RTS-6A
                      Employer’s Reciprocal Coverage Election                                                    R. 01/13
                                Supplemental Attachment                                                               TC
                                                                                                                 Rule 73B-10.037
                                                                                                Florida Administrative Code
                                                                                                           Effective Date 11/14

This form must be attached to each copy of the Employer’s Reciprocal Coverage Election (RTS-6).

1.  The jurisdictions listed below are hereby included in Item 1 of the election to which this sheet is attached:

           State                % Of Service                       State                       % Of Service

2.  The employees listed below are hereby included in Item 2 of the election to which this sheet is attached:

                                                                               Basis for Election in Florida
                      Social Security          Employee’s Legal 
 Employee’s Name                                                   a)  Does some work in Florida
                      Number                             Residence b)  Residence in Florida
                                                                   c)  Related to a place of business in Florida

  ____________________________  _________________________________________________________________
                 Date                                    Firm – Name of Employer

Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the 
administration of Florida’s taxes.  SSNs obtained for tax administration purposes are confidential under sections 213.053 
and 119.071, Florida Statutes, and not subject to disclosure as public records.  Collection of your SSN is authorized 
under state and federal law.  Visit our Internet site at www.floridarevenue.com and select “Privacy Notice” for more 
information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized 
exceptions.

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