R14-017and
RESOLUTION R14 -017
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
BOYNTON BEACH, FLORIDA, APPROVING CHANGES TO THE
COMMERCIAL RENT REIMBURSEMENT ASSISTANCE AND
COMMERCIAL INTERIOR BUILD -OUT ASSISTANCE
PROGRAM GUIDELINES; PROVIDING FOR AN EFFECTIVE
DATE.
WHEREAS, in April, 2012, the City Commission approved a Commercial Rent
Reimbursement Assistance Program and a Commercial Interior Build -out Assistance
Program to assist small business owners and entrepreneurs the opportunity to establish or
expand their business within the City; and
WHEREAS, to better support the goals of the Economic Development Program and
for administrative purposes, changes to the Commercial Rent Reimbursement and the
Commercial Interior Build -out Grant program guidelines are being recommended by staff;
WHEREAS, upon recommendation of staff, the City Commission has determined that
it is in the best interests of the citizens and residents of the City to approve the changes to
the guidelines of the Commercial Rent Reimbursement Assistance Program and a
Commercial Interior Build -out Assistance Program.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
THE CITY OF BOYNTON BEACH, FLORIDA:
Section 1. The foregoing "Whereas" clauses are hereby ratified and confirmed as
being true and correct and are hereby made a specific part of this Resolution upon adoption
hereof.
Section 2. The City Commission of the Boynton Beach, Florida, hereby approves
\\apps3.city. cbb\auto\Data\206\Items\ 197\2905\3688\Reso_-
_Changes_to_guidelines_of commercial_ rent_ and _interior_buildout _programs.doc
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
the changes to the guidelines of the Commercial Rent Reimbursement Assistance Program
and a Commercial Interior Build -out Assistance Program, copies of which are attached
hereto as Exhibit "A ".
Section 3. This Resolution shall become effective immediately upon passage.
ATTEST:
PASSED AND ADOPTED this 18 day of February, 2014.
t M. Prainito, MMC
City Clerk
m _ILLGu,ILLib
\ \apps3.city. cbb \auto\Data\206\Items\ 197\2905 \3688\Reso_ -
Changes_to guidelines_of commercial_rent_and_interior buildout_programs.doc
CITY OF BOYNTON BEACH, FLORIDA
Vice Mayor — Woodrow L
Commissioner — David T. Merker
Commissioner — Michael M. Fitzpatrick
missioner — Joe Casello
The Commercial Interior Build -Out Assistance Program is designed to help facilitate the establishment
of new businesses and aide in the expansion of existing businesses within the City who are not
located in the Community Redevelopment Area. The program is designed to provide financial
assistance to new and existing businesses in the form of a subsidy intended to reduce a business's
initial costs associated with the construction and interior finishing of a new or expanding location.
Improvements must be permanent and stay with the building.
Applicants may be eligible for up to $15,000 in grant funding to assist with the cost of commercial
interior construction or renovations. The amount of grant funding is determined by the number of jobs
created by the applicant. Each full -time equivalent (FTE) job created is worth $5,000.00 in funding
assistance from the City with a maximum grant award of $15,000.
Businesses applying for financial assistance with the cost of interior build out must receive City of
Boynton Beach Development Department Building Division building permit approval. The City
reserves the right to approve or deny any Commercial Interior Build -Out Assistance Program
application and to discontinue payments at anytime if, in its sole and absolute discretion, it determines
that the business will not advance the goals and objectives established for the economic development
of the City.
1. Program
2013/2014
City of Boynton Beach
Commercial Interior Build -Out Assistance Program Guidelines
The Commercial Interior Build -Out Program offers financial assistance in the form of a reimbursable
grant to the landlord or business owner for eligible expenses associated with the construction or
renovation of the interior elements of the commercial operating space. Items eligible for funding
under the program are limited to:
1. Interior walls
2. Interior plumbing
3. Interior electrical system including lighting
4. HVAC system
5. Flooring
6. Fire and /or Burglar Alarm systems
7. Fire suppression systems
The Commercial Interior Build -Out Program funding may be budgeted annually by the City and
awarded on a first -come, first -serve basis. All applications are subject to City Commission approval.
Making application to the program is NOT a guarantee of funding.
