Georgia New Hire Reporting Form printable pdf download

Georgia New Hire Reporting Form

GEORGIA NEW HIRE REPORTING FORM

Georgia New Hire Reporting Program

Fax form to: 1-888-541-0521

Send Completed Form to:

P. O. Box 38480

404-525-2983

Atlanta, GA 30334-0480

For more information: 1-888-541-0469

Or 404-525-2985

EMPLOYER INFORMATION

Federal Employer

Identification Number

_______________________________________________________________

Employer Name

_______________________________________________________________

Address

_______________________________________________________________

City/State/Zip Code+4

_______________________________________________________________

Contact Phone/Name

_______________________________________________________________

Medical Insurance Coverage Available?

Y______

N_______

Employer Address for Income Deduction Orders

Address

_______________________________________________________________

City/State/Zip Code+4

_______________________________________________________________

Contact Phone/Name

EMPLOYEE INFORMATION

____________-_______-____________

Social Security Number

Employee Name

______________________________________________________________

Employee Address

City/State/Zip Code

______________________________________________________________

State of Hire_______ Date of Hire_________________ Date of Birth___________________(Please use four digit year)

Georgia New Hire Reporting Form