Oregon New Hire Reporting Form - Department Of Justice
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1
2Oregon New Hire Reporting Form
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Send completed form to:
Telephone: (503) 378-2868
Reset
Department of Justice
Fax:
(503) 378-2863
Employer New Hire Reporting Program
Toll Free Fax: (877) 877-7415
1495 Edgewater St NW #120
(877) 877-7416
Salem OR 97304
Reports must be submitted no later than 20 days after the date the employer hires or rehires an employee.
Employer Information
Employers may make copies of this form
Employer Federal Identification Number (FEIN)
State Identification Number
Submission Date
Employer Name
Contact Phone Number *
Employer Street/Mailing Address
Contact Name *
Employer City
State
Zip Code
Contact Title *
(By reporting health insurance availability information below, your Company may avoid receiving unnecessary forms)
* Is dependent or family health care coverage available?
Yes [ ] No [ ]
If yes, is there a waiting period for eligibility?
Yes [ ] No [ ]
If yes, how long? _______
* Should the Child Support Program mail income withholding orders to the above address?
Yes [ ] No [ ]
If no, please provide payroll office address and contact person information below.
Payroll Office Mailing Address
Contact Name
City
State
Zip Code
Contact Phone Number
Employee Information
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire
*
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
* Providing this optional data enhances our ability to perform services more efficiently
Page 1 of 2 - OREGON NEW HIRE REPORTING FORM
CSF 01 0580 (Rev. 04/23/03)
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