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HomeMy WebLinkAbout2022-107JOBS GRANT AGREEMENT BETWEEN INDIAN RIVER COUNTY AND LEMNATURE AQUAFARMS USA, INC. THIS INDIAN RIVER COUNTY JOBS GRANT AGREEMENT ("Agreement") is made as of the 17'' day of May, 2022 (the "Effective Date") 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 Lemnature AquaFarms USA, Inc, a company 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 COUNTY by either attracting new businesses to COUNTY or by encouraging the expansion of existing businesses within COUNTY; and WHEREAS, the creation of new employment opportunities for residents of COUNTY and the increased tax revenues resulting from such business expansions or relocations within 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 COUNTY and thereby creates new employment opportunities for the residents of COUNTY; and WHEREAS, COUNTY, through its Board of County Commissioners, has created a local Jobs Grant Program; and WHEREAS, COMPANY currently has 113 full time employees employed within Indian River County, and WHEREAS, COMPANY, in accordance with the COUNTY's Jobs Grant Program criteria, is an Existing Business that will expand its business in COUNTY to create 46 additional full-time jobs which pay at least 75% of COUNTY's average annual wage level; and WHEREAS, COUNTY has determined that COMPANY is 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: -1- a. "Adjacent Counties" means Brevard, Osceola, St. Lucie, Okeechobee, and Martin Counties. b. "Annual Wage" - includes salary, bonuses, and commissions. c. "Default" - failure to comply with the terms of this Agreement. d. "Expanding Business" — shall be defined as a business expanding its operation over and above its base employment amount at the time of jobs grant approval by 5 or more new jobs to employ 5 or more new full-time employees in the COUNTY within the term of the Grant. 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 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 $46,289 (effective January 11 2022 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 new jobs to employ 5 or more new 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. Commencement Date" — the date that the COUNTY begins tracking qualifying jobs for potential local jobs grant payments. Such date shall start on one of the following dates: January 1St, April V, July 1St, or October 1St of a year agreed to by COUNTY as established within this Agreement or as otherwise modified in accordance with this Agreement. i. "Qualifying job" — a full-time equivalent job having an annual wage equal to or greater than 75% of Indian River County's Average Annual Wage. Such jobs must be filled by people who live in COUNTY or Adjacent Counties. j. "Quarterly Reemployment Compensation Report (RT -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 reemployment compensation should employees cease to be employed. For -2- purposes of this Agreement, this definition shall also include other similar COUNTY approved certified forms from COMPANY or COMPANY's professional employer organization. k. "Relocation of a business" — a business relocating to COUNTY and employing 5 or more full-time employees in the COUNTY. 1. "Target Industry" — An industry identified within the Target Industry List of the Economic Development Element of COUNTY's Comprehensive Plan (Policy 2.5 of the Economic Development Element). 2. Term; Termination. This Agreement shall be effective as of the date of this Agreement stated on page 1 and shall automatically terminate after one of the following has occurred (whichever occurs first), unless terminated earlier by COUNTY because of a Default by COMPANY. a. COUNTY has made the last payment to COMPANY; b. COMPANY did not employ a minimum of 5 new Qualifying Jobs by the Commencement Date, as may be modified; or c. COMPANY failed, for a period of 3 consecutive years (12 quarters), to provide required Quarterly Reemployment Compensation Reports (RT -6 form) to COUNTY. 3. Grant Eli fg bility; Payment Schedule. a. COMPANY will be eligible for total Jobs Grant Funding (hereinafter a "Grant") in an amount of up to $200,000. COMPANY acknowledges and agrees that the initial Grant under this Agreement is payable on a re -imbursement basis. The number of jobs estimated to be provided is listed below. Jobs grant payments are dependent upon the number of employees exceeding the company's employment level at the time that this Agreement is approved by the Indian River County Board of County Commissioners, and by the criteria set forth below. (i) For Phase I, 10 new qualifying jobs meeting the wage level commitment in Section 5 of this Agreement shall be provided by the phase commencement date 7/01/22. 