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UCS-6B

Employee Notice

R. 02/10

for Unemployment Compensation Coverage

Rule 60BB-2.037

Florida Administrative Code

(Employer’s Reciprocal Coverage Election)

Social

—

Employee’s Name: ______________________________________ Security No.:

Residence Address: _____________________________________________________________________________________

City, State ZIP: _ _________________________________________________________________________________________

Effective as of ___________________ 20_____, and until further notice, the Florida unemployment compensation

law will be the law which applies to all work you perform for the undersigned employer, in any or all of the following

jurisdictions:

________________________________________________________________________________________________________

This will be true under an election duly filed by the undersigned employer and approved by the state of Florida,

Department of Revenue, to which the other jurisdictions listed above duly consented.

If you become unemployed, and live in Florida, you can file your unemployment claim through the Internet at

Should you be unable to file your claim through the Internet,

please contact the nearest One Stop Career Center for further instructions on how to file your claim.

If you live in another state, you can file through the Internet at ,

or you may file your claim by calling 800-318-0133. Should you be unable to file your claim through either the

Internet or by telephone, please contact the nearest One Stop Career Center, or it’s equivalent, in the state where

you live.

Save this notice in case it is needed, if and when you file a claim for benefits.

Firm-Name of Employer: _____________________________________________________________________________

—

Employer’s Florida Unemployment Tax Account No.:

Date this notice is given or mailed to the employee:

The employer must complete at least two copies of this notice, and distribute them as follows:

1. One copy must be delivered (or mailed) to the employee.

Florida Department of Revenue

2. One copy must be sent to the:

PO Box 6510

Tallahassee FL 32314-6510

I understand and agree to the above statements.

_______________________________________________________________

(Signature of Employee)

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-6b - Employee Notice For Unemployment Compensation Coverage (Employer'S Reciprocal Coverage Election)

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