Kentucky New Hire Reporting Form printable pdf download

Kentucky New Hire Reporting Form

Mail completed form to:

Kentucky New Hire Reporting Center

P.O. Box 3818

Dublin, OH 43016

Or fax completed form to: 1-800-817-0099

We also offer fast and easy-to-use online reporting options. For more information please

visit our website at

or call us toll-free at 1-800-817-2262.

EMPLOYER INFORMATION

Federal Employer Identification Number (FEIN): __________-______________________

(Please make certain you use the same 9-digit FEIN you use to report your quarterly wage information)

Kentucky Employer Identification Number (KEIN): __________-____________________

Employer Name: ___________________________________________________________

Address: _____________________________________________________________________________________

(Please indicate the address where the Income Withholding Order should be sent)

City: _________________________________ State: __________ Zip Code: _________________ +4: __________

Contact Name: _______________________________

E-mail Address: _____________________________

Phone Number: _________-_________-____________

Fax Number: _________-_________-____________

COMPLETE ONE ENTRY FOR EACH NEW OR REHIRED EMPLOYEE

EMPLOYEE INFORMATION

Social Security Number: __________-________-_______________

First Name: _______________________ Middle Name: _______________________ Last Name:__________________________

Employee Address: _____________________________________________________________________________

City: _____________________________________ State: __________ Zip Code: ____________ +4: ___________

Date of Hire: _______________________

*Date of Birth: _______________________

Is medical insurance available to this employee?

Yes ____

No ____

* OPTIONAL