Page 1 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www.boynton -beach org
Initials
II. Eligibility Requirements
Applicants must meet all of the following requirements in order to be considered eligible to receive
grant funding under the Commercial Interior Build -Out Program:
1. The business location must be within the City limits, in Commercial, Industrial or Suburban
Mixed -Use districts, excluding those within the Community Redevelopment Area (see attached
map).
2. The business must provide proof that it is properly licensed by all necessary levels of
government, professional associations or agencies, including applications or business tax
receipts with the City of Boynton Beach and Palm Beach County.
3. A new business venture is defined as a company in operation for less than six months.
4. An existing business is defined as being in operation for more than six months at the time of
application.
5. An existing business must expand to occupy more than thirty percent (30 %) of its current
square footage size. Verification of this threshold must be provided in the application package.
6. Applicant must own the building it plans to operate within or it must have an executed multi-
year lease (two year minimum).
7. Businesses must employ a minimum of two (2) full -time equivalent W -2 or 1099 contracted
employees whose wages are reported to the state and federal government; a position
occupied by the business owner may count toward one of the required job positions. For the
purposes of this grant, an FTE is defined as working a minimum of 2,080 annual hours at the
prevailing Federal minimum wage.
8. Applicants shall pay 10% above than Palm Beach County's average wage for all new
FTEs required to be created (1 per $5,000 in awarded grant funds). The hourly wage
shall be determined by the most recent available Census data or American Community
Survey data. Currently, the average per capita wage is $15.98/hour or $33,239 annually.
9. The applicant's Experian Consumer report must reflect an acceptable level of financial
stability, within the sole discretion of the City, as an eligibility requirement for funding_
The following businesses are considered ineligible for assistance under the Commercial Interior
Build -Out Program:
a. Businesses that employ less than two full -time equivalent W -2 employees or 1099
contracted employees.
b. Businesses who do not report employees' wages to the State of Florida Department of
Revenue.
c. New businesses using a D /B /A that has been used by another business within the past
twelve (12) months.
Page 2 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www. bovnton- beach.org
Initials
III. Grant Terms and Conditions
A commercial lease must define the landlord- tenant relationship and at minimum provide the following
information:
• A description of the space being rented including square footage and a drawing of the
space.
• Description of utilities that the tenant is responsible for.
• Rental rate and deposits along with terms of lease and methodology for future rent
increases.
• Responsible party for interior and exterior repairs and /or improvements.
• Insurance requirements.
• Ability to terminate.
• Consequences of default on the lease.
The City reserves the right to approve or deny any Commercial Interior Build -Out Program application
and to discontinue payments at any time if in its sole and absolute discretion it determines that the
business will not further the goals and objectives established for the economic development of the
City.
IV. Procedures for Application and Approval
Application Process - All applicants are strongly encouraged to meet with Development Department
staff in order to determine eligibility before submitting an application. Funding requests will not be
considered until all required documentation is submitted to the City's Development Department.
Application packets must include the following documentation:
1. Completed and signed application
2. Copy of the corporate documents for the applying business entity.
3. Copy of executed multi -year commercial lease agreement.
4. Qualifications, experience and track records of business owners.
5. Two (2) years of corporate tax returns (for existing businesses only).
6. Two (2) years of tax returns for the owners of a new business.
7. W9 Form (attached with this grant application)
8. List of jobs to be created and filled including job descriptions, pay range
For existing businesses, provide a list of all current positions including
range and weekly schedule.
9. Copy of design and construction plans associated with the proposed
existing business, indicate expansion area (30% or greater) on floor plan.
10. Specific list (quotes) breaking down the use of the funds and providing the total cost of the
project.
11. A minimum of four (4) 3 "x5" color "before" photos of the project.
12. Proof of funds to complete the build -out.
Page 3 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www.bovnton- beach.org
and weekly schedule.
job descriptions, pay
improvements. If an
Initials
Approval of Funding Request — Once eligibility is verified and all required documentation has been
submitted, City staff will present the funding request to the City Commission for approval. The City
Commission meets on the first and third Tuesday of each month. Applicant will be notified of the date
and time their application will be presented to the City Commission. It is recommended that the
Applicant attend the City Commission Meeting in order to answer any questions the Commission may
have regarding their application. City Staff will notify the applicant of approval or denial in writing.
Site Visits — Proof of required building permit(s) must be provided on site. City staff will conduct a site
visit before the reimbursement payment is made in order to verify that the business is in operation and
in compliance with the requirement of the building permit(s). Staff may also conduct unannounced
site visits periodically in order to ensure compliance with the terms of the grant agreement.
