Free UCS-6C - Florida


File Size: 40.0 kB
Pages: 1
File Format: PDF
State: Florida
Category: Tax Forms
Word Count: 39 Words, 1,331 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dor.myflorida.com/dor/forms/2007/ucs6c.pdf

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Employee's Consent Form Reciprocal Coverage Election

UCS-6C R. 07/07

Social Employee'sName: ______________________________________ SecurityNo.





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ResidenceAddress:_____________________________________________________________________________________ City,StateZIP: _________________________________________________________________________________________ _ InasmuchasIcustomarilyperformservicesfor: Employer'sName:_______________________________________________________________________________________ Employer'sAddress: ____________________________________________________________________________________ _ City,StateZIP: _________________________________________________________________________________________ _ inmorethanonestate,Itheundersigned,concurinmyemployer'srequestthatmyservicesforthepurpose ofunemploymentcompensationbedeemedtobeperformedentirelywithintheStateofFloridaeffectiveasof ________________________,andherebyconsenttosuchdetermination.Thiscoverageistoremainineffectuntilsuch timeastheconditionsofmyemploymentwithrespecttowheremyservicesareperformedchangetotheextentthatI nolongercustomarilyperformservicesinmorethanonestate,ortheagreementisotherwiseterminated. Date:___________________________Signed:_______________________________________________________________

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