Free UCS-72 - Florida

UCS-72 N. 07/07 Page 1

Affidavit of Concurrent Employment

STATE OF ___________________________________ COUNTY OF ________________________________ __________________________________________________, BEING DULY SWORN, DOES DEPOSE AND SAY: [name of person signing this form (affiant)] 1. I hold the office indicated for the following common paymaster and related corporation(s) or liability company(ies) LLC(s) treated as corporations for federal income tax purposes: Corporate or LLC Name UT Account No. Office Held

and I have personal knowledge regarding the facts stated in this affidavit. 2. I understand that "concurrent employment" means simultaneous employment relationships between an individual, the common paymaster, and related corporations/LLCs. That those relationships require the performance of services by the employee for the benefit of the related corporations/LLCs, including the common paymaster, in exchange for wages that, if deductible for federal income tax, are deductible by the related corporation/LLCs. That there is "concurrent employment" between the individual, the common paymaster, and the related corporation/ LLC(s) listed below. That the employees perform services for the benefit of the related corporation/LLC(s), including the common paymaster, in exchange for wages that, if deductible for the purposes of federal income tax, are deductible by the related corporations/LLCs. That the name and unemployment account number of the common paymaster is: ______________________________________________________ Name 5. ___________________________________________. UT Account No.:

3.

4.

That the names and unemployment account numbers of the related corporations/LLCs, which are related according to section 443.1216(1)(d)3, Florida Statutes (F.S.) are: Related Corporation/LLC UT Account No.

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

UCS-72 N. 07/07 Page 2

6.

The following is a list of employees who are engaged in concurrent employment, their social security numbers, the quarter and year they were first engaged in concurrent employment, the name of the corporation/LLCs for which their services are performed (other than the common paymaster), and the corporation/LLCs' unemployment tax account numbers: Name of Employee Social Security Quarter/Year No. First Engaged Name of Corporation/LLC Other than Common Paymaster UT Account No.

7.

That I understand s.443.071(2), F.S., states that "Any employing unit or any officer or agent of any employing unit or any other person who makes a false statement or representation, knowing it to be false, or who knowingly fails to disclose a material fact, to prevent or reduce the payment of benefits to any individual entitled to benefits, to avoid becoming or remaining subject to this chapter, or to avoid or reduce any contribution, reimbursement, or other payment required from an employing unit under this chapter commits a felony of the third degree, punishable as provided in s.775.082, s.775.083, or s.775.084, F.S." ___________________________________________________ (signature of affiant)

Sworn to and subscribed before me this _____ day of _____________ by _____________________, who is personally known to me or has produced ________________________________ as identification. NOTARY PUBLIC Commission Number ___________________ (Attach additional sheets, if necessary.) www.myflorida.com/dor