Initial Expense Reimbursement - This program is designed as a quarterly reimbursement grant.
That is, all work must be done and paid for by the Applicant, prior to the City's funds being released.
The City will provide quarterly reimbursements to the grantee upon submittal of a complete
Reimbursement Request package. The total monies expended by the grant applicant (up to a
maximum of $15,000) will be divided into four equal payments and released on a quarterly basis
following the Initial Reimbursement Request.
The property owner, or tenant if applicable, must complete the interior improvement project, obtain a
Certificate of Occupancy (CO) from the City of Boynton Beach and submit for reimbursement within
one hundred twenty (120) days of the grant award. Failure to complete the improvements within the
specified timeframe may result in the property owner, or tenant if applicable, losing the grant
reimbursement opportunity. Applicants may apply for only one ninety (90) day time extensions.
Once the work is completed the Initial Reimbursement Request shall be summarized in a
report and accompanied by proper documentation.
Proper documentation will consist of:
Page 4 of 9
100 E. Boynton Beach Blvd
PO. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www.boynton-beach.org
(1) Project accounting including invoices, receipts or other acceptable evidence of payment
from suppliers and licensed contractor(s) that have been marked "paid in full ". Proposals
for "work to be completed" or "bids" are not considered proper documentation. Each item
will be supported by a canceled check showing the face of the check, as well as the back
of the canceled check.
(2) Copy of Certificate of Occupancy /Completion for all permits related to this work.
(3) A release of lien signed by each licensed contractor.
(4) Copy of City and County Business Tax Receipts.
(5) Applicant shall warrant that all bills related to the Project are paid in full including, but not
limited to, all contractors, subcontracts, labor, materials, related fees and permits, and
(6) Applicant shall provide color digital "during" and "after" photos of the Project. Photos
should be from approximately the same position as the "before" photos submitted in the
Application and the "during" photos.
(7) For W -2 eligible employees, timely Florida Department of Revenue Employers Quarterly
Report (UCT -6) for each consecutive quarter must be submitted.
For sole proprietorships, partnerships, s- corporations and 1099 -MISC eligible employees
Initials
copies of all cancelled salary checks or proof of direct deposits for each full time /full time
equivalent employee for each month within that specific quarter.
By submitting for reimbursement, the applicant warrants that all bills related to this project are paid in
full, including, but not limited to, all contractors, subcontracts, labor, materials, related fees and
permits.
Quarterly Reimbursement Requests - By accepting the grant, the applicant agrees to comply with
the reporting requirement of providing the City with proof of employee wage reporting for the three
consecutive quarters following the Initial Reimbursement Request. This is to verify that the required
job positions are properly fulfilled and maintained. In order to receive quarterly funding after the Initial
Reimbursement Request grant applicant must submit a written request for that quarter's
reimbursement payment along with:
If the applicant does not submit its quarterly reimbursement request with a copy of its quarterly UCT -6
form within thirty (30) days following the end of the quarter in which the applicant is requesting
reimbursement, the applicant forfeits that quarter's reimbursement.
This is to verify that the required job positions are properly filled and maintained. In order to receive
quarterly funding after the initial reimbursement request, grant applicant must submit a written request
for that quarter.
For W -2 eligible employees, timely Florida Department of Revenue Employers Quarterly
Report (UCT -6) for each consecutive quarter must be submitted.
or
For sole proprietorships, partnerships, s- corporations and 1099 -MISC eligible employees
copies of all cancelled salary checks or proof of direct deposits for each full time /full time
equivalent employee for each month within that specific quarter.
Grant funds will be reimbursed exclusively for approved work, approved change orders and only for
work that has been performed and paid for after the grantee has received notification that the Grant
Application has been approved by the City. Any work completed prior to receiving grant approval is
ineligible for reimbursement.
Grantees may not submit work improvements for reimbursement which have been used as
reimbursement requests in any other grant program offered by the City of Boynton Beach, Palm
Beach County or the State of Florida. The Commercial Interior Build -Out Assistance program will only
honor new expenditures that have not been submitted under other grant programs.
The Commercial Interior Build -Out Assistance program may only be used one time in any five year
period for any one specific commercial unit or business entity. Businesses are limited to one
Commercial Interior Build -Out Assistance Program award.
