Louisiana New Hire/rehire Form - New Hire Reporting

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Louisiana New Hire/Rehire Form
Effective October 1, 1997 Act 97 of the 1997 LA Legislative Session requires all Louisiana Employers, both public and private,
to report all newly hired or rehired employees to the State of Louisiana within 20 days of hire. Information about new hire
reporting and online reporting is available on our Web site:
Send completed forms to:
To ensure the highest level of accuracy, please print neatly in
capital letters and avoid contact with the edges of the boxes.
Louisiana New Hire Reporting
The following will serve as an example:
P.O. Box 142513
Austin, TX 78714-2513
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B
C
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Toll-Free Fax: (888) 223-1462
EMPLOYER INFORMATION
Federal Employer ID Number (FEIN):
State ID Number (required if available):
Employer Name:
Employer Address:
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone (optional):
Extension:
Employer Fax (optional):
Email (optional):
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
Date of Hire : (First day employee works for pay)
Employee First Name:
Middle Name:
Employee Last Name:
Employee Address:
Employee City:
Employee State:
Zip Code (5 digit):
Occupation ( required if available ):
Date of Birth (optional):
REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING
Questions? Call us at toll-free (888) 223-1461

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