Form Ucs-2 - Voluntary Election To Become An Employer Under The Florida Unemployment Compensation Law

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UCS-2
Voluntary Election to Become an Employer
R. 11/10
Under the Florida Unemployment Compensation Law
Complete this form only if you do not meet the liability criteria
Owner name:
(Legal name of individual, principal partner, or corporation)
Mailing address:
City
State
ZIP
The above named, being an employing unit under the Florida unemployment compensation law, to the same
extent as any other employer liable to pay contributions thereunder, does hereby voluntarily elect, according to
the terms and provisions of Section 443.121(3), Florida Statutes (F.S.), thereof, to become, as of
(a)
first day of January, 20
(b) date stated in firm’s request
–
–
Month
Day
Year
an employer liable to pay contributions under the Florida unemployment compensation law, to the same extent as any
other employer, and hereby makes application for the written approval of such election by the Department.
The undersigned agrees to be governed by all the terms, conditions and provisions of the Florida unemployment
compensation law and the rules and regulations of the Florida Department of Revenue to pay the contributions required
of employers by said law.
The undersigned attaches hereto fully executed DR-1.
Date:
–
–
Owner name: _ ________________________________________________________
Month
Day
Year
(Legal name of individual, principal partner, or corporation.)
By: _ _________________________________________________________________
Title: ________________________________________________________________
Phone number: (________) _____________________________________________
FOR DEPARTMENTAL USE
Approved
Denied
By: _ _______________________________________________
State of Florida
Date:
Department of Revenue
–
–
Month
Day
Year
Effective date of liability:
–
–
Month
Day
Year
Return address:
For assistance call:
Florida Department of Revenue
PO Box 6510
800-352-3671
Tallahassee FL 32314-6510

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