HomeMy WebLinkAbout2011-148 a7 / 05/jf
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INDIAN RIVER COUNTY JOBS GRANT AGREEMENTa C) 1 ) ` q y
THIS INDIAN RIVER COUNTY JOBS GRANT AGREEMENT ("Agreement") is made
as of the 5 `" day of July , 2011 by and between Indian River County, a political subdivision of the
State of Florida, by and through its Board of Commissioners , hereinafter referred to as COUNTY,
and SMI Telecoms, LLC a limited liability corporation authorized to do business in the State of
Florida, hereinafter referred to as COMPANY.
BACKGROUND RECITALS .
WHEREAS, it is the policy of COUNTY to stimulate economic growth in Indian River
County by either attracting new businesses to Indian River County or by encouraging the expansion
of existing businesses within Indian River County ; and
WHEREAS, the creation of new employment opportunities for residents of Indian River
County and the increased tax revenues resulting from such business expansions or relocations within
Indian River County is beneficial to the local economy ; and
WHEREAS, COUNTY has determined that offering a Jobs Grant Program encourages
businesses to expand within or new businesses to locate in Indian River County and thereby creates
new employment opportunities for the residents of Indian River County ; and
WHEREAS, Indian River County , through its Board of County Commissioners, has created
a local Jobs Grant Program ; and
WHEREAS, COMPANY, in accordance with the county ' s Jobs Grant Program criteria, will
relocate to and expand its existing business in Indian River County to create new employment
opportunities that pay at least 75 % of Indian River County ' s average annual wage level ; and
WHEREAS, COMPANY has been determined to be eligible to receive a Jobs Grant ; and
WHEREAS, COMPANY acknowledges that this Agreement shall be based upon
compliance with County jobs grant program requirements ; and ,
WHEREAS, COUNTY finds and declares that it is in the public interest to award a Jobs
Grant to COMPANY pursuant to the terms of this Agreement.
NOW, THEREFORE , in consideration of the premises and mutual covenants hereinafter
contained , the parties do agree as follows :
1 . Definitions . As used in this Agreement, the following terms shall mean :
a . "Annual Wage" - includes salary , bonuses, and commissions .
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b . " Default " - failure to comply with the terms of this Agreement.
C . "Effective Date" - shall have the meaning set forth in Paragraph 2 herein.
d . " Expansion of an existing business " - shall be defined as a business
establishing 5 or more jobs to employ 5 or more full -time employees in the
County .
e . "Full -time Equivalent Job" - shall be defined as a position that is scheduled
for at least 35 hours per week.
f. "Indian River County Average Annual Wage " — shall be defined as the
average annual wage per job in Indian River County as determined by
Florida Agency for Workforce Innovation, Labor Market Statistics Center,
Quarterly Census of Employment and Wages Program , in cooperation with
the U . S . Department of Labor, Bureau of Labor Statistics . Currently , the
County ' s average annual wage is $ 34 , 730 (2009 value, effective January 1st
2011 for the state QTI Tax Refund Program) . This dollar value shall be used
for the duration of this agreement for determining local jobs grant incentives .
g . "New Business " — shall be defined as a business establishing 5 or more jobs
to employ 5 or more full -time employees in the County within the term of the
Grant, (as such term is hereinafter defined) provided that such business first
begins operations on a site in the County clearly separate from any other
operation owned by the same business .
h. "Quarterly Unemployment Compensation Report (UCT- 6 form) " — Form
from the Florida Department of Revenue that businesses in the state of
Florida must complete and submit to the state on a quarterly basis .
Information collected on the form includes the names of employees , their
social security numbers , and the gross wages paid to each employee on a
quarterly basis . The information is used for unemployment compensation
should employees cease to be employed . For purposes of this jobs grant
agreement, this definition shall also include other similar county approved
certified forms from COMPANY or COMPANY ' s professional employer
organization.
2 . Term ; Termination. This Agreement shall be effective on July 5 , 2011 (the
"Effective Date ") and shall automatically terminate after COUNTY has made the last
payment to COMPANY unless terminated earlier by COUNTY because of a default
by COMPANY.
3 , Grant Eligibility ; Payment Schedule .
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a. COMPANY will be eligible for total Jobs Grant Funding (hereinafter a
" Grant" ) in an amount of up to $ 169,000 if COMPANY locates within Indian
River County . Said Grant shall be payable in 3 one year periods by Phase as
more specifically set forth herein .
