Free UCS-2 - Florida

Voluntary Election to Become an Employer Under the Florida Unemployment Compensation Law
Completethisformonlyifyoudonotmeettheliabilitycriteria

UCS-2 R. 07/07

Ownername: Mailingaddress:

(Legalnameofindividual,principalpartner,orcorporation) City State ZIP

Theabovenamed,beinganemployingunitundertheFloridaunemploymentcompensationlaw,tothesame extentasanyotheremployerliabletopaycontributionsthereunder,doesherebyvoluntarilyelect,accordingto thetermsandprovisionsofSection443.121(3),FloridaStatutes(F.S.),thereof,tobecome,asof (a) (b)


firstdayofJanuary,20


Month

datestatedinfirm'srequest

­


Day

­


Year

anemployerliabletopaycontributionsundertheFloridaunemploymentcompensationlaw,tothesameextentasany otheremployer,andherebymakesapplicationforthewrittenapprovalofsuchelectionbytheDepartment. Theundersignedagreestobegovernedbyalltheterms,conditionsandprovisionsoftheFloridaunemployment compensationlawandtherulesandregulationsoftheFloridaDepartmentofRevenuetopaythecontributionsrequired ofemployersbysaidlaw. TheundersignedattachesheretofullyexecutedDR-1. Date:
Month



­

Day



­

Year



Ownername: ________________________________________________________ _
(Legalnameofindividual,principalpartner,orcorporation.)

By: _________________________________________________________________ _ Title:________________________________________________________________ Phonenumber:(________)_____________________________________________

FOR DEPARTMENTAL USE Approved Denied Date: ­ ­
Month Day

By: _______________________________________________ _ StateofFlorida DepartmentofRevenue

Year

Effectivedateofliability:
Month



­

Day



­

Year



Return

address:



FloridaDepartmentofRevenue POBox6510 TallahasseeFL32314-6510 www.myflorida.com/dor

For assistance call: 800-482-8293