Grantees shall allow the City the rights and use of photos and project application materials.
SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF FUNDING
It is the responsibility of the applicant to READ AND UNDERSTAND all aspects of the Grant Program
Application and Guidelines.
Page 5 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www boynton -beach org
Initials
City of Boynton Beach 2013/2014
Commercial Interior Build -Out Assistance Program Application
(Please Type or Print Only — Use Additional Sheets if Necessary)
Applicant Name:
Affiliation with Business:
Applicant Mailing Address:
Business Name (D /B /A if applicable):
Current Business
Address:
Phone: Fax:
Email: Fed ID#
Months/Years @ Current Location: Monthly Rent:
Do you have an executed lease agreement: Yes No
Landlord Name:
Landlord SSN /EIN:
Landlord's Mailing Address:
New Business Address (if applicable ):
New Business to Boynton Beach: Yes No Existing Business: Yes No
Number of years in existence
Square footage of existing space: Square footage of expansion:
Type of Business:
Number of Employees: Hours of Operation:
Are you applying for grant assistance under any other program offered by the City: Yes No
If yes, what additional programs are you applying for?
Are you receiving grant assistance from any other governmental agencies: Yes No
If yes, list any aditional grant sources and amounts:
Page 6 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www bovnton- beach.org
Initials
Principal /Owner's Signature Date
Printed Name Title
Principal /Owner's Signature Date
Printed Name Title
Principal /Owner's Signature Date
Printed Name Title
Page 7 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www.bovnton- beach.org
CERTIFICATION AND WAIVER OF PRIVACY:
I, the undersigned, applicant(s) certify that all information presented in this application, and all of the
information furnished in support of the application, is given for the purpose of obtaining a grant under
the City of Boynton Beach Commercial Interior Build -Out Program, and it is true and complete to the
best of the applicant(s) knowledge and belief. The applicant(s) further certifies that he /she is aware of
the fact that he /she can be penalized by fine and /or imprisonment for making false statements or
presenting false information. I further acknowledge that I have read and understand the terms and
conditions set forth and described in the City of Boynton Beach Commercial Interior Build -Out
Program Guidelines.
I understand that this application is not a guarantee of grant assistance. Should my application be
approved, I understand that the City may at its sole discretion discontinue subsidy payments at any
time if in its sole and absolute determination it feels such assistance no longer meets the program
criteria or is no longer benefiting the furtherance of the City mission.
I hereby waive my rights under the privacy and confidentiality provision act, and give my consent to
the City of Boynton Beach, its agents and contractors to examine any confidential information given
herein. I further grant permission, and authorize any bank, employer or other public or private agency
to disclose information deemed necessary to complete this application.
I give permission to the City or its agents to take photos of myself and business to be used to promote
the program.
I understand that if this application and the information furnished in support of the application are
found to be incomplete, it will not be processed.
SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF FUNDING
It is the responsibility of the applicant to READ AND UNDERSTAND all aspects of the Grant Program
Application and Guidelines.
Initials
aforesaid on this
(Notary seal /stamp)
NOTARY
Notary as to Principal /Owner's Signatures. Multiple Notary pages may be used if signing individually.
STATE OF
COUNTY OF
BEFORE ME, an officer duly authorized by law to administer oaths and take acknowledgements,
personally appeared , who is personally
known to me or produced as identification, and
acknowledged he /she executed the foregoing Agreement for the use and purposes mentioned in it
and that the instrument is his /her act and deed.
IN WITNESS OF THE FOREGOING, I have set my hand and official seal in the State and County
day of , 20
Page 8 of 9
100 E. Boynton Beach Blvd
P.O. Box 310
Boynton Beach, FL 33425 -0310
Phone 561- 742 -6350 Fax 561- 742 -6357
www bovnton- beach.ora
NOTARY PUBLIC
My Commission Expires:
Initials
It is the responsibility of the applicant to READ AND UNDERSTAND all aspects of the Grant Program
Application and Guidelines.
SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF FUNDING
Landlord /Property Owner's Signature
Printed Name Title
STATE OF
COUNTY OF
BEFORE ME, an officer duly authorized by law to administer oaths and take acknowledgements,
personally appeared , who is personally
known to me or produced as identification, and
acknowledged he /she executed the foregoing Agreement for the use and purposes mentioned in it
and that the instrument is his /her act and deed.