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 10 jobs. (ii) For Phase Il, 36 new qualifying jobs meeting the wage level commitment in Section 5 of this agreement shall be provided by the phase commencement date 10/01/22. 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 36 jobs. -3- (iv) It is understood that the quantity of jobs proposed above, their annual wages, and dates of hire are estimates. Because of that, the quantity of jobs provided may be less than 46, and the Commencement Date (for Grant tracking) may be extended. Proposed jobs will remain eligible for Grant incentives provided: a. The minimum number of qualifying jobs provided in Phase I is 5. b. The maximum number of jobs eligible for local jobs grant funds for Phases I, and II is 46. c. The maximum extension for a phase commencement date shall be one year. Such commencement date extension may be approved administratively by the County Community Development Director or his designee provided the extension date meets the requirements of Section 3 of this agreement. If any of the 46 eligible jobs proposed for Phases I, and II are created after the Phase II commencement date or, if applicable, after an administratively approved extension to the Phase II commencement date, those jobs shall not be eligible for local jobs grant funds. In no case shall the total Grant exceed $200,000. (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, as set forth herein. 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, the Community Development Department Director, or his designee, will lower the jobs grant award for the respective year by the amount allocated in such year for each job for which the requirements of this agreement are not met. Thus, the total jobs grant award could be less than $200,000 by the end of this Agreement. (vi) If COMPANY changes the products or services it provides in such a way that would make COMPANY no longer qualify as a "Target Industry" or if COMPANY relocates outside of Indian River County, COMPANY shall be in Default of this Agreement. COMPANY shall reimburse COUNTY for payments made to COMPANY while COMPANY was not a "Target Industry or if while COMPANY was not relocated within Indian River County." (vii) During the Term of this Agreement, COMPANY shall have a majority (greater than 50%) of its goods and services, attributable to the Indian River County location, sold or distributed outside of Indian River County. -4- COMPANY shall reimburse COUNTY for payments made to COMPANY while COMPANY did not meet this requirement. b. Performance Evaluation for Payment. Prior to the submittal of COMPANY's 1' Quarterly Reemployment Compensation Report COMPANY shall provide to the COUNTY Community Development Director, or his designee, an employee census and a copy of the Quarterly Reemployment Compensation Report for the Effective Date of this Agreement. That employee census must list employee name, job title, city and state in which the employee lives, annual salary, location where employee works, and date of hire. COMPANY's performance evaluation will be conducted on an annual basis using the information provided on the Quarterly Reemployment Compensation Report (RT -6 form) and COMPANY's quarterly updates to its employee census. Each updated employee census must include the information referenced above plus the date of termination for each employee (if the employee terminates employment with the COMPANY). COMPANY shall supply additional documentation to the Community Development Director, or his designee, in a form acceptable to the Community Development Director, or his designee, showing that positions for which Grant funds will be awarded are filled by people who live in COUNTY or Adjacent Counties. The Grant eligibility determinations will cover one year periods, with each yearly period beginning and ending as follows: Phase Grant Eligibility Determinations 1st 2nd 3rd (anal Begin End Begin End Begin End I 7/01/2022 6/30/2023 7/01/2023 6/30/2024 7/01/2024 6/30/2025 I1 10/01/2022 9/30/2023 10/01/2023 9/30/2024 10/01/2024 9/30/2025 (i) Each job must meet the minimum wage requirements specified in this Agreement. Payment of Grant funds shall be made based on the County's current adopted payment calculation methodology (methodology approved by the BCC on 10-24-2017) within forty-five (45) days after the date COMPANY