RTS-1SA
                                     List of Employees to be Transferred                                R. 12/15
                                                                                                                        TC
                                                                                                        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 
                                              of Revenue as unique identifiers for the administration of Florida’s 
   Please attach this form to your RTS-1S 
                                              taxes.  SSNs obtained for tax administration purposes are 
                 (formerly UCS-1S) and
                                              confidential under sections 213.053 and 119.071, Florida Statutes, 
   Mail to:      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 
                 P.O. Box 6510
                                              site at www.floridarevenue.com and select “Privacy Notice” for 
                 Tallahassee, FL 32314-6510
                                              more information regarding the state and federal law governing the 
                                              collection, use, or release of SSNs, including authorized exceptions.
* Formerly Unemployment Tax                   www.floridarevenue.com