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

                                                          Social
Employee’s Name:  ______________________________________  Security No.:           —   —                         

Residence Address:  _____________________________________________________________________________________

City, State ZIP:  __________________________________________________________________________________________

Inasmuch as I customarily perform services for:

Employer’s Name:  _______________________________________________________________________________________

Employer’s Address:  _____________________________________________________________________________________

City, State ZIP:  __________________________________________________________________________________________

in more than one state, I the undersigned, concur in my employer’s request that my services for the purpose of 
the Reemployment Assistance Program Law (formerly Unemployment Compensation Law) be deemed to be 
performed entirely within the State of Florida effective as of ________________________, and hereby consent to such 
determination.  This coverage is to remain in effect until such time as the conditions of my employment with respect 
to where my services are performed change to the extent that I no longer customarily perform services in more than 
one state, or the agreement is otherwise terminated.

Date: ___________________________  Signed:  _______________________________________________________________

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