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Fill and Sign the Revoking a Subchapter S Electioninternal Revenue Service Form

Fill and Sign the Revoking a Subchapter S Electioninternal Revenue Service Form

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DFS - F2 - DWC 251 - R, REVOCATION OF ELECTION OF COVERAGE - REVISED 08/13 MS 10 - 1 6 REVOCATION OF ELECTION OF COVERAGE By filing this Revocation, you are revoking a previously filed Notice of Election of Coverage. (C heck one): Sole Proprietor Partner PLEASE TYPE OR PRINT Business Entity Name of Business: Trade Name; d/b/a; or a/k/a: Business Mailing Address: City: County: State: Zip Code: Federal Employer Identification Number: Telephone Number: Email: Workers’ Compensation Insurance Provider Name of Insurer: Address of Insurer: Policy Number: Effective Date of Policy: Applicant SUBMIT THIS FORM TO : DIVISION OF WORKERS’ COMPENSATION BUREAU OF COMPLIANCE 200 East Gaines Street Tallahassee, FL 32399 - 4228 Name:____________________________________________ Date:____________________ Signature:____________________________________________________________________

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