Form Rts-6a - Employer'S Reciprocal Coverage Election Supplemental Attachment printable pdf download

Form Rts-6a - Employer'S Reciprocal Coverage Election Supplemental Attachment

RTS-6A

Employer’s Reciprocal Coverage Election

R. 01/13

Supplemental Attachment

Rule 73B-10.037

Florida Administrative Code

Effective Date 11/14

This form must be attached to each copy of the Employer’s Reciprocal Coverage Election (RTS-6).

1. The jurisdictions listed below are hereby included in Item 1 of the election to which this sheet is attached:

State

% Of Service

State

% Of Service

2. The employees listed below are hereby included in Item 2 of the election to which this sheet is attached:

Basis for Election in Florida

Social Security

Employee’s Legal

a) Does some work in Florida

Employee’s Name

Number

Residence

b) Residence in Florida

c) Related to a place of business in Florida

____________________________

_________________________________________________________________

Date

Firm – Name of Employer

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-6a - Employer'S Reciprocal Coverage Election Supplemental Attachment