COMPANY acknowledges and agrees that the initial Grant under this
Agreement is payable on a re -imbursement basis . There are a total of 3
separate Phases . The number of jobs estimated to be provided by phase is
listed below.
(i ) For Phase I , 5 new qualifying jobs meeting the wage level commitment in
Section 6 of this Agreement will be provided by 12/31 / 11 . For each of the
three successive annual periods that those jobs are maintained at the required
wage level , COMPANY shall receive 1 /3 of the Grant amount for those 5
jobs .
(ii ) For Phase II , 8 new qualifying jobs meeting the wage level commitment
in Section 6 of this agreement will be provided by 9/30/ 12 . For each of the
three successive annual periods that those jobs are maintained at the required
wage level , COMPANY shall receive 1 /3 of the Grant amount for those 8
jobs .
(iii) For Phase III, 12 new qualifying jobs meeting the wage level
commitment in Section 6 of this agreement will be provided by 3 /31 / 13 . For
each of the three successive annual periods that those jobs are maintained at
the required wage level , COMPANY shall receive 1 /3 of the Grant amount
for those 12 jobs .
(iv) It is understood that the quantity and types of jobs proposed by phase ,
their annual wages, and dates of hire are estimates . Because of this, the
quantity and types of j obs provided in each phase may shift between phases ,
and phase commencement dates maybe extended . Proposed jobs will remain
eligible for local jobs grant incentives provided :
a. The minimum number of qualifying jobs that must be provided in
Phase I is 5 .
b . The maximum number of jobs eligible for local jobs grant funds
between Phases I , II , and III is 25 .
c . The maximum extension for a phase commencement date shall be
one year. Such commencement date may be approved
administratively by County staff. If any of the total 25 eligible
jobs proposed for Phases I , II , and III are created after their
proposed commencement date or, if applicable , after their
administratively approved extension to the proposed
commencement date, those jobs shall not be eligible for local jobs
grant funds unless an amendment is made to this agreement to
allow for this .
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d. In no case shall the total local jobs grant award exceed $ 169,000 .
(v) Failure of COMPANY to maintain claimed jobs for at least 3 years at
required wage levels will result in the reduction of the Grant amount paid to
COMPANY. If, by the end of any of the annual periods, COMPANY has not
maintained the total number of claimed jobs required or if COMPANY has
provided the total jobs required but the annual wage for any of those jobs is
less than required for that year, COUNTY will lower the jobs grant award for
the respective year. Thus, the total jobs grant award could be less than
$ 169 ,000 by the end of this Agreement .
b . Performance Evaluation for Payment . COMPANY ' s performance evaluation
will be conducted on an annual basis by the information provided on the
State ' s Quarterly Unemployment Compensation Report (UCT- 6 form) .
COMPANY shall supply additional documentation to COUNTY, in a form
acceptable to COUNTY, showing that positions for which jobs grant funds
will be awarded are filled by people who live in the general area/region and
listing the type of position filled by each employee .
The Grant eligibility determinations will cover one year periods for each of
the Phases , with each yearly period beginning and ending as follows :
Phase Grant Eligibility Determinations
1st 2nd 3rd final
Begin End Begin End Begin End
I 12/31 /2011 12/31 /2012 1 / 1/2013 12/31 /2013 1 / 1 /2014 12/31 /2014
it 9/30/2012 9/30/2013 10/ 1 /2013 9/30/2014 10/ 1 /2014 9/30/2015
111 3 /31/ 13 3 /31 / 14 4/ 1 / 14 3 /31 / 15 4/ 1 / 15 3 /31 / 16
(i) Each job must meet the minimum wage requirements specified in this
Agreement . Payment of Grant funds shall be made within forty-five (45 )
days after the date COMPANY submits the latest State Quarterly
Unemployment Compensation Report comprising the Annual Job Status
Report (as defined in Paragraph 7) , and this payment obligation shall survive
the termination of this Agreement. Notwithstanding the foregoing, should
the date for filing the last quarterly unemployment compensation report, as
described above , not coincide with the date that an eligibility determination is
made , COMPANY shall have the right to file a report, in a form substantially
similar to a quarterly unemployment compensation report, and such report
shall constitute the Annual Job Status Report, the fling of which shall begin
the running of the forty - five (45 ) -day period within which payment shall be
made .
