Form RTS-6A Fillable Employer's Reciprocal Coverage Election Supplemental Attachment R.01/13
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

% Of Service 1 The jurisdictions listed below are hereby included in Item 1 of the election to which this sheet is attached: 2 The employees listed below are hereby included in Item 2 of the election to which this sheet is attached: a) Does some work in Florida 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 b) Residence in Florida Basis for Election in Florida c) Related to a place of business in Florida Date Firm Name of Employer Effective Date 11/14 Employee s Legal Employee s Name Employer s Reciprocal Coverage Election exceptions Florida Administrative Code information regarding the state and federal law governing the collection use or release of SSNs including authorized Number R 01/13 Residence RTS 6A Rule 73B 10 037 Social Security Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the State Supplemental Attachment This form must be attached to each copy of the Employer s Reciprocal Coverage Election (RTS 6) under state and federal law Visit our Internet site at www myflorida com/dor and select Privacy Notice for more www myflorida com/dor