RTS-5
                                                                                                        R. 01/13
                                       Application to Terminate                                         TC
                                                                                                      Rule 73B-10.037
                                    Reemployment Tax* Account                    Florida Administrative Code
                                                                                                   Effective Date 01/14

 Your application must be received by April 30 of the year for which termination is requested.

                           Legal Entity
                                                             Reemployment Tax account number 

                   Mailing Address

                   City, State, ZIP

As an employer under the Florida reemployment assistance program law, we hereby make formal 
application to cease to be an employer in accordance with the provision of said law as of the first day 
of January, 20    .

                                    Please check appropriate box below:

For Domestic Employment
            ❑  Did not pay cash of $1,000 or more in any calendar quarter in either the current or 
               preceding calendar year.

For Regular Employment
            ❑  Did not pay wages of $1,500 or more in any calendar quarter in either the current or 
               preceding calendar year.
            ❑  Did not have at least one employee for any portion of a day in 20 different calendar 
               weeks in either the current or preceding calendar year.

For Agricultural Employment
            ❑  Did not pay wages of $10,000 or more for agricultural service in any calendar quarter in 
               either the current or preceding calendar year.
            ❑  Did not have at least five employees for any portion of a day in 20 different calendar 
               weeks in either the current or preceding calendar year.

For Non-Profit Organizations
            ❑  Did not have at least four or more employees for any portion of a day in each of 20 
               different weeks in either the current or preceding calendar year.

I understand that if my reemployment tax account is terminated and I subsequently have 
employment sufficient to reestablish liability for reemployment tax, I will be treated as a new 
employer for the purpose of establishing a reemployment tax rate.

                Signature                                              Date

                                          (                  )
                     Title                                       Telephone Number

For Department of Revenue use only          Mail completed form to:
                                            Florida Department of Revenue
❑  Approved    ❑  Denied 
                                            Account Management
Date _____________________________          PO Box 6510
                                            Tallahassee,FL 32314–6510
By ______________________________

* Formerly Unemployment Tax            www.floridarevenue.com