Tennessee New Hire Reporting Form
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1STATE OF TENNESSEE
NEW HIRE REPORTING
Effective October 1, 1997, all Tennessee employers are required to report certain information about employees who have been
newly hired, rehired, or have returned to work. Employers must either (1) complete this form, or (2) submit a copy of the
employee’s IRS W-4 form, (3) other form with required information at a minimum, or (4) submit the information by Internet,
magnetic tape or diskette. This form may be reproduced as necessary. Reports made on this form must be within 20
calendar days of hire or if you wish to help the Department of Labor and Workforce Development, within 5 days of date
of hire.
TO ENSURE ACCURACY, PLEASE PRINT (or TYPE) NEATLY IN UPPER-CASE
LETTERS AND NUMBERS, USING A DARK, BALL-POINT PEN
REQUIRED INFORMATION:
EMPLOYEE DATA
Social Security Number:
First
M.I.
Name:
Last
Home
Address:
(Do not use
Employer
Address, Do
City
State
Zip Code
not leave
blank)
Employee Date of
Hire:
EMPLOYER DATA
Federal EIN:
Employer
Name:
Address:
City
State
Zip Code
ADDITIONAL INFORMATION:
Store or
Outlet Number:
Date of Birth:
Gender (M/F):
Employee State of Hire:
Earned Income Tax Credit Available? (Y/N):
Employee Left Your Employment? (Y/N):
(if unknown, leave blank)
(Has this employee left your employment before
you filed this report?)
Does your company offer Medical Insurance? (Y/N):
Corporate
or Payroll
Address:
(if different from
business address)
City
State
Zip Code
REPORTS WILL NOT BE PROCESSED WITHOUT MANDATORY INFORMATION
Send Reports To:
Tennessee New Hire Reporting Program
P.O. Box 17367
Nashville, Tennessee 37217
Fax: (877) 505-4761
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