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Use black ink. Example A - Handwritten Example B - Typed <br />Fxampie A <br />. F.ramge8 <br />caoo®c�a®M ❑0 45 ❑ <br />�QUARTER <br />iC0/C07G <br />Name <br />Mailing <br />Address <br />City/St/Zlia <br />Location <br />Address <br />City/StIZIP <br />1. Enter the total number <br />of full-time and part-trme <br />covered workers who <br />performed services during <br />or received pay for the <br />payroll period including the <br />12th of the month. <br />Exhibit "C" <br />Florida Department of Revenue Employer's Quarterly Report <br />Employers are required to fie quarterly UxAvage reports regardless of employment a6 ity or whelller any farces are due. <br />DUE DATE <br />C __1 <br />1st Month ❑❑�7(, (❑❑ <br />2nd Month❑❑i�❑❑ <br />31d Month a ❑ ❑ ❑ ❑ ❑ <br />❑Check if final return: ( j❑/j—j❑/❑jam❑a <br />Date operations ceased. u tUl lul <br />RT -6 <br />.Use Black Ink to Complete This Form R.01/15 <br />PENALTY AFTER DATE TAX RATE RTACCOUNTNUMBER <br />[1❑1❑nn❑ <br />Do not make any changes 8 you do not have an account number, you <br />to the pre-printed are required to negister(we insfrucfioos} <br />information on this form. F.E.I. NUMBER <br />II changes are needed, <br />request and complete an a _ a ❑ <br />6rrptoyerAccarnf <br />Change Form(RTS-3). FOR OFFICIAL USE ONLY PO.STMAID(DATE <br />Reverse Side Must be Completed a ago o� ❑ a ❑ <br />2. Gross wages p qra for <br />(Must total at pages) <br />❑ oa� ❑ (� <br />ISI <br />❑ ❑ ■ ❑ ❑ <br />3. Excess wages d des quarter <br />(Seeinstructions) <br />!� <br />❑ a ❑ ❑ ❑ o ■ ❑ <br />4. Taxable paid this quarter <br />(See instructions) <br />(See <br />�� f❑ <br />o a o a oo ❑ o a ■ ❑o <br />5. Tairdue <br />(Multiply Line 4 by Tay. Rate) <br />❑ a 1111 1111 . 1111 <br />6. true <br />(See <br />(n <br />See instructions) <br />ID <br />( 0 011 0 ❑'D [10. [1 0 <br />U <br />T. Interest due <br />(S� instructions) <br />(Seein❑❑❑'❑0❑f❑[I❑ <br />I`II <br />■ [I [I <br />8. Insta(See lmentfee <br />(See instrircfions) <br />❑ ■ ❑ ❑ <br />ga. it <br />(Sefamamdue <br />(See instructions)strucinstructions) <br />000,aao,oaa. oa <br />9b. Amount Endmil <br />(See mstruc5ons) <br />111111 .1111 � II <br />—11 <br />a Check if you had out-of-state wages. Attach Employer's <br />Quarterly Report for Outof-State Taxable Wangs (RT-6NF).ii <br />T^ r <br />R 6 <br />If you are filing as a sole proprietor, is this fa <br />❑��'❑�❑!❑❑�.❑❑ <br />1 <br />domestic (household) employment only? Yes No <br />Under penes of pe . I declare that I ha a read the return and the facts stated in it are true (sections 44.3.1 FIR, Rada Statutes). <br />Title <br />Sign here <br />Phone <br />Fax <br />here if you are electing to <br />Sign of otGcer <br />Date <br />( ) <br />( ) <br />Preparer9 <br />funds electronically. <br />Preparer check <br />Preparer's <br />Paid signature <br />Itself -employed <br />SS r4or KIN <br />preparers Firm's name (or yours <br />Date <br />FEIN <br />only If self-employed) <br />ZIP Preparer a <br />and address <br />phone number ( ) <br />TC <br />Rule 738-10.037 <br />Florida Administrative Code <br />Effective Date 11/14 <br />Florida Department of Revenue <br />T <br />DO NOT - <br />Employer's Quarterly Report Payment Coupon <br />COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY <br />Please write your RT ACCOUNT NUMBER on check 00 / 11 ❑ / 1111 ❑ <br />Make check payable to: Florida U.C. Fund CI?OSTMARK OR HAND -DELIVERY DATE <br />RT ACCOUNT NO. a a ❑ RT -6 <br />F.E.I. NUMBER �❑_���O�O�j <br />Name <br />Mailing <br />Address <br />Cityist/ZIP <br />RT -6 <br />R. 01/15 <br />L <br />i U.S. Dollars I Cents <br />GROSS WAGES <br />(From Line 2 above.) <br />❑�'�❑❑'❑a❑.00 <br />AMOUNT EN <br />(From Line 9b above.) <br />❑��'❑�❑!❑❑�.❑❑ <br />PAYMENT FOR QUARTER <br />ENDING.MM/YY <br />HCheck <br />here if you are electing to <br />a <br />Check here if you transmitted <br />pay tax due in installments. <br />funds electronically. <br />L68 <br />9100 0 99999999 0068054031 7 5009999999 0000 4 <br />