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DRAFT Exhibit "C" Use black ink. Exurnple A - HandiNrittion Exanple B - Typed Florida Department of Revenue Employer's Quarterly Report E—pit e SEmployers are required to file quartedy tmWage reports regardless of employment activity or whether any taxes are due. , RT -6 Use Black Ink to Complete This Form R. 01/15 QUAFTER ENIDNG DUE DATE PENALTYAFrER DATE TAX RATE RTACCOUNTNUNEER T V1711I F Do not month gesuIII II IIID II III II II IIII I II IIII II thepareuiredbregisterpeehioslrwfions}informs form. F.E.I.NUMBER Name Mailing Addre ss City/St/ZIP Location Address City/stfzlp 1. Enter the total number of full-time and part-time covered workers who performed services during or received pay for the payroll period including the 12!h of the month. if El I st Month 1] _1 2nd Month i;—i r7171 F7 Li 3rd Mmth I I F IL Check if firial return. i H i Lj Date operations Ceased. 1V Li Check if you had out -d -state wages. Attach Enpk)yieris, QUaltertif Report for Out -of -State Takabk- Wages, (RT-6NF). read !hr� S ign here Title !7 1 �Phone Fax - ---- -- Dare :.Phone check -1 Preparer's Preparer's Paid signature if self-employed SSN or FTIN PreParerS Firm's name (or yours FON Dale orgy tselt-empfoyel arId address ZIP Preparer's pricne number DO NOT ------------------------ MACA -------------------- To Rule 7384M037 Employer's Quarterly Report Payment Coupon RT -6 Florida Administrative Code R. 01/15 Effective Date 11/14 Florida Effective of Revenue COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY i Please write your RT ACCOUNT NUMBER on check Make check payable to: Florida I.I.C. Fund POSTMARK OltIHA�D� 7 _DE LIWRY DATIE FIT ACCOUNT NO. t L __j -U.S. Dollars Cents GROSSWAGES F.E.I. NUMBER LJ 1 !1 Ll (From Line 2 above.) ■ AMOUNT ENCLOSED rom Line Ob above.) 7� L IE F-17 Name PAYMENT FOR QUARTER Mailing ENDING MM/YY Address Check here if you are electing to Check here if you transmitted City/Stfzlp pay tax due in installments. funds electronical280 L gi.nn n 99999999 nnL.An;4nqi. 7 ;nn9999999 nnnn 4 It changes are needed,, request and complete an F—i EmployerAccount Ch8n99 F— (RTS -3). FOR OFFICK 119 011Y POSTMAK DKE Reverse Side Must be Completed �Ht 2. Gross wages paid this quarter (Must total all pages) 11 D 1. Excess wages paid this quarter (See rstructons)Ll pjlj ILI 4. Taxable wages paid his quarter instructions) lLi(See 5. Taxdue (Mulblety Line 4 by Tax Rate) F :0 L J' --- 6. Penalty due (See instructions) ! F-1 [7� I Interest due (See instructors) (See Instrualions) I_i Lj Tatalawasaidoe See instructions) E11---, 1`01 El 0_1 [I r IF] Anwast Eadesed F] F^ If you are filing as a sole proprietor, is this for domestic (household) employment only? read !hr� S ign here Title !7 1 �Phone Fax - ---- -- Dare :.Phone check -1 Preparer's Preparer's Paid signature if self-employed SSN or FTIN PreParerS Firm's name (or yours FON Dale orgy tselt-empfoyel arId address ZIP Preparer's pricne number DO NOT ------------------------ MACA -------------------- To Rule 7384M037 Employer's Quarterly Report Payment Coupon RT -6 Florida Administrative Code R. 01/15 Effective Date 11/14 Florida Effective of Revenue COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY i Please write your RT ACCOUNT NUMBER on check Make check payable to: Florida I.I.C. Fund POSTMARK OltIHA�D� 7 _DE LIWRY DATIE FIT ACCOUNT NO. t L __j -U.S. Dollars Cents GROSSWAGES F.E.I. NUMBER LJ 1 !1 Ll (From Line 2 above.) ■ AMOUNT ENCLOSED rom Line Ob above.) 7� L IE F-17 Name PAYMENT FOR QUARTER Mailing ENDING MM/YY Address Check here if you are electing to Check here if you transmitted City/Stfzlp pay tax due in installments. funds electronical280 L gi.nn n 99999999 nnL.An;4nqi. 7 ;nn9999999 nnnn 4