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Exhibit "C" <br />tuna ileac ink Aktatrifwritten 1W.- <br />Florida Department of Revenue Employer's Quarterly Report <br />Employers ars required tipfile quarterly twMage repwAmg rdless of,efnplaymen[acttvity or wtretller any taxes are due. <br />r, .. RT --6 <br />sw <br />i R. 01/15 ok 11 <br />b 1ARl p' 3NCt DUE DME.7, <br />Pfh(AL11 t ,,. 1131 <br />[11 00` # 1 <br />Done fineliaamrdiaiiyris aygpdomot tisveatii(see tnumber,.}roa <br />I I to the pre -pooled are mqubed to regbt�(eee insfructiors} <br />mimmation on this loan. 1 NUMBER <br />It changes are needed, I' �( <br />request and complete an 00 <br />6rsployerAccount <br />Change Form (RTS -3) FOR p IIML ' <br />E10,11 <br />t Om wages paid this quar*. <br />(Must total all pages) <br />3. Excess wages paid this quWw <br />(See instructions) #� <br />4. Tile wages paid this quarter <br />(See instructions) : - <br />S 5. Tox due <br />(Mulb*Line4byTaxRate) <br />6. Penaltydue <br />t5 Enterth Ntalnumbef ( ►( "{J j j `j j`'( (See instructions) . <br />of full-time and part-time 1 st Mordh ! I 7. Interest due <br />J <br />covered workers who L J i J �L 1 �J Ld (See instructions) <br />t# �I <br />performed services during 0: <br />''""j �� ■ <br />2nd Month i f I f <br />or received pay for the I - i L. 6 (nstaltinent fee <br />payroll penodinoludingthe { (j *"j (�} f'" ((�`( (See instructions) , <br />12tk.h of the month. 3rd Month I I { } # j I I'j I 9a. Taal amount due j <br />(Seeinsbucoons)I �� <br />Chedk'rf final retains +-Ac+ �4------++ <br />Bate operations ceased. 1 9b. (SeeAmoin Encased �{"'''�� <br />(See lost ce6ons) L. - <br />!!l --- +++ <br />Check if you had aR of state wages A#ecth Emp%yarrs <br />RT <br />Quarterly Report for Ot*-of-State Taxable Wages (RT-&*). If you are filing as a sole, prbprretor, is thus for <br />domestic (houisehdd) employment only? , lwJsib <br />.. jAektylires':!Rrtki( fitwRntsairsfetumnrri?[w ,. o#Ika4l�4!e:%!!!'!f�l , ." <br />_ . <br />�trn+lAwoa(t►irwtiM Polk.' a S <br />Paid il, fa?t?[+1 <br />preparers A"1111ame9ar dura .. <br />oily tttit✓thgtit °' <br />Rli.9a�..psr�.e..�.�a. ���:�!T.RT���T�i---p.a—.-.l ----------- •wn w.�rs. r+....+.:r <br />tow <br />Employer's Quarterly Report Payment Coupon 1 <br />1T4 <br />,moan p.lf't?� <br />COMPLETE and MAIL with your REPORT/PAYMENT. <br />Please write your RT ACCOUNT NUMBER on check. <br />Make check payable to: Fbrida U.C. Fund <br />RT ACCOUNT NO. T:1 <br />F.E.I. NUMBER �(�D "�{ 0000. <br />'^� 0f{''"�� GROSS WAGES <br />1 111 (Fr rmi line 2 above.) <br />(FMOUNT abme;SEti <br />'� <br />ran Lirte9bls atawe:) <br />PAYMENT- FAR QUARTER D� <br />ENQING,MMrYY <br />'Check hate it ydty are electirif 1A if you trankril"e <br />Ud <br />PAY taxdueih"irtstallmertts, 'fat :Iectronically. <br />ri 4 <br />