submits the latest Quarterly Reemployment Compensation Report comprising the Annual Job Status Report (as defined in Paragraph 6), and this payment obligation shall survive the termination of this Agreement. Notwithstanding the foregoing, should the date for filing the last Quarterly Reemployment Compensation Report, as described above, not coincide with the date that an eligibility determination is made, COMPANY shall have the right to file a Quarterly Reemployment Compensation Report, in a form substantially similar to a Quarterly Reemployment Compensation Report, and such Quarterly Reemployment -5- Compensation Report shall constitute the Annual Job Status Report, the filing of which shall begin the running of the forty-five (45) -day period within which payment shall be made. If COMPANY applies for a Qualified Target Industry (QTI) Tax Refund from the State of Florida and if COMPANY has that QTI Tax Refund approved by the State, the Community Development Director or his designee will reduce the Grant amount paid directly to COMPANY for each eligibility determination in an amount sufficient to cover COUNTY's QTI Tax Refund 20% contribution obligation to the State for COMPANY's QTI Tax Refund agreement. The Community Development Director or his designee will submit the 20% payment obligation to the State for placement in the Florida Economic Development Trust Fund. (ii) If at the time of performance evaluation for payment as described in subsection 3.b COMPANY is not current on COUNTY Real Estate and Tangible Personal Property Taxes, COUNTY shall withhold Grant payments for that eligibility determination time period and COMPANY shall automatically forfeit its right to collect Grant payments for that eligibility time period. COMPANY shall remain eligible for any remaining future Grant payments for future eligibility time periods provided COMPANY is current on such taxes referenced above at the time of future Grant eligibility determination time periods. 4. Job Creation Commitment. COMPANY estimates that it will provide 46 new Qualifying Jobs within 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. Grant funds will be awarded up to a maximum of $200,000. The Grant award will be based on the following: Category* Amount Per Job 75% to 99.99% of Indian River County $3,000 Average Annual Wage 100% to 149.99% of Indian River County $5,000 Average Annual Wage 150% of Indian River County Average $7,000 Annual Wage (or greater) *One average annual wage category will be utilized consistent with Exhibit "D" and the County's current adopted payment calculation methodology. 5. Wage Level Commitment. COMPANY estimates that it will pay 23 employees whose jobs are eligible for a Grant hereunder an annual wage of not less than $34,716.75, will pay 15 employees an annual wage of not less than $46,289, and -6- will pay 8 employees an annual wage of not less than $69,433.50. The annual wage of the positions will be determined without taking into account the value of any benefits. COMPANY shall, in accordance with the provisions of paragraph 6 below, provide written verification of such wages satisfactory to the Community Development Director or his designee. 6. Annual Job Status. COMPANY must provide the Community Development Director or his designee with Quarterly Reemployment Compensation Reports (Form RT -6) of its business operations within COUNTY on State form RT -6, as amended, a sample of which is attached hereto and made a part hereof as Exhibit "C". - COMPANY must also provide the Community Development Director or his designee with quarterly updates to its employee census for employees working at its Indian River County location(s) (see section 3.b. of this Agreement). The cumulative Quarterly Reemployment Compensation Reports required to be filed for the annual period, correlated with each eligibility determination and the corresponding quarterly employee census shall collectively comprise the Annual Job Status Report. Quarterly, COMPANY must also provide the Community Development Director or his designee a signed statement indicating the percent of its total sales/services from the Indian River County location provided outside of Indian River County for the jobs grant payment time period. Starting with calendar quarter 3 in 2023, quarterly reports must be submitted for Grant eligibility determination. Those quarterly reports must be submitted no later than 60 days after the end of each quarter, until the termination of this Agreement. Submittal deadline may be waived by the Community Development Director, for good cause. 