IN WITNESS OF THE FOREGOING, I have set my hand and official seal in the State and County
aforesaid on this
(Notary seal /stamp)
day of , 20
Page 9 of 9
100 E. Boynton Beach Blvd
PO. Box 310
Boynton Beach, FL 33425 -0310
Phone 561 - 742 -6350 Fax 561 - 742 -6357
www.boynton -beach org
NOTARY PUBLIC
My Commission Expires:
Date
Initials
City of Boynton Beach
Commerical /Industrial Zoning Districts
Fairfax I W
Knollwood Rd
Disc Dr
rr Key Lime Blvd
r tuga Ln Citrus Park L
l
White Rock Clr
Sausalito Dr
Edatgate Or
T ' Ocean Dr y
° d'
N
SW Congress Blvd SW 13th Ave V N
� SW 14th Ave „ ,y
C _w t il,
SW 17th Ave
t a
P al m la n
Coral Dr 5
WOcean Av
Main Blvd
South Blvd
1 a SE 1st
y- .T. SE r d
»Golf Rd win25t SW 23rd Ave 2 0 SW 24th Ave
S
Ave v+ rp
SW 25th PI S 2 g
SW 28th Ave
g w m g
it SW 27th Ave w L°-' ss
3
S W 28th Ave h SW 28th Ave ; SE 281h A l ve
Sunset Rd O
x
g SE 31st Ave -.
c3
e' Mission HlR Rtl
SW 33rd PI
d a O SW 34th Ave
tivAV II I
a Lancaster Rd f g or y SW 38th
g 7
y
5'
' -, Al
PaIm Dr
NE 28th Ct
a W NE 28th Ave
i N
m �
EGateway Blvd
1 U
} n g
NE 20th Ln
t9 NE19th Ave br
� '$ m St
NE 17th Ave w St�
NW 18th Ct
N y
O 1;
g
/ /NWp(h Ave/ //
NWV //
artIn,Luther$ing Jr
NW 84h Ave /
/ NW Bth Ave/ NE Av
th - Ava /
/ / N `` ✓
' NW Ave 6th A4
/ 1 N
a SW let Avo
SW 2nd Ave �•�#
SW 3rd Ave t j
x SW 4th Ave It
sit s L SE 5th
S W 6th Ave a
6 SW 8th Ave w i
SW 8th A o e r
SW 18th A ve
12
12 SW 12th Ave
SW 13th Ave
g SW 14th Ave
W Woolbright
SE 34th Ave
th Ave
8th Ave
NEl A
NE 11. / Ave
1st Ave S
7 stLnS
3 New Ave
Legend
Q City Boundary
CRA Boundary
Zoning
I C1 Office Professional Commercial
I C2 Neighborhood Commercial
C3 Community Commercial
C4 General Commercial
CBD Central Business District
M1 Light Industrial
PCD Planned Commercial Development
PID Planned Industrial Development
SMU Suburban Mixed Use
MU Mixed Use
0
S ;
7
Cedar Ln
Baytre• O Mayfair Ln
Miner Rd
W Ga sW
Re dyorrr,
2
Farnworth Dr
Walcott Dr
Inter Lagos a
Use black ink. Example A - Handwritten Example B - Typed
❑u 3 4 rfti❑ 8 0 ❑ ° PS3 ❑�
QUARTER ENDING
Name
Mailing
Address
City /St /ZIP
Location
Address
City /St /ZIP
/
I II 010111 iii ii a iini i ii i iii ii
1. Enter the otal - number
of full -time and part -time
covered workers who
performed services during
or received pay for the
payroll period including the
12th of the month.
Check if final return:
Date operations ceased.
Rule 6088.2.037
Florida Administrative Code
UT ACCOUNT NO.
F.E.I. NUMBER
Name
Mailing
Address
City /St/ZIP
L
T
1st Month
2nd Month
3rd Month
DUE DATE
H
/
7
Check if you had out -of -state wages. Attach Employer's
Quarterly Report for Out -of -State Taxable Wages (UCT - 6NF).
Honaa Department of Revenue COMPLETE and MAIL with your REPORT /PAYMENT.
Please write your UT ACCOUNT NUMBER on check.
