Free UCS-1SA - Florida

UCS-1SA R. 06/08

List of Employees to be Transferred

Print or type in blue or black ink.
Successor Name: Predecessor Name: Contact Name: UT Account No.: UT Account No.: Telephone No.:

Form UCS-1SA should list employees, who work or have worked for the transferred unit(s) from the date the unit was first reported by the predecessor(s) through the date of acquisition. The list must be in social security number sequential order and include employees' names. The Employer's Annual Federal Unemployment (FUTA) Tax Return (Form 941) and Employer's Quarterly Report Form (UCT-6) cannot be used in lieu of Form UCS-1SA. If transferring more than ten employees, this information must be submitted electronically. For more information call 800-482-8293 Monday through Friday, 8 a.m. through 7 p.m., ET.

List of Employees to be Transferred to the Successor
Social Security Number 1 2 3 4 5 6 7 8 9 10 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ Please attach this form to your UCS-1S or Mail to: Account Management Florida Department of Revenue P.O. Box 6510 Tallahassee, FL 32314-6510 www.myflorida.com/dor Employee's Name (print or type last name first)