7. Default; Termination. Except as set forth herein, 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. 8. Indemnification. COMPANY shall indemnify and hold 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. 9. 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. -7- 10. 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. 11. 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. 12. 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. 13. 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. 14. Assignment. 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 the Community Development Director. The Community Development Director shall not unreasonably withhold its consent to any Transfer. Any such attempted Transfer without the express prior written Community Development Director consent shall be null and void and may, at the option of the County Community Development Director, be deemed a Default under this Agreement. COMPANY acknowledges and agrees that the Community Development Director 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 COUNTY Community Development Director, in his sole discretion, deems appropriate. -8- If COMPANY seeks the Community Development Director's consent for a Transfer, COMPANY shall submit to the Community Development Director 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 COUNTY; and (iii) a financial statement or other reasonably detailed financial information concerning the proposed Transferee. If the Community Development Director withholds the consent to Transfer, COMPANY may appeal to the County Administrator. If the County Administrator withholds the consent to Transfer, COMPANY may appeal to the Board of County Commissioners. 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) if appealed to the Board of County Commissioners such request for a Transfer is expressly subject to the approval of the Transfer by the Board of County Commissioners, and such Transfer 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. 15. Conflict of Interest. COMPANY 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 Part III, Chapter 112. COMPANY further represents that no person having any interest shall be employed for said performance. 16. 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: Community Development Director Indian River County 1801 270i Street Vero Beach, Florida 32960 and if sent to COMPANY shall be mailed to (or current, official address): 1991 740i Ave., Suite B Vero Beach FL 32966 17. 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 -9- conditions contained in this Agreement may be added to, modified, superseded or otherwise altered, except by written instrument executed by the parties hereto. 18. 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. 19. Public Records. COMPANY shall comply with the provisions of Chapter 119, Florida Statutes (Public Records Law) in connection with this Agreement, as modified by exemptions in Chapter 288, Florida Statutes. 20. 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. 21. General. The Background Recitals are true and correct and form a material part of this Agreement. 22. TERMINATION IN REGARDS TO F.S. 287.135: COMPANY certifies that it and those related entities of COMPANY as defined by Florida law are not on the Scrutinized Companies that Boycott Israel List, created pursuant to s. 215.4725 of the Florida Statutes, and are not engaged in a boycott of Israel. In addition, if this agreement is for goods or services of one million dollars or more, COMPANY certifies that it and those related entities of COMPANY as defined by Florida law are not on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to Section 215.473 of the Florida Statutes and are not engaged in business operations in Cuba or Syria. OWNER may terminate this Contract if COMPANY is found to have submitted a false certification as provided under section 287.135(5), Florida Statutes, been placed on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or been engaged in business operations in Cuba or Syria, as defined by section 287.135, Florida Statutes. OWNER may terminate this Contract if COMPANY, including all wholly owned subsidiaries, majority-owned subsidiaries, and parent companies that exist for the purpose of making profit, is found to have been placed on the Scrutinized Companies that Boycott Israel List or is engaged in a boycott of Israel as set forth in section 215.4725, Florida Statutes. 