4 . Relocation/Expansion Commitment. As a condition precedent to and as
consideration for obtaining Jobs Grant Funds from COUNTY, COMPANY agrees to
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locate in and expand its business operations on a suitable site in Indian River County
as described on Exhibit "A" , whish is attached hereto and made a part thereof.
5 . Job Creation Commitment. COMPANY estimates that it will provide 25 new jobs
within the county as set forth in Exhibit "B " , which is attached hereto and made a
part hereof. The exact number of jobs actually supplied and their salaries , however,
may vary . Local jobs grant funds will be awarded up to a maximum of $ 169 ,000 . The
jobs grant award will be based on the following :
Category Amount Per Job
75 % to 99 . 99% of Indian River County $300
Average Annual Wage
100% to 149 . 99% of Indian River County $ 5 , 000
Average Annual Wage
150% of Indian River County Average $ 75000
Annual Wage (or greater)
6 . Wage Level Commitment . COMPANY estimates that it will pay 1 employee whose
job is eligible for a Grant hereunder an annual wage of not less than $26 , 047 . 50 ; will
pay 1 employee an annual wage of not less than $ 34 , 730 . 00 ; and will pay each of 23
employees an annual wage of not less than $ 52 , 095 . 00 . The annual wage of the
positions shall be determined without taking into account the value of any benefits .
COMPANY shall, in accordance with the provisions of paragraph 7 herein below,
provide written verification of such wages satisfactory to COUNTY . COMPANY ' S
failure to maintain its wage level commitment for any one year will result in the
reduction of the Grant amount for that year(s) .
7 . Annual Job Status . COMPANY must provide COUNTY with State Quarterly
Unemployment Compensation Reports (Form UCT- 6) of its business operations
within Indian River County on State form UCT-6 as amended, a sample of which is
attached hereto and made a part hereof as Exhibit " C" . The cumulative Quarterly
State Unemployment Compensation Reports required to be filed for the annual
period correlated with each eligibility determination shall collectively comprise the
Annual Job Status Report .
For Phase I , there are 5 quarterly reports that must be submitted per grant eligibility
determination time period ; for the first grant eligibility determination time period, the
five quarterly reports are for calendar quarter 4 in 2011 , and calendar quarters 1 , 2 , 3 ,
and 4 in 2012 . For the second grant eligibility determination time period, the five
quarterly reports are for calendar quarter 4 in 2012 , and calendar quarters 1 , 2 , 3 , and
4 in 2013 . For the third grant eligibility determination time period, the five quarterly
reports are for calendar quarter 4 in 2013 , and calendar quarters 1 , 2 , 3 , and 4 in
2014 .
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For Phase II , there are 5 quarterly reports that must be submitted per grant eligibility
determination time period ; for the first grant eligibility determination time period , the
five quarterly reports are for calendar quarters 3 and 4 in 2012 , and calendar quarters
15 2 , and 3 in 2013 . For the second grant eligibility determination time period , the
five quarterly reports are for calendar quarters 3 and 4 in 2013 , and calendar quarters
1 , 2 , and 3 in 2014 . For the third grant eligibility determination time period , the five
quarterly reports are for calendar quarters 3 and 4 in 2014 , and calendar quarters 1 , 2 ,
and 3 in 2015 .
For Phase III , there are 5 quarterly reports that must be submitted per grant eligibility
determination time period; for the first grant eligibility determination time period, the
five quarterly reports are for calendar quarters 1 , 2 , 3 and 4 in 2013 , and calendar
quarter 1 in 2014 . For the second grant eligibility determination time period , the five
quarterly reports are for calendar quarters 1 , 2 , 3 and 4 in 2014 , and calendar quarter
1 in 2015 . For the third grant eligibility determination time period, the five quarterly
reports are for calendar quarters 1 , 2 , 3 and 4 in 2015 , and calendar quarter 1 in 2016 .
8 , Default; Termination . In the event that COMPANY defaults in the performance of
its guarantees and commitments as provided for in this Agreement, COUNTY may ,
at its option, terminate this Agreement.
9 . Indemnification. COMPANY shall indemnify and save harmless and defend
COUNTY, its agents, servants , and employees from and against any and all claims ,
liabilities , losses , and/or causes of action which may arise from any negligent act or
omission of COMPANY, its agents , servants, or employees in the performance of
services under this Agreement.
