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III II VIII I II III II II VIII I II IIII II III II L Florida Department of Revenue Employer's Quarterly Report R. 01/15 <br />Employers are recuira4 to fila quarterly tex/avags reports regr9ess of employ^nert activity a whether arty axes are due. <br />Use Black Ink to Complete This Form <br />QUARTER ENDING EMPLOYER'S NAME <br />10. EMPLOYEE'S SOCIAL SECURITY NUMBER <br />F1'El---- --- <br />007111 — Ell ---- <br />(� (—[--1 E -^ <br />th _ <br />11. EMPLOYEE'S NAME (please pnrl first twaw cheraciers of lain noire and lira! <br />eWdaWetaoffrSnwreinboxesl <br />RT 4CCOUNT NUMBER <br />12a EMPLOYEE'S GROSS WAGES PAID THIS QUARTER <br />12b. EMPLOYEE'STAxABLE WAGES PAID THS WART ER <br />Only the fiwt V000 poid to each employee per cdendar year is tenable. <br />DO NOT <br />Mail Reply Ta <br />Social security numbers (SSNs) are used by the Rodda Department of Revenue as unique <br />Reemployment Tax <br />identifiers for the administration of Florida's taxes. SSNs obtained for tax administration <br />rr <br />r <br />purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not <br />5050 W Temessee St Bldg L <br />subject to disclosure as public records. Collection of your SSN is authorized under state <br />�, <br />C .:E <br />for more information regarding the state and federal law governing the collection, use, or <br />-.i--u -- <br />-- <br />12a. <br />r <br />---� - - <br />I <br />� 1-17-1 <br />"M:ae <br />a, <br />.�- <br />,Zb.,� <br />,i� <br />E. <br />_ <br />- <br />L <br />I] ---- <br />— — <br />I- - __-12..-. <br />_ <br />� ` <br />Flt <br />-r-� <br />�L <br />,. <br />12b. <br />�. <br />-E- C --- <br />C ,ti. <br />_ <br />I ,I <br />i <br />C. <br />r <br />11 Ell ID Ell— <br />I <br />L..�_ <br />Name-- <br />-----C <br />12■.--. <br />r fstd <br />I <br />---- --- <br />t he <br />„a <br />12b.C. <br />-- <br />11 - CMCJ <br />EllEE <br />Fist <br />El <br />E <br />h <br />a <br />12b. <br />t�r— <br />t , <br />---------- <br />- ,�.-� <br />i <br />- <br />--. <br />,L. <br />E <br />Nan <br />i <br />[I <br />,t::_.a <br />, <br />h <br />13a. Told (kris Wages (add Lines 12a only). Total this page only. <br />Inckide itis and totals from additional pages in Line 2 on page 1. <br />I <br />( ! - <br />,� <br />i - <br />,_ <br />J ■ Ell, <br />+ I <br />u <br />13b. Total Taomble Wages (add Lines 12b only). Total this page only. <br />Include this and totals from additional pages in Line 4 on page 1. <br />! �u <br />DO NOT <br />----------------- DETACH _--__..-----------------------------"'------------------------------ <br />Mail Reply Ta <br />Social security numbers (SSNs) are used by the Rodda Department of Revenue as unique <br />Reemployment Tax <br />identifiers for the administration of Florida's taxes. SSNs obtained for tax administration <br />Florida Department of Revenue <br />purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not <br />5050 W Temessee St Bldg L <br />subject to disclosure as public records. Collection of your SSN is authorized under state <br />Tallahassee FL 32399-0180 <br />and federal law. Visit our website at www.myfloridacomt/dor and select "Privacy Notice' <br />for more information regarding the state and federal law governing the collection, use, or <br />release of SSNs, including authorized exceptions. <br />Please save your instructions! <br />Quarterly Report instructions (RT-6NlRTSA are only mailed <br />with new accounts or when there are changes. tl you misplace <br />your instructions, you can dowNoad thein from <br />wwwnyflorida.com/dor <br />104 <br />