23. Contractor is registered with and will use the Department of Homeland Security's E -Verify system (www.e-verify.,gov) to confirm the employment eligibility of all newly hired employees for the duration of this agreement, as required by Section 448.095, F.S. Contractor is also responsible for obtaining proof of E -Verify registration and utilization for all subcontractors. -10- IN WITNESS WHEREOF, the Board of County Commissioners of Indian River County, Florida has made and executed this Agreement on behalf of COUNTY and COMPANY has hereunto set its hand the day and year above written. BOARD OF COUNTY COMMISSIONERS OF IN7 RIVER COUNTY =•*: � s:, Peter D. O'Bryan, Chairma ATTEST BY: Jeffrey R. Smith, Clerk of Court and Comptroller By: ihLk��� — Deputy Clerk APP VED: Jason rown, County Administrator APPROVED AS TO FORM AND LEGAL SUFFICIENCY Dyla eingold, County Attorney Title: l GePre- antj �Uwo-*�e56U-r^c-�5 Typed Name WITNESS: Title: Sign e -11- EXHIBIT "A" TO THE JOBS GRANT AGREEMENT BETWEEN INDIAN RIVER COUNTY & LEMNATURE AQUAFARMS USA, INC COMPANY Identification and Information: Application received date: April 27, 2022. COMPANY description: LEMNATURE AQUAFARMS USA, INC. is an existing manufacturer in the County that manufactures plant -based food & beverage products. COMPANY'S current mailing address: 1991 74h Ave., Suite B Vero Beach FL 32966 -12- EXHIBIT "B" TO THE JOBS GRANT AGREEMENT BETWEEN INDIAN RIVER COUNTY & LEMNATURE AQUAFARMS USA, INC I. Target Industry Categories eligible for application: COMPANY qualifies for the Jobs Grant Program under the "Manufacturing/Warehouse/Distribution" category. Under the North American Industrial Classification System (NAICS), COMPANY's activities are classified in the category of "Beverage Manufacturing", NAICS Code #3121. II. Employment Commitment: The COMPANY is receiving this Grant based upon its representation that it will bring the following employment opportunities to COUNTY: 1) 23 # of new, full-time employees whose annual wages are between 75% and 99.9% of Indian River County's average annual wage. 2) 15 # of new, full-time employees whose annual wages are between 100% and 149.99% of Indian River County's average annual wage 3) 8 # of new, full-time employees whose annual wages are 150% or greater of Indian River County's average annual wage III. Maximum Potential Grant Amount Category Qualified Jobs Amount per Job Total 75% of county average wage 23 $3,000 $69,000 100% of county average wage 15 $5,000 $75,000 150% of county average wage 8 $7,000 $56,000 Sub -Total Grant Amount $200,000 *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 $200,000. As noted in the agreement, incremental payments will be made for qualified jobs based upon phase dates and actual company performance in meeting local jobs grant requirements. FXommunity Development\Users\EDplannr\INCENTIVES & FUNDINGUOBS GRANT PROGRAWACTIVE JOBS GRANTS\Project Green\Approved Jobs Grant Agreement - Lemnature.docx -13- Use black ink. Example A - Handwritten Example B - Typed 11 E `g 1❑❑2 Al 3 ©0®C ❑� 3 �ew�� QUARTERENDING DUE DATE II II NII I II III II I IIN I II NII II Name Mailing Address City/St/ZIP Location Addre ss City/st/ZIP 1. Enter thetotalnumber of full -lime and part-time covered workers who performed services during or received pay for the payroll period including the 121h of the month. 1s11 Month ❑❑❑7❑❑❑ 2nd Month 3rd Month LLJIJa�7��I I Check if final return: [ Date operations ceased. Check if you had out-of-state wages. Attach Employer's Quarterly Report for Out -of -State Taxable Wages (RT-6NF). Exhibit "C" Florida Department of Revenue Employer's Quarterly Report Employers are required to file quarterly tax/wage reports regardless of employment acbmty or whether any taxes are due. RT -6 Use Black Ink to Complete This Form R. 01/15 PENALTY AFTER DATE TAX RATE RTACCOUNTNUMBER, Under penalties of peguty, I decla tr r:r r a r and the facts stated Ind are true (sec�ons 44;,.171(5), Florida Statutes), Title Sign here Siplature of offo;er Date Phone ( ) Fax ( ) Preparor% Preparer check Prepare Paid signature _ if self-employed or PFIN preparers Firm's name (a yours "Date FEIN only if self-employed) ---_..-- --- - -- -. and adcirm ZIP Preparer's phonenumber ( ) TC Rule 7313-10.037 Employer's Quarterly Report Payment Coupon Florida Administrative Code Effecli Date 11/14 Florida Department of Revenue COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY T Please write your RT ACCOUNT NUMBER on check. 