10 . Forum; Venue . This Agreement shall be governed by the laws of the State of
Florida. Any and all legal action necessary to enforce the Agreement will be held in
Indian River County or the Federal District Court for the Southern District of
Florida. No remedy herein conferred upon any party is intended to be exclusive of
any other remedy , and each and every such remedy shall be cumulative and shall be
in addition to every other remedy given hereunder or now or hereafter existing by
law or in equity or by statute or otherwise . No single or partial exercise by any party
of any right, power, or remedy hereunder shall preclude any other or further exercise
thereof. Parties hereby waive their right for a jury trial .
11 . Lobbyist Certification . COMPANY warrants that it has not employed or retained
any company or person, other than a bona fide employee working solely for
COMPANY, to solicit or secure this Agreement and that it has not paid or agreed to
pay any person, company , corporation , individual , or firm , other than a bona fide
employee working solely for COMPANY, any fee, commission, percentage , gift, or
any other consideration contingent upon or resulting from the award or making of
this Agreement.
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12 . No Discrimination Certification . COMPANY warrants and represents that all of its
employees are treated equally during employment without regard to race, color,
religion, disability , sex, age , national origin, ancestry , marital status, or sexual
orientation .
13 . Attorneys Fees . If any legal action or other proceeding is brought for the
enforcement of this Agreement, or because of an alleged dispute, breach, default or
misrepresentation in connection with any provisions of this Agreement, each party
shall bear its own costs .
14 . Enforceability . If any term or provision of this Agreement, or the application thereof
to any person or circumstances , shall to any extent be held invalid or unenforceable ,
the remainder of this Agreement, or the application of such terms or provision , to
persons or circumstances other than those as to which it is held invalid or
unenforceable, shall not be affected, and every other term and provision of this
Agreement shall be deemed valid and enforceable to the extent permitted by law.
The Company ' s failure to maintain its job creation commitment or annual wage level
commitment for any one year will result in the decrease of the Grant amount it was
scheduled to receive for that year; however, such decrease will not preclude the
Company ' s receipt of scheduled Grant amounts for those subsequent years in which
it is able to maintain its job creation and wage level commitment .
15 . Assi ng ment . COMPANY shall not, directly or indirectly, assign or transfer any of
its rights or obligations under this Agreement, or any interest therein (the foregoing
herein collectively "Transfer") , without the express prior written consent of
COUNTY . COUNTY shall not unreasonably withhold its consent to any Transfer.
Any such attempted Transfer without the express prior written COUNTY consent
shall be null and void and may , at the option of COUNTY, be deemed an event of
default under this Agreement. COMPANY acknowledges and agrees that COUNTY
has the right, in granting or withholding consent to any Transfer, to consider, among
other things, the financial responsibility and business reputation of the proposed
assignee or transferee (the foregoing herein collectively "Transferee") ; and any other
items that the Indian River County Board of County Commissioners , in its sole
discretion , deems appropriate . If COMPANY seeks COUNTY ' s consent for a
Transfer, COMPANY shall submit to COUNTY a written request therefore ,
accompanied by the following documentation : (i) the name , address , and telephone
number of the proposed Transferee ; (ii ) a description of the business and jobs ,
including wages, to be created in Indian River County ; and (iii ) a financial statement
or other reasonably detailed financial information concerning the proposed
Transferee . COMPANY acknowledges and agrees that : (a) the County
Administrator or his designee , or the Indian River County Board of County
Commissioners, has the right to request any additional information deemed
necessary to make the decision relating to consent to the Transfer; and (b) any such
request for a Transfer is expressly subject to the approval of the Transfer by the
Board of County Commissioners at a formal meeting thereof, and such Transfer
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shall become effective only when signed by the Transferee and approved by the
Board, which consent shall not be unreasonably withheld . The foregoing covenant
shall be binding on the permitted successors or assigns of COMPANY . The
prohibition on Transfers shall not prohibit a change in the form in which COMPANY
conducts business . COMPANY will be released from further liability under this
Agreement in the event of an approved Transfer; provided that the County ' s consent
to any Transfer will not otherwise relieve COMPANY from any pre- existing
obligation to COUNTY under this Agreement.
16 . Conflict of Interest . COUNTY represents that it presently has no interest and shall
acquire no interest, either direct or indirect, which would conflict in any manner with
the performance of services required hereunder, as provided for in Florida Statutes
112 . 311 . COMPANY further represents that no person having any interest shall be
employed for said performance .
