Successor Name:
Predecessor Name:
Contact Name:
List of Employees to be Transferred
Print or type in blue or black ink.
RTS-1SA
R. 12/15
TC
Rule 73B-10.037
Florida Administrative Code
Effective 12/15
RT* Account No.:
RT Account No.:
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.
Social Security
Number
Employee’s Name
(print or type last name first)
1
2
3
4
5
10
9
8
6
7
List of Employees to be Transferred to the Successor
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 Internet site
at www.floridarevenue.com and select "Privacy Notice" for 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
Please attach this form to your RTS-1S
(formerly UCS-1S) and
Mail to:
Account Management
Florida Department of Revenue
P.O. Box 6510
Tallahassee, FL 32314-6510