1111 / ❑ ❑ � ❑ ❑ Make check payable to: Fonda U.C. Fund POSTMARK OR HAND-DELIYE RY DATE RT ACCOUNT NO. L__J 11 E F1 L1 F1 LJ F.E.I. NUMBER 1111_1111E1111E11 Name Mailing Address City/St/ZIP L ------------------- FtT-B R. 01/15 L U.S. Dollars Cents Do not make any charges U you do not have an account number, you to the pre-printed are required to rapietarl"s iosfructipnsj It chargese information on this form. F.E.I.NUMBER nn request and complete an c- a Emp/oyerAcoount J Change For -(RTS -3). FOBOIRMUSE01LLyMMM WE Reverse Side Must be Completed 1111/11 [X I 1 a 11 2. Gross wages paid this quarter ❑ �'� �'� (Must toil all pages) ■ ❑ S. Excess wages paid this quarter a'� �'� (See instructions) ❑ . 4. Taxable wages pad this (See instructions) quarter �'� �'� ■ 5. due VulliplyLine 4byTax Rate) ❑��'���'�❑a� �� 6. Penalty due (See (SeeInstructions) ❑�❑'I1011 1111 7. Interest (See instructions) (S ❑ � 1111a �EE■ IL II �❑ 8. Installment fee (See instrucuons) ! ■ ❑ 9a. Total amount due (Se (See instructions) 111111 'il 11119111111 Is[111 96. Amount Enclosed (See instructions) n a �'n n :� ■ If you are filing as a sole proprietor, is this for domestic (household) employment only? Yes n L.] No Under penalties of peguty, I decla tr r:r r a r and the facts stated Ind are true (sec�ons 44;,.171(5), Florida Statutes), Title Sign here Siplature of offo;er Date Phone ( ) Fax ( ) Preparor% Preparer check Prepare Paid signature _ if self-employed or PFIN preparers Firm's name (a yours "Date FEIN only if self-employed) ---_..-- --- - -- -. and adcirm ZIP Preparer's phonenumber ( ) TC Rule 7313-10.037 Employer's Quarterly Report Payment Coupon Florida Administrative Code Effecli Date 11/14 Florida Department of Revenue COMPLETE and MAIL with your REPORT/PAYMENT. DOR USE ONLY T Please write your RT ACCOUNT NUMBER on check. 1111 / ❑ ❑ � ❑ ❑ Make check payable to: Fonda U.C. Fund POSTMARK OR HAND-DELIYE RY DATE RT ACCOUNT NO. L__J 11 E F1 L1 F1 LJ F.E.I. NUMBER 1111_1111E1111E11 Name Mailing Address City/St/ZIP L ------------------- FtT-B R. 01/15 L U.S. Dollars Cents GROSS WAGES (From Line 2 above.) L J ❑��'❑�119E❑E. DE I—I AMOUNT 9blabove.) ❑ [11111 9 E 11 E . 1117 PAYMENT FOR QUARTER ENDING MM/YY I I Check here if you are electing to Check here if you transmitted pay tax due in installments. funds electronically. 9100 0 99999999 0068054031 7 5009999999 0000 4 LFlorida Department of Revenue Employer's Quarterly Report RT -6 Employers are required to file quarterly taxhvage reports regardless of employment act vity or whether any taxes are due. mi R. 01/15 Use Black Ink to Complete This Form QUARTER ENDING EMPLOYER'S NAME AT ACCOUNT NUMBER ❑❑/❑❑/I❑❑❑❑ ❑❑❑❑❑❑11 10. EMPLOYEE'S SOCIAL SECURITY NUMBER �1. EMPLOYEE'S NAME (please i first twelve characters of lag name and I rst t 2a. EMPLOYEE'S GROSS WAGES eight characters o f first name in boxes) 12b EMPLOYEE'S TAXABLE WAGES -- --------- only the first $7,000paid toeach PAID THIS PAID THIS employeepercalendwyearivtaxable. QUARTER QUARTER 1111❑ -1111-1111❑❑ Last Name ❑❑❑❑❑❑❑❑❑❑❑❑ 12a. 1111❑:❑❑❑'❑❑LI■❑❑ First. Nam❑❑'❑❑❑.1111 1111❑❑❑❑❑❑ IrnMiddle 161131126. 11 1111❑ -1111-1111❑❑ Name 11111111111111111111111112a. 11❑❑�❑❑❑'❑❑11■ 1111 Nam12b. Name Middle 1111❑❑❑❑❑11 InitialMiddle 11 11❑'111111.11❑ 1111❑-1111-1111❑❑ Last Name ❑❑❑❑11❑❑❑❑❑❑❑ 12a. 1111❑:❑❑❑'❑❑❑�❑❑ Nam Name ❑_❑❑❑❑❑❑❑ v1lQdle �I rndd a 121 11,11❑❑.1111 1111❑ -1111-1111❑❑ Laat Name ❑❑❑❑❑❑�❑❑❑❑❑ 12a. ❑❑11'❑❑11'11111■ ❑❑ Firstt Name Liddle ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Iniad ❑ 121 11 711 1111 . 11 F1 1111❑-1111—❑❑�❑ Narcie 11❑❑❑❑❑❑❑❑❑❑❑ 12a. ❑❑❑711❑�111.11 First Name 1111❑1111❑❑❑ Middle ❑ Initid 12b. ❑❑'1111❑■ 1111 ❑❑❑—❑-1111❑ Name 1111❑1111❑❑❑1111❑❑ 12a. ❑❑'❑❑'❑❑. ❑ Name 1111❑❑❑1111❑ Miti ❑ 121 1111'11❑❑■ 1111 1111❑ -1111-1111❑❑ lLast ame ❑❑❑❑❑❑❑❑❑❑❑❑ 12a. ❑❑❑'❑❑❑'❑❑❑■ 1111 Name a mita 126. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Middle 11 1111'111111 ■ 1111 1111❑ -1111-1111❑❑ lame ❑❑❑❑❑❑❑❑❑❑❑❑ 12a.First ❑❑❑'❑❑❑'❑❑❑�❑❑ Nam N ame ! 1❑❑❑❑❑ Inhale ❑ 12b. i�11111111111111 1111'111111 1111 13a. Total Gross Wages (add Lines 12a only). Total this page only. Include this and totals from additional pages in Line 2 on page 1. ❑ ❑ 11'❑ ❑ ❑,11 ❑ 11.11 ❑ Include this and totals from additional pages in Line 4 on page 1. L 13b. Total Taxable Wages (add Lines 1 on only) Total this page only.111171111 111111 • DO NOT --------------- DET/SCR---- ------------------------------- Mail Reply To: Reemployment Tax Florida Department of Revenue 5050 W Tennessee St Bldg L Tallahassee FL 32399-0160 Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized under state and federal law. 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