Form Rts-72 - Affidavit Of Concurrent Employment

Form Rts-72 - Affidavit Of Concurrent Employment - 2013 Page 2

RTS-72

R. 01/13

Page 2

The following is a list of employees who are engaged in concurrent employment, their social security numbers, the quarter

and year they were first engaged in concurrent employment, the name of the corporation/LLCs for which their services

are performed (other than the common paymaster), and the corporation/LLCs’ reemployment tax account numbers:

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.

Name of Employee

Social

Quarter/Year

Name of Corporation/

RT Account

Security No.

First Engaged

LLC Other than Common

No.

Paymaster

That I understand s.443.071(2), F.S., states that “Any employing unit or any officer or agent of any employing unit or

any other person who makes a false statement or representation, knowing it to be false, or who knowingly fails to

disclose a material fact, to prevent or reduce the payment of benefits to any individual entitled to benefits, to avoid

becoming or remaining subject to this chapter, or to avoid or reduce any contribution, reimbursement, or other payment

required from an employing unit under this chapter commits a felony of the third degree, punishable as provided in

s.775.082, s.775.083, or s.775.084, F.S.”

___________________________________________________

(signature of affiant)

Sworn to and subscribed before me this _____ day of _____________ by _____________________, who is personally

known to me or has produced ________________________________ as identification.

NOTARY PUBLIC Commission Number ___________________

(Attach additional sheets, if necessary.)

Form Rts-72 - Affidavit Of Concurrent Employment - 2013 Page 2