Florida Department of Revenue 800 352 3671
PO Box 6510
Tallahassee FL 32314 6510
(Attach additional sheets if necessary )
(i e 1/1/07 4/1/07 7/1/07 10/1/07)
* Formerly Unemployment Tax
**Effective
**Effective End Date is the last day of the reporting period for which you represent the client (i e 3/31/07 6/30/07 9/30/07 12/31/07)
*Effective
*Effective Begin Date is the date you begin representing your client This date must be the beginning of a reporting period
Account No
Agent Name:
Agent Number (5 digits):
Agent/Client Change Form
Begin Date
Client Name and Mailing Address
Contact:
Date:
DELETE
Effective Date 11/14
End Date
FEIN:
Florida Administrative Code
Florida Department of Revenue
Mail to: Account Management For more information call
Mailing Address:
Page 2
Phone:
R 01/13
Reemployment Tax*
RTS 10
Rule 73B 10 037
Signature of Agent:
Title:
Use this form to add or delete clients for the purpose of filing or paying reemployment tax
www myflorida com/dor
