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Exhibit "C" <br /> Florida Department of Revenue Employer's Quarterly Report <br /> 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. <br /> Example A Exampe B <br /> 01 234 56789 0123456789 RT-6 <br /> Use Black Ink to Complete This Form T R.01/15 <br /> QUARTER ENDING DUE DATE PENALTY AFTE R DATE TAX RATE RT ACCOUNT NUMBER <br /> III IIIIIII I II III II II IIIII I II IIIA II Do mtmateartychanges if you&e,aqu not have an account numbw,you <br /> to the pre-prides are required to register(see instructions} <br /> information an this tam. F.E.I NUMBER <br /> N changes are needed, <br /> request and complete an _ <br /> Employer Account <br /> Change Form(NTS-3). FOR OFFICIAL USE ONLY POMPANO(DATE <br /> Reverse Side Must be Completed <br /> Name <br /> Mailing 2. Gross wages paid this quarter i ` <br /> Address (Must total all pages) i _-- -- ' J5 ■ <br /> City/St/ZIP 3. Excess wages paid this quarterr —( I <br /> (See instructions) <br /> 4. Taxable wages paid this quarter !I ■ <br /> Location (See instructions) ' �' • <br /> Address 5. Tax due <br /> City/SUZIP (Multiply Line 4 by Tax Rate) <br /> _ 6. Penalty due <br /> 1. Enter the total number (See instructions) a <br /> of full-time and part-time 1st Month ? 7 <br /> covered workers who 7. Ante est due <br /> (See instructions) <br /> performed services during2nd Month ) R ■ �__ -_ <br /> or received pay for the 8. Installment fee <br /> payroll period including the (See instructions) a <br /> 12th of the month. 3rd Month 9a. Tetai afloat due <br /> (See instructions) <br /> Check if final return: § > • ` _ <br /> Date operations ceased. 9b. Arnaud Endowed j <br /> (See instructions) [ I <br /> . it _I <br /> Check if you had out-of-state wages.Attach Employer's H you are filing as a sole proprietor,is this for <br /> Quarterly Report for Out-of-State Taxable Wages(RT-6NF). <br /> domestic(household)employment only? Yes No <br /> 71'der peritms of perjury,!da_iare itMt t ha,e read rhin return and the fac.ts stated in if are tru. sectors 4 1:1 i5`..r <br /> Title <br /> Sign here <br /> Date Phone ( Fax i ) <br /> Preparerslot Preparer check ` - ' Prepaer's l I <br /> Paid signature if self-employed SSN a PTIN <br /> preparers Firms name la yours - FEIN <br /> only if self-employeDate <br /> d <br /> and edkfess ZIP Preparer's <br /> phone number, ' <br /> ii <br /> DO NOT <br /> Rule 73B-10.037 Employer's Quarterly Report Payment Coupon RT-6 <br /> Florida Administrative Code R.01/15 <br /> Effective Date 11/14 <br /> Florida Department of Re.;i:: COMPLETE and MAIL with your REPORT/PAYMENT. - DOR USE ONLY <br /> Please write your RT ACCOUNT NUMBER on check —, <br /> T Make check J` / /payable to: Rlxida U.C.ford TMARK OR HAND DELIVERY DATE i <br /> RT ACCOUNT NO. <br /> I U.S.Dollars I I Cents I <br /> F.E.I.NUMBER _ GROSS WAGES <br /> (From Line 2 above.) L.J L__1 i__J'LJ L.):__ill ■ <br /> AMOUNT ENCLOSED F <br /> (From Line 9b above.) I'' <br /> Name PAYMENT FOR QUARTER <br /> ENDING MM/YY <br /> Mailing <br /> Address Check here if you are electing to Check here if you transmitted <br /> City/St/ZIP pay tax due in installments. funds electronically. <br /> L - <br /> 9100 0 99999999 0068054031 7 5009999999 0000 4 <br />