RTS-1SA 
                                                                                                                       R. 12/15 
                                                                                                                         TC 
                                         List of Employees to be Transferred                            Rule 73B-10.037 
                                                                                                        Florida Administrative Code 
                                                                                                           Effective 12/15

                                              Print or type in blue or black ink.
Successor Name:                                          RT* Account No.:

Predecessor Name:                                        RT Account No.:

Contact Name:                                            Telephone No.:

Form RTS-1SA should list employees, who work or have worked for the transferred unit(s) from the date the unit was first 
reported by the predecessor(s) through the date of acquisition.  The list must be in social security number sequential order 
and include employees’ names.  The Employer’s Annual Federal Unemployment (FUTA) Tax Return(Form 940) and 
Employer’s Quarterly Report Form (RT-6, formerly UCT-6) cannot be used in lieu of Form RTS-1SA. In addition, if the 
predecessor was an Employee Leasing Company that had not updated its client list to delete clients who left prior to the 
transfer, please submit a list of the client companies that left prior to the transfer. 
If transferring more than ten employees, this information must be submitted electronically. For more information, call 
850-488-6800, Monday through Friday, excluding holidays. 

                            List of Employees to be Transferred to the Successor
                       Social Security                                                  Employee’s Name 
                                 Number                                  (print or type last name first)

1

2

3

4

5

6

7

8

9

10

                                                 Social security numbers (SSNs) are used by the Florida Department 
    Please attach this form to your RTS-1S 
                                                 of Revenue as unique identifiers for the administration of Florida's 
                   (formerly UCS-1S) and         taxes.  SSNs obtained for tax administration purposes are 
    Mail to:                                     confidential under sections 213.053 and 119.071, Florida Statutes, 
                   Account Management            and not subject to disclosure as public records.  Collection of your 
                   Florida Department of Revenue SSN is authorized under state and federal law.  Visit our Internet site 
                   P.O. Box 6510                 at www.floridarevenue.com and select "Privacy Notice" for more 
                   Tallahassee, FL 32314-6510    information regarding the state and federal law governing the 
                                                 collection, use, or release of SSNs, including authorized exceptions.

 * Formerly Unemployment Tax
                                                 www.floridarevenue.com