Free UCS-9 - Florida

UCS-9 N. 04/07

Florida Department of Revenue Unemployment Tax

Application for Agent Registration

DOR Use Only: ____________________ Agent Number

Agent Name: Mailing Address: UT Account Number (if applicable): FEIN:

Contact: Title: Phone: Fax:

Registering as an agent allows you to file and/or pay on behalf of the clients listed. For the Department to disclose confidential tax information, a Power of Attorney (DR-835) must be submitted for each client. You will not be allowed to register as an agent unless you represent at least one client. Client Name and Mailing Address UT Account No. FEIN *Effective Begin Date

*Effective Begin Date is the date you begin representing your client. This date must be the beginning of a reporting period (i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07).
Signature of Agent: Date:

Mail to:

Account Management Florida Department of Revenue PO Box 6510 Tallahassee, FL 32314-6510

For more information regarding agent/client relationships or completing this form call 800-482-8293 or 850-487-8099. www.myflorida.com/dor

UCS-9 N. 04/07 Page 2

Client Name and Mailing Address

UT Account No.

FEIN

*Effective Begin Date

*Effective Begin Date is the date you begin representing of your client. This date must be the beginning of a reporting period (i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07).

(Attach additional sheets, if necessary.) www.myflorida.com/dor