Arizona New Hire Reporting Form - Department Of Economic Security

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Arizona New Hire Reporting Form
Mail completed form to:
Arizona New Hire Reporting Center
P.O Box 402
Holbrook, MA 02343
Or fax completed form to:
1-888-282-0502
EMPLOYER INFORMATION
Federal Employer Identification Number (FEIN): _____________________________________________
(Please use the same FEIN for which listed employee(s) quarterly wages will be reported under.)
Employer Name: _________________________________________
DBA:________________________________ Contact Name: __________________________
Telephone:_________________ Email: ____________________
Address:____________________________________________________________________________________
(Please indicate the address where the Income Withholding Order will be sent)
City: _________________________________ State: __________ Zip Code: ________________ +4:__________
Is medical insurance an employee benefit?
Yes ____
No ____
Complete one entry for each new employee
EMPLOYEE INFORMATION
Social Security Number: _____________-_____________-_____________
Employee First Name: __________________ M.I.: ________ Employee Last Name:_______________________
Employee Address:____________________________________________________________________________
City: _____________________________________ State: __________ Zip Code: ____________ +4: __________
Date of Hire: _______________________
*Date of Birth:_______________________
* OPTIONAL
EMPLOYEE INFORMATION
Social Security Number: _____________-_____________-_____________
Employee First Name: __________________ M.I.: ________ Employee Last Name:_______________________
Employee Address:___________________________________________________________________________
City:_____________________________________ State: __________ Zip Code: ____________ +4: __________
Date of Hire: _______________________
*Date of Birth:_______________________
* OPTIONAL
For information please visit our web-site at
or call us toll-free at 1-888-282-2064
The Arizona New Hire Reporting Center is an authorized agent of the Arizona Department of Economic Security
Rev 08/2011

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