Employer's Quarterly Report Payment Coupon
Make check payable to: Florida U.C. Fund
Florida Department of Revenue Employer's Quarterly Report
Employers are required to file quarterly tax/wage reports regardless of employment activity or whether any taxes are due.
Use Black Ink to Complete This Form
PENALTY AFTER DATE TAX RATE UT ACCOUNT NUMBER
Reverse Side Must be Completed
2. Gross wages paid this quarter
(Must total all pages)
3. Excess wages paid this quarter
(See instructions)
4. Taxable wages paid this quarter
(See instructions)
5. Tax due
(Multiply Line 4 by Tax Rate)
6. Penalty due
(See instructions)
7. Interest due
(See instructions)
8. Installment fee
(See instructions)
9a. Tatal amount due
(See instructions)
9b. Amount Enclosed
(See instructions)
GROSS WAGES
(From Line 2 above.)
AMOUNT ENCLOSED
(From Line 9b above.)
PAYMENT FOR QUARTER
ENDING MM/YY
Do not make any changes H you do not have an account number, you
to the pre - printed are required to register (see instructions).
Information on this form. F.E.I. NUMBER
If changes are needed,
request and complete an —
Employer Account
Change Form (UCS -3). FOR OFFICIAL USE ONLY POSTMARK DATE
Check here if you are electing to
pay tax due in installments.
II
7
7
DOR USE ONLY
II
1
U.S. Dollars
,Il ,
7
7
7
7 '
If you are filing as a sole proprietor, is this for
domestic (household) employment only?
DO NQT
DETACH
Yes
L
Sign here
Paid
preparers
only
Under penalties of perjury. I declare that I have read this return and the tacts stated in it are true (sections 443.171(5) and 443141(2), Florida Statutes).
Signa[u e of office! Date
Preparer's
signature
Firm's name (or yours
Date
Title
Phone
Preparer check
if self - employed
Preparers
SSN or PTIN
FEIN
if self - employed)
and address
ZIP
Fax,
Preparers
phone number ( )
POSTMARK R HAND-DELIVERY DATE
L
No
1 I Cents
•
•
•
T
U 03 / 2
R. 3/12
R. 03/12
Check here if you transmitted
funds electronically.
9100 0 99999999 0068054031 7 5009999999 0000 4
UCT 6
1
DI 0111110 111011011111 1111 11111 11 L
QUARTER ENDING
/ I
10. EMPLOYEE'S SOCIAL SECURITY NUMBER
H-
i
L
J/ 11 IL]
DO NOT
DETACH
Mail Reply To:
Unemployment Tax
Florida Department of Revenue
5050 W Tennessee St Bldg L
Tallahassee FL 32399 -0180
LJ
EMPLOYER'S NAME
Last
Name
First
Name
Last
Narne
First
Name
Last
Name
First
Name
Last
Name
First
Name
Last
Name
First
Name
Last
Name
First
Name
Last
Name
First
Name
Last
Name
First
Name
Florida Department of Revenue Employer's Quarterly Report
Employers are required to file quarterly tax/wage reports regardless of employment activity or whether any taxes are due.
Use Black Ink to Complete This Form
11. EMPLOYEE'S NAME (please print first twelve characters of last name and first
eight characters of first name in boxes)
L
Middle
Initial
Middle
Initial
Middle
Initial
Middle
Initial
Middle
Initial
Middle
India)
Middle
Initial
12a.
12b.
12a.
12b.
12a.
12b.
12a.
Middle ri
Initial 12b■
12a.
12b.
12a.
12a.
12b.
12a.
12b.
13a. Total Gross Wages add Lines 12a on y). Total this page only.
Include this and totals from additiona pages in Line 2 on page 1.
13b. Total Taxable Wages (add Lines 12b only). Total this page only.
Include this and totals from additional pages in Line 4 on page 1.
12a. EMPLOYEE'S GROSS WAGES PAID THIS QUARTER
12b. EMPLOYEE'S TAXABLE WAGES PAID THIS QUARTER
Only the first $8,000 paid to each employee per calendar year is taxable.
UT ACCOUNT NUMBER
7
7
7
7
7
7
7
7
7
7
I
■
■
■
■
■
■
■
iJ UCT 6
R. 03/12
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. Visit our Internet site at www.myflorida.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.
Tired of paperwork? We can help!
File and pay your Florida unemployment tax online.
It's fast, easy, accurate, and secure.
Internet Address: www.myflorida.com /dor