Form Rts-6 - Employer'S Reciprocal Coverage Election (Page 2 of 2) in pdf

RTS-6

R. 01/13

Page 2

ELECTION (continued)

8. This election, if approved, shall remain operative, as to the individuals listed herewith, until terminated in accordance

with the currently applicable regulations of the Florida Department of Revenue.

9. The employer hereby agrees to give each individual covered by this election a notice thereof, promptly after its

approval, on a form to be supplied by the Florida Department of Revenue, and to file copies thereof with said

agency.

10. The employer hereby agrees to comply with any requirements applicable to this election under the Florida

Department of Revenue.

11. To prevent this election from denying reemployment assistance/unemployment compensation coverage to workers

not listed hereon, the employer hereby agrees with each interested jurisdiction approving this election that it may

count the workers covered by this election, and their wages, as if this election did not apply, for the purpose

of determining whether the employer is covered by the law of such jurisdiction and whether any other workers

employed by him are covered by said law.

SIGNED, for the employer by: ______________________________________________________________________________

Date: ____________________________________________ Title: _________________________________________________

APPROVAL by the state of Florida, Department of Revenue

The foregoing election is hereby approved, in accordance with the applicable regulations, as submitted by the elect-

ing employer.

APPROVED for the state of Florida, Department of Revenue.

By: __________________________________________________

Date: ____________________________________________ Title: _________________________________________________

APPROVED by the interested jurisdiction of _________________________________________________________________

The foregoing is similarly approved.

Name of Agency: ______________________________________

By: __________________________________________________

Date: ____________________________________________ Title: _________________________________________________

NOTE: The employer should submit two (2) signed copies for each jurisdiction listed under item 1, plus two (2) additional

copies. All copies should be sent to the state of Florida, Department of Revenue, P.O. Box 6510, Tallahassee, FL

32314-6510. Two copies will be sent to each “interested jurisdiction” for approval or disapproval. The employer will be

notified of the final action.

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 and select “Privacy Notice” for more

information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized

exceptions.

Form Rts-6 - Employer'S Reciprocal Coverage Election Page 2