Free UCS-6 - Florida

Employer's Reciprocal Coverage Election

UCS-6 R. 07/07

Employer'sName:_______________________________________________________

UnemploymentTaxAccountNumber --

Theaboveemployerherebyelects,subjecttoapprovalbytheunemploymenttaxagenciesinvolved,tocovercertain individuals(thosecustomarilyperformingservicesinmorethanonejurisdiction)namedbelowandonanyattached form,undertheunemploymenttaxlawofFlorida. 1. TheemployeraccordinglyrequeststhestateofFlorida,DepartmentofRevenuetoenterintoareciprocalcoverage arrangementtothateffect,witheachofthefollowingother"interestedjurisdictions"(inwhichtheindividuals namedunderItem2performsomeservicesfortheemployer,andunderwhoseunemploymentcompensationlaws theymightotherwisebecovered): STATE % OF SERVICE STATE % OF SERVICE

(Ifmorespaceisrequired,useandattachFormUCS-6A) 2. Listemployeescoveredbythiselection: SOCIAl SECURITy NUmbER EmplOyEE'S lEGAl RESIDENCE bASIS FOR ElECTION IN FlORIDA a) DoessomeworkinFlorida b) ResidenceinFlorida c) RelatedtoaplaceofbusinessinFlorida

EmplOyEE'S NAmE

(Ifmorespaceisrequired,useandattachFormUCS-6A) 3. Natureofemployer'sbusiness. _________________________________________________________________________ 4. Theemployerhasaplaceofbusinessinthestateslistedabove.____________________________________________ 5. Natureofworktobeperformedbytheindividual(s)listedunderItem2.______________________________________ 6. Employer'sreasonforrequestingcoverageinFlorida. _____________________________________________________ 7. Theemployerrequeststhatthiselectionbecomeeffectiveasofthebeginningofacalendarquarter,namely asof______________________________________

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UCS-6 R. 07/07 page 2

ELECTION(continued) 8. Thiselection,ifapproved,shallremainoperative,astotheindividualslistedherewith,untilterminatedinaccordance withthecurrentlyapplicableregulationoftheFloridaDepartmentofRevenue. 9. Theemployerherebyagreestogiveeachindividualcoveredbythiselectionanoticethereof,promptlyafterits approval,onaformtobesuppliedbytheFloridaDepartmentofRevenue,andtofilecopiesthereofwithsaid agency. 10. TheemployerherebyagreestocomplywithanyrequirementsapplicabletothiselectionundertheFlorida DepartmentofRevenue. 11. Topreventthiselectionfromdenyingunemploymentcompensationcoveragetoworkersnotlistedhereon,the employerherebyagreeswitheachinterestedjurisdictionapprovingthiselectionthatitmaycounttheworkers coveredbythiselection,andtheirwages,asifthiselectiondidnotapply,forthepurposeofdeterminingwhetherthe employeriscoveredbythelawofsuchjurisdictionandwhetheranyotherworkersemployedbyhimarecoveredby saidlaw. SIGNED,fortheemployerby:______________________________________________________________________________ Date:____________________________________________ Title:_________________________________________________ APPROVALbythestateofFlorida,DepartmentofRevenue Theforegoingelectionisherebyapproved,inaccordancewiththeapplicableregulation,assubmittedbytheelecting employer. APPROVEDforthestateofFlorida,DepartmentofRevenue. By:__________________________________________________

Date:____________________________________________ Title:_________________________________________________ APPROVEDbytheinterestedjurisdictionof_________________________________________________________________ Theforegoingissimilarlyapproved. NameofAgency: _____________________________________ _ By:__________________________________________________

Date:____________________________________________ Title:_________________________________________________

NOTE:Theemployershouldsubmittwo(2)signedcopiesforeachjurisdictionlistedunderitem1,plustwo(2)additional copies.AllcopiesshouldbesenttothestateofFlorida,DepartmentofRevenue,P.O.Box6510,Tallahassee,FL 32314-6510.Twocopieswillbesenttoeach"interestedjurisdiction"forapprovalordisapproval.Theemployerwillbe notifiedofthefinalaction.

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