17 . Notices . All notices required in this Agreement shall be sent by certified mail , return
receipt requested and if sent to COUNTY shall be mailed to :
Indian River County Community Development Director
1801 27' h Street
Vero Beach, Florida 32960
and if sent to COMPANY shall be mailed to (or current, official address) :
SMI Telecoms , LLC
280 Madison Avenue , 9'h Floor
New York, NY 10016
18 . Entire Agreement . COUNTY and COMPANY agree that this Agreement sets forth
the entire Agreement between the parties, and that there are no promises or
understandings other than those stated herein . None of the provisions , terms and
conditions contained in this Agreement may be added to , modified, superseded or
otherwise altered , except by written instrument executed by the parties hereto .
19 . No Pledge of Credit. COMPANY shall not pledge COUNTY' s credit or make it a
guarantor of payment or surety for any contract, debt, obligation, judgment, lien, or
any form of indebtedness .
20 . Public Records . COMPANY shall comply with the provisions of Chapter 119 ,
Florida Statutes (Public Records Law) in connection with this Agreement .
21 , Counterparts. This Agreement may be executed in one or more counterparts , each of
which shall be deemed to be an original copy and all of which shall constitute but
one and the same instrument .
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22 . General . The Background Recitals are true and correct and form a material part of
this Agreement.
IN WITNESS WHEREOF, the Board of County Commissioners of Indian River County ,
Florida has made and executed this Agreement on behalf of the COUNTY and the COMPANY has
hereunto set its hand the day and year above written .
BOARD OF COUNTY COMMISSIONERS °daaaaanaa°°°
°°°
OF INDIAN RIVER COUNTY ° °�•��t , , . . . . . , , 5�0.�
J'
BY : °
a , o
Bob Solari , Chairman
° : O
ATTEST BY :
990 , o�a
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Jeffrey K. Barton , Clerk
APPROVED : Jul 201
( .'. , A -
o eph A. haird, County Administrator
APPROXED , TO F A LEGAL SUFFICIENCY. 4
4
Man Polackwich , ounty Attorney
COMPANY : SMI Telecoms, LLC
BY : Title * C '�
y2C� 0ks
Typed Name
WITNESS .
�,� �,L, Title • "'� �'u
Signature
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EXHIBIT " A " TO THE .LOBS GRANT AGREEMENT
BETWEEN INDIAN RIVER COUNTY & SMI TELECOMS LLC
Company Identification and Information :
Application date : May 31 , 2011
Company description :
COMPANY ' s proposed facility will be its national headquarters . COMPANY develops
software solutions for the global telecommunications industry . COMPANY also provides
implementation and support services for its products . While administrative , sales, support,
project office (logistical management), research and development, and management staff will
be located within the headquarters office , implementation and consultancy staff tend to be
geographically dispersed . Because implementation and consultancy positions within
COMPANY are geographically dispersed , some of the 25 proposed employees may
ultimately not live within Indian River County or in the surrounding region (adjacent
counties) , and those positions will not be eligible for jobs grant funds . The exact number of
positions that will be eligible for the local jobs grant program will be determined as
COMPANY proceeds with its hiring and expansion plans .
Company ' s proposed new physical address in Indian River County :
10305 102nd Terrace
Sebastian , FL 32958
Company ' s local mailing address :
SMI Telecoms , LLC is proposing to locate its National Headquarters at the address listed
above . If the location changes , COMPANY will promptly notify COUNTY of its new
location . To be eligible for and remain eligible for the local jobs grant program, COMPANY
must locate its National Headquarters within Indian River County . Positions eligible for the
jobs grant program must be based out of the National Headquarters and meet other
applicable requirements of this agreement.
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EXHIBIT " B " TO THE JOBS GRANT AGREEMENT
BETWEEN INDIAN RIVER COUNTY & SMI Telecoms , LLC (COMPANY)
I. Target Industry Categories eligible for application :
COMPANY qualifies for the jobs grant program under the "Telecommunications" category .
Under the 2007 North American Industrial Classification System (NAICS ) , COMPANY ' s
activities are classified in categories 5112 " Software Publishers" , 5415 " Computer Systems
Design and Related Services" , and 5416 "Management, Scientific, and Technical Consulting
Services" .
II. Employment Commitment :
The COMPANY is receiving this grant based upon its representation that it will bring the
following employment opportunities to Indian River County :
1 ) 1 # of new, full-time employees whose annual wage is between 75 % and
99 . 9% of Indian River County' s average annual wage .
