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

                                                                          Reemployment Tax Account Number
Employer’s Name:  _______________________________________________________                   — 
The above employer hereby elects, subject to approval by the agencies involved, to cover certain individuals (those 
customarily performing services in more than one jurisdiction) named below and on any attached form, under the
Reemployment Tax (formerly Unemployment Tax) law of Florida.

1.   The employer accordingly requests the state of Florida, Department of Revenue to enter into a reciprocal coverage 
 arrangement to that effect, with each of the following other “interested jurisdictions” (in which the individuals 
 named under Item 2 perform some services for the employer, and under whose unemployment compensation laws 
 they might otherwise be covered):

 State          % Of Service                                State                    % Of Service

       (If more space is required, use and attach Form RTS-6A, formerly UCS-6A)

2.   List employees covered by this election:

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

       (If more space is required, use and attach Form RTS-6A, formerly UCS-6A)

3.  Nature of employer’s business. _________________________________________________________________________
4.  The employer has a place of business in the states listed above. ____________________________________________
5.  Nature of work to be performed by the individual(s) listed under Item 2. ______________________________________
6.  Employer’s reason for requesting coverage in Florida.  _____________________________________________________
7.  The employer requests that this election become effective as of the beginning of a calendar quarter, namely
 as of  ______________________________________

                                             www.floridarevenue.com

                                                                                                                  RTS-6
                                                                                                             R. 01/13
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                                         ELECTION (continued)
8.  This election, if approved, shall remain operative, as to the individuals listed herewith, until terminated in accordance 
 with the currently applicable regulations of the Florida Department of Revenue.
9.  The employer hereby agrees to give each individual covered by this election a notice thereof, promptly after its 
 approval, on a form to be supplied by the Florida Department of Revenue, and to file copies thereof with said 
 agency.
10. The employer hereby agrees to comply with any requirements applicable to this election under the Florida 
 Department of Revenue.
11. To prevent this election from denying reemployment assistance/unemployment compensation coverage to workers 
 not listed hereon, the employer hereby agrees with each interested jurisdiction approving this election that it may 
 count the workers covered by this election, and their wages, as if this election did not apply, for the purpose 
 of determining whether the employer is covered by the law of such jurisdiction and whether any other workers 
 employed by him are covered by said law.

SIGNED, for the employer by: ______________________________________________________________________________

Date:  ____________________________________________  Title:  _________________________________________________

APPROVAL by the state of Florida, Department of Revenue
The foregoing election is hereby approved, in accordance with the applicable regulations, as submitted by the elect-
ing employer.
APPROVED for the state of Florida, Department of Revenue.

                                                          By:  __________________________________________________

Date:  ____________________________________________  Title:  _________________________________________________

APPROVED by the interested jurisdiction of  _________________________________________________________________
The foregoing is similarly approved.
                                                          Name of Agency:  ______________________________________

                                                          By:  __________________________________________________

Date:  ____________________________________________  Title:  _________________________________________________

NOTE:  The employer should submit two (2) signed copies for each jurisdiction listed under item 1, plus two (2) additional 
copies.  All copies should be sent to the state of Florida, Department of Revenue, P.O. Box 6510, Tallahassee, FL 
32314-6510.  Two copies will be sent to each “interested jurisdiction” for approval or disapproval.  The employer will be 
notified of the final action.
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.
                                         www.floridarevenue.com