7. That I understand s. 443.071(2), F.S., states that "Any employing unit or any officer or agent of any employing unit or any
other person who makes a false statement or representation, knowing it to be false, or who knowingly fails to disclose
a material fact, to prevent or reduce the payment of benefits to any individual entitled to benefits, to avoid becoming
or remaining subject to this chapter, or to avoid or reduce any contribution, reimbursement, or other payment required
from an employing unit under this chapter commits a felony of the third degree, punishable as provided in s. 775.082,
s. 775.083, or s. 775.084, F.S."
(signature of affiant)
Sworn to and subscribed before me this _____ day of _____________ by _____________________, who is personally
known to me or has produced ________________________________ as identification.
NOTARY PUBLIC Commission Number ___________________
*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, F.S.,
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.
(Attach additional sheets, if necessary.)
6. The following is a list of employees who are engaged in concurrent employment, their social security numbers, the quarter
and year they were first engaged in concurrent employment, the name of the corporation/LLCs for which their services
are performed (other than the common paymaster), the corporation/LLCs' reemployment tax account numbers, and the
physical locations where the services are performed:
Name of Employee
Social Security Number*
Name of Corporation/LLC
Other than Common Paymaster
Quarter/Year
First Engaged
RT Account Numbers
Reported Under
RTS-72
R. 10/17
Page 2
Physical Locations Where
the Services are Performed
