Arizona New Hire Reporting Form

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Douglas A. Ducey
Timothy Jeffries
Governor
Director
New Hire Reporting Form
Mail: Arizona New Hire Reporting Center
Fax: 1-888-282-0502
PO Box 142901 Austin TX 78714
Report online at
EMPLOYER INFORMATION
* REQUIRED INFORMATION
*Federal Employer Identification Number (FEIN)-the same FEIN used to report quarterly wages:
__________________________________________________________________________________________________
*Employer Name:
DBA:
__________________________________________________________________________________________________
*Contact Name:
__________________________________________________________________________________________________
*Payroll Address-address where an Income Withholding Order may be sent:
__________________________________________________________________________________________________
*City: ______________________________ *State: _______________ *Zip Code: _______________ Zip 4: ____________
Telephone:
Fax:
Email:
__________________________________________________________________________________________________
Does employer offer Medical Insurance Benefits? Yes ________ No _________
EMPLOYEE INFORMATION
Complete one entry for each new employee
* REQUIRED INFORMATION
*Social Security Number: ________________-_________________-________________
*Employee First Name: _________________________ M.I.: ________ Last Name: _________________________________
*Employee Address: __________________________________________________________________________________
*City: _______________________________________ *State: ____________ *Zip Code: _____________ +4:__________
*Date of Hire (First day of work): ________________________
Medical Insurance Available? Yes _______ No ________
Date of Birth: ___________________________ Employee Salary (Use decimal point if including cents): __________________
Pay Frequency-Please indicate: H=Hourly; B=Bi-Weekly; W=Weekly; S=SemiMonthly; M=Monthly; Y=Yearly _____________
*Social Security Number: ________________-_________________-________________
*Employee First Name: _________________________ M.I.: ________ Last Name: _________________________________
*Employee Address: __________________________________________________________________________________
*City: _______________________________________ *State: ____________ *Zip Code: _____________ +4:__________
*Date of Hire (First day of work): ________________________
Medical Insurance Available? Yes _______ No ________
Date of Birth: ___________________________ Employee Salary (Use decimal point if including cents): __________________
Pay Frequency-Please indicate: H=Hourly; B=Bi-Weekly; W=Weekly; S=SemiMonthly; M=Monthly; Y=Yearly _____________
Arizona New Hire Reporting Center  PO Box 142901 Austin TX 78714
Telephone 888-282-2064  Fax 888-282-0502 

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