Form Rts-72 - Affidavit Of Concurrent Employment (Page 2 of 2) in pdf

Form Rts-72 - Affidavit Of Concurrent Employment Page 2

RTS-72

R. 10/17

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), the corporation/LLCs' reemployment tax account numbers, and the

physical locations where the services are performed:

Name of Employee

Name of Corporation/LLC

Quarter/Year

RT Account Numbers

Physical Locations Where

Social Security Number*

Other than Common Paymaster

Reported Under

the Services are Performed

First Engaged

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 ___________________

*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, F.S.,

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.

(Attach additional sheets, if necessary.)

Form Rts-72 - Affidavit Of Concurrent Employment Page 2