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Multi-State Employer Notification Form For New Hire Reporting - Department Of Health And Human Services

OMB Control No: 0970-0166

Expiration date: 04//30/2007

MULTISTATE EMPLOYER NOTIFICATION FORM

FOR NEW HIRE REPORTING

(OPTIONAL FORM)

Federal law requires employers to furnish to the State Directory of New Hires of the State in which a

newly hired employee works, a report that contains the name, address, and social security number

of the employee, and the name, address and Federal Employer Identification Number (FEIN) of the

employer (42 USC 653A(b)(1)(A)).

If you are an employer who has employees in two or more States AND you will transmit the required

reports magnetically or electronically, Federal law allows you to comply with the new hire reporting

requirement by exercising one of the following options (42 USC 653A(b)(1)(B)):

Option #1: Furnish the new hire report to the State Directory of New Hires of the

State in which your newly hired employee works; or

Option #2: Designate one State in which any of your employees works and transmit

ALL new hire reports to the State Directory of New Hires of that State.

If you select Option #2, you must notify the Secretary of the U.S. Department

of Health and Human Services in writing of your choice to report to only one

State and identify the chosen State (42 USC 653A(b)(1)(B)). The purpose

of this optional form

is to provide a convenient means for such notification.

Multistate employers may also notify the Secretary by letter, fax machine,

or Internet. (see the last page for further instructions).

1. Federal Employer

2. Date: __/__/____

Identification Number(FEIN): _______________________

3. (FEIN)Employer Name:

______________________________________________________

4. (FEIN)Employer Address: ______________________________________________________

______________________________________________________

City: _____________________ State:___ Zip: ___________

5. (FEIN)Phone Number:

(

)________________________

6. SUBSIDIARY INFORMATION:

FEIN: _______________

Name: _____________________________

State/ZIP _______________

State/Zip: _______________

Multi-State Employer Notification Form For New Hire Reporting - Department Of Health And Human Services