2) 1 # of new, full-time employees whose annual wage is between 100% and
149 . 99% of Indian River County ' s average annual wage
3 ) 23 # of new, full -time employees whose annual wage is 150% or greater of
Indian River County ' s average annual wage
III . Grant Amount
Category Qualified Amount Per Total
Jobs Job
75 % to 99 . 9% of Indian River County Average 1 $ 3 , 000 $ 39000
Annual Wage
100% to 149 . 99% of Indian River County Average 1 $ 500 $ 5 , 000
Annual Wage
150% or greater of Indian River County Average 23 $ 7 , 000 $ 161 , 000
Annual Wage
Total 25 $ 1691000 *
* The actual amount of the grant will depend upon the actual number of jobs provided and the salary paid for those jobs .
In no case shall the total amount of the grant exceed $ 169 , 000 .
F:\Community Development\Users\GDplannr\lncentives & FundingVobs Grant Program\SMI TelecomsUob Grant Agreement SMI Telecoms - Proposed 0 - For
Creating PDF .doc
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Exhibit " C "
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0000 — ❑ - 0000 ❑ ❑ Last Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 72a ❑ ❑ 119❑ ❑ ❑ 9❑ 11 . 11 ❑
First
Name 0000 ❑ ❑ ❑ ❑ nit�18 ❑ t2b. 11 ❑ 901111 ❑
• U ❑
0000 ❑ — ❑ - 0000 ❑ tame ❑ ❑ ❑ ❑ 111100 ❑ ❑ ❑ ❑ t2a. ❑ ❑ ❑ 9❑ ❑ 1190 ❑ ❑ . 0000
First Name ❑ F1 11 11111111 Inittiiale ❑ 12b. ❑ ❑ 9110 ❑ • ❑ ❑
0000 ❑ - 0000 - 0000 ❑ ❑ Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12a. 00119❑ ❑ ❑ 90L.111 . 00
First Old
Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Initial"'
❑ 12b. ❑ 119❑ ❑ ❑ • ❑ ❑
0000 ❑ - 0000 - 0000 ❑ ❑ Last Na" e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 12a. 0000 ❑ 9❑ ❑ ❑ 9 ❑ Ir❑�I '�11II ❑ • ❑ ❑
First Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ In F] 12b. ❑ ❑ 9O LJ ❑ • 0000
0000 ❑ — ❑ ❑ - 1111 ❑ ❑ Nme ❑ ❑ ❑ ❑ 1111 ❑ ❑ ❑ ❑ ❑ ❑ 120. 0 ❑ 119❑ ❑ ❑ y❑ I(❑�1I (I11
11 [1111
First Middle
Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ddle ❑ 12b-
Name ❑ ❑ 9111_! i-1 . L—I ❑
0000 ❑ — ❑ - 0000 ❑ Last
Name 0 ❑ ❑ ❑ ❑ ❑ 00 ❑ C11I ❑ 12a. ❑First ❑ ❑ 911011 :[111
❑ ❑ • ❑ ❑
Name ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Initial ❑ 12b. t�T ❑ ❑ f1 ❑ . 1111
t3a. Total Gross Wages (add Lines 12a only). Total this page only. ❑ 0 11911 ❑ ❑ 91111 11 • ❑ ❑
Include this and totals from additional pages in Line 2 on page t .
I 3b. Total Taxable Wages {acrd Lines 1 only}. Total this page only. F1 ❑ 9110 11 . 1111
include this and totals from additional
al pages in Lune 4 on page T .
00 NOT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ' - - " - - - - - - � .. . - _ ... _ _ . - - _ _ .
_ - _ _
_ _. ._ _ _ _ _ - _ _ _ _ _ _ ` - _ - - -
bETACH
Mail Reply To : Social security numbers (SSNs) are used by the Florida Department of Revenue as unique
Unemployment Tax identifiers for the administration of Florida's taxes. SSNs obtained for tax administration
Florida Department of Revenue purposes are confidential under sections 213.053 and 119.071 , Florida Statutes .. and not
5050 W Tennessee St Bldg L subject to disclosure as public records. Collection of your SSN is authorized under state
Tallahassee FL 32399-0180 and federal law. Visit our Internet site at www.mytlorida.com/dor and select " Privacy
Notice" for more information regarding the state and federal law governing the collection,
use, or release of SSNs, including authorized exceptions.
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