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


Employer’s Reciprocal Coverage Election
R. 01/13
Supplemental Attachment
Rule 73B-10.037
Florida Administrative Code
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:
% Of Service
% 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
b) Residence in Florida
c) Related to a place of business in Florida
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


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