARTER ENDhr , t . t -r,1 F <br />III II VIII I II III II II VIII I II IIII II <br />Name <br />klaifing <br />Addry ssi <br />CSf;•i`u'.lfi6a <br />Location <br />tlddw-,s <br />Ci tyTatly-IF' <br />1, Enter aw. total nu-Inbei <br />of GAi urre a d ,a Une <br />cov e sv rK rS rihe <br />perforin sservv .� duilrq <br />or rcer;ed pay lar the <br />payroll penoc ncluding Die <br />12th of themonth. <br />1st Month <br />2nd Month <br />3rd Month <br />Check if final return: <br />Date operations reared. <br />Check if you had oul-o1 tale w:agN Alla.-A) t rnr yer's <br />Quarterly heporl lot Ord of ,Stab 1 ax afire.- ry aye s (P.'F 6NF). <br />Exhibit "C" <br />Florida Department of Revenue Employer's Quarterly Report <br />Employers a�e required to his quarterly taxhtage repa is regardless of employment acnvity or whether any taxa` are due. <br />RT -6 <br />Use Black Ink to `c)m lete TNs Fort � R.01115 <br />N <br />PEAt r 1 , FFR DATE' TAX PATE RT ACCC01I NUMBER <br />,i <br />Do rat make any changes N you do not have an account nurnber, you <br />to the pr •-printed are required to register (see instructions} <br />iniomtation on this form. F.EJ. h;UMEER <br />If changes are needed, _ F <br />request mid complete an <br />i <br />Employer Account J G .....:? ... ; t.. -.-_.I <br />Change Form (RTS -3). FOR OFFICIAL USE ODLY POSTMARK DATE <br />rt <br />�a?ireT':G i'+E,. {F,`a+&��"�t fry �:Qt"""s�al:":'(€l <br />-s paid Ulu qu.-ioler <br />■ <br />3. E,(e ;waves paid G� quarter <br />, <br />4. Ta .able wataes paid 0%, quarter <br />,�'t. 1151U1:Uenyi i ' <br />s. Tar due. - <br />Multpiy _me 4 by lax Hale; i � <br />, <br />a. P n `rydue r <br />i5 - rrso,nsj <br />If <br />(,restcue <br />}`•fit 51��:Bieas) + - <br />?:. ]rslalmentfc� <br />($ee instruc6aas) ! <br />Ofi. Total am runt due <br />r <br />■i ! <br />son AmouulEndured <br />t. inS.l-;rjpp0'Si '; r ii <br />_ If you we filing as a sole prolinotor, is this for - <br />domestic (hous(hold) employment only? <br />Yes NO <br />M' ,O;�' <br />lN <br />ONE' <br />Sign here <br />Paid srnraw.. <br />re arers <br />P P im n .nae v a. <br />h a 8CG <br />Only rt9jl n hIC; r �'aq <br />Title <br />`Phone ,, r <br />Pr 1ar<er r•)7 I � 7 ?tier`s <br />f i r.trs ., <br />r' <br />ZIP <br />'- - .Frvr_ r rsh. <br />^' hhor ! r b a <br />--..._......___.._..,...____-----___-_.__ a_._...__a._----,_.,_,_.-----------aw__wm.,....-._.,_.__----..........----. <br />"___..,.....,,----......---- <br />TC <br />Rule 738-10.037 <br />Employer's Quarterly Report Payment Coupon <br />RT -6 <br />Florida Administrative Code <br />R. 01/15 <br />Effective Date 11114 <br />Florida De; '-,r�.r <br />COMPLETE and MAIL with your REPORT,`PAYNIENT. <br />fi+�tt USE i?JL'? , <br />Itttttttt� <br />Please write your RT ACCOUNT NUMBER on check. <br />Make check payable to: Florida U.C. Fund <br />110S- hn„x c. N <br />RY r a <br />RT ACCOUNT NO. <br />Dollars —1 I Cents <br />F.E.I. NUMBERGROSS WAGES <br />IF Line, 2 above.) I <br />■i <br />AMOUNT ENCLOSED 4 �) <br />F (From Line 9b above.) <br />Nam© PAYMENT FOR QUARTER <br />Maitiny <br />ENDING MMNY <br />Ad`# Check here if you are electing to Check here if you transmitted <br />CityfEif?I° <br />pay tax due in installments, funds electronically. <br />L <br />9100 0 99999999 OD68OS4011 7 5009999999 0000 4 <br />