Company ID Here 
                                                                                                                                                                                             RT-6EW 
                                                                                                                                                                                              R. 07/23  
                                                                                                                                                                                             Rule 73B-10.037, F.A.C. 
                                                                                                                                                                                             Effective XX/XX
                                                                                                                                                                                             Page ___ of ___

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 website at www.floridarevenue.com and select “Privacy Notice” for more information regarding the
stateand federal law governing the collection, use, or release of SSNs, including authorized exceptions. 

                                                                  EMPLOYER’S Name: FDOR – Employer Test

 1234567                 012345678                      0318 

 123456789               LAST NAME                      FIRST NAME & MI                      01234567890                                                  01234567890            0123456789 0

   123456789             LAST NAME                      FIRST NAME & MI                      01234567890                                                  01234567890            01234567890 

 123456789              LAST NAME                      FIRST NAME & MI                       01234567890                                                  01234567890            01234567890 

   123456789               LAST NAME                    FIRST NAME & MI                      01234567890                                                  01234567890            01234567890 

 123456789               LAST NAME                     FIRST NAME & MI                       01234567890                                                  01234567890            01234567890 

   123456789             LAST NAME                      FIRST NAME & MI                      01234567890                                                  01234567890            01234567890 

 123456789               LAST NAME                     FIRST NAME & MI                       01234567890                                                  01234567890            01234567890 

   123456789             LAST NAME                      FIRST NAME & MI                      01234567890                                                  01234567890            01234567890 

                                                                                             01234567890                                                  01234567890            01234567890 

                                                                                             01234567890                                                  01234567890            01234567890 

E-Verify Certificatio
I attest, under penalty of perjury, that this employer uses the E-Verify system defined in section 448.095(1)(c), Florida Statutes or the Employment 
Eligibility Verification (Form USCIS I-9), if E-Verify is not available within three business days of a new hire, to verify the employment eligibility of 
newly hired employees.
                                      Signature       _________________________________________________
                                      Title                _________________________________________________
                                      Today’s Date  _________________________________________________