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Exhibit "C" Sign here Phone Date i ) Preparers Preparer check Properer's Paid signature rt self-employed SSN or PTIN preparers Firm's name (or yours Date FEIN I f I f only i se. -amp oyed) and access Florida Department of Revenue Employer's Quarterly Report Use black ink. Example A - Handwritten Example B - Typed Employers are required to file quarterly tax/wage reports regardless of employment activity or whether any taxes are due, Example A Example B 01 234 56789 0123456789 L RT -6 phone number r Us- Black Ink to Complete This Form R. 01/15 WARTERENDING DUE DATE PENALTY AFTER DATE TAX RATE RT ACCOUNT NUMBER DO NOT --------------------------------- --------------------------------------- ... --------" ----------- 1)�TACR Employer's Quarterly Report Payment Coupon Do not make any changes you do notan account number, you Rule 738-10.037 I I I II III I I I I I I II II I II I I I I I I I I I II a to re to the pre -prided are required to register (see instructbns} to II Please write your RT ACCOUNT NUMBER on check. T L Make check payable to: Fbride U.C. Fund POSTM ARh OR HAND -DELIVERY information on this form. F.E I NUMBER If changes are needed, request and complete an _ EmployerAaoount Change Form (RTS -3). FOR OFFICIAL USE ONLY POSTMARK DATE Reverse Side Must be Completed Narne 2. Gross wages paid this quarter Mailing (Must total all pages) Address city/svzlp 3. Excess wages paid this quarter (See instructions) 4. Taxable wages pand this quarter (See instructions) Location ■ Address 5. Tax due (Multiply Line 4 by Tax Rate) City/stop ■ 6. Penalty due 1. Enter the total number (See instructions) of full-time and part-time 1st Month■ 9 7. Interest due covered workers who (See instructions) performed services during 2nd Month ,l „r ■ or received pay for the 3 6. Installment fee payroll period including the (See instructions) ■ 12th of the month. 3rd Month 9a Total amount due (See instructions) I__'' ■ Check if final malum:Amot Date operations ceased. i 9b. nt Enclosed (See in (See nstructions) i ■ Check 0 you had out-of-state wages. Attach Employer's If you are filing as a sole proprietor, is this for Quarterly Report for Out -of -State Taxable Wages (RT-6NIF).rry- �-- domestic (household) employment orgy? _..INo Cagier ci c rl � " 1 oFr lac trtat `: ha e read this return Ti the fK:ts stated in it are pue (sect cl ,d_ Sign here Phone Date i ) Preparers Preparer check Properer's Paid signature rt self-employed SSN or PTIN preparers Firm's name (or yours Date FEIN I f I f only i se. -amp oyed) and access erer's ` ZIP Prophone L phone number r DO NOT --------------------------------- --------------------------------------- ... --------" ----------- 1)�TACR Employer's Quarterly Report Payment Coupon RT -6 Rule 738-10.037 R. 01/15 Florida Administrative Code Effective Data 11/14 Honda Departmerit of Revere.:, COMPLETE and MAIL with your REPORT/PAYMENT. USE T Please write your RT ACCOUNT NUMBER on check. T L Make check payable to: Fbride U.C. Fund POSTM ARh OR HAND -DELIVERY DATE J RT ACCOUNT NO. U.S. Dollars Cents F.E.I. NUMBER _ GROSS WAGES (From Line 2 above.) ■ AMOUNT ENCLOSED (From Line 9b above.) , ■ Name PAYMENT FOR QUARTER ENDING MM/YY M ailing Address Check here if you are electing to Check here if you transmitted City/St/ZIP pay tax due in installments. funds electronically. L 7 5009999999 0000 4 9100 0 99999999 0068054031