Form Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election printable pdf download

Form Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election

UCS-6C

Employee’s Consent Form

R. 02/10

Reciprocal Coverage Election

Rule 60BB-2.037

Florida Administrative Code

Social

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Employee’s Name: ______________________________________ Security No.:

Residence Address: _____________________________________________________________________________________

City, State ZIP: _ _________________________________________________________________________________________

Inasmuch as I customarily perform services for:

Employer’s Name: _ ______________________________________________________________________________________

Employer’s Address: _ ____________________________________________________________________________________

City, State ZIP: _ _________________________________________________________________________________________

in more than one state, I the undersigned, concur in my employer’s request that my services for the purpose

of unemployment compensation be deemed to be performed entirely within the State of Florida effective as of

________________________, and hereby consent to such determination. This coverage is to remain in effect until such

time as the conditions of my employment with respect to where my services are performed change to the extent that I

no longer customarily perform services in more than one state, or the agreement is otherwise terminated.

Date: ___________________________ Signed: _______________________________________________________________

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 Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election