Free UCS-10 - Florida

UCS-10 N. 04/07

Florida Department of Revenue Unemployment Tax

Agent/Client Change Form
Agent Name: Mailing Address: Agent Number (5 digits): FEIN: Contact: Title: Phone: Fax:

Use this form to add or delete clients for the purpose of filing or paying unemployment tax. ADD Client Name and Mailing Address UT FEIN Account No. DELETE

*Effective **Effective Begin Date End Date

*Effective Begin Date is the date you begin representing your client. This date must be the beginning of a reporting period (i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07). **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).
Signature of Agent: Date:

Mail to:

Account Management Florida Department of Revenue PO Box 6510 Tallahassee, FL 32314-6510

For more information regarding agent/client relationships or completing this form call 800-482-8293 or 850-487-8099. www.myflorida.com/dor

UCS-10 N. 04/07 Page 2

ADD Client Name and Mailing Address UT FEIN Account No.

DELETE

*Effective **Effective Begin Date End Date

*Effective Begin Date is the date you begin representing your client. This date must be the beginning of a reporting period (i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07). **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).

(Attach additional sheets, if necessary.) www.myflorida.com/dor