RTS-2
                                Voluntary Election to Become an Employer                                     R. 01/13
                                Under the Florida Reemployment Tax* Law                                                                                             TC
                                                                                                           Rule 73B-10.037
                                                                                                  Florida Administrative Code
                            Complete this form only if you do not meet the liability criteria              Effective Date 11/14

Owner name:
                            (Legal name of individual, principal partner, or corporation)

Mailing address:
                                                       City                State                  ZIP

The above named, being an employing unit under the Florida reemployment tax law, to the same
extent as any other employer liable to pay contributions thereunder, does hereby voluntarily elect, according to 
the terms and provisions of Section 443.121(3), Florida Statutes (F.S.), thereof, to become, as of

          (a)       first day of January, 20  
          (b)       date stated in firm’s request          –      –     
                                                    Month    Day       Year
an employer liable to pay contributions under the Florida reemployment tax law, to the same extent as any other 
employer, and hereby makes application for the written approval of such election by the Department.

The undersigned agrees to be governed by all the terms, conditions and provisions of the Florida reemployment
tax law and the rules and regulations of the Florida Department of Revenue to pay the contributions required of employers 
by said law.

The undersigned attaches hereto fully executed DR-1.

Date:  Month   –    Day  –  Year Owner name: _________________________________________________________(Legal name of individual, principal partner, or corporation.)
                                 By: __________________________________________________________________

                                 Title: ________________________________________________________________

                                 Phone number: (________) _____________________________________________

* Formerly Unemployment Tax

                                             FOR DEPARTMENTAL USE

     Approved            Denied                        By: ________________________________________________
                                                       State of Florida
Date:                                                  Department of Revenue
        Month  –    Day  –  Year 

Effective date of liability:

        Month  –    Day  –  Year 

    Return address:     Florida Department of Revenue                            For assistance call:
                        PO Box 6510                                              850-488-6800
                        Tallahassee FL 32314-6510
                                             www.floridarevenue.com