District Of Columbia New Hire Registry Reporting Form
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1DISTRICT OF COLUMBIA NEW HIRE REGISTRY
Reporting Form
To submit new hire reports online, please register at
-Please Make All Entries in CAPS
-All Required Items 1-7 and 12-22 MUST Be Completed
EMPLOYER INFORMATION
ITEMS 1-7 ARE REQUIRED INFORMATION
1. Unemployment
2. Federal Employer
Insurance Number
ID Number (FEIN)*
3. Employer‘s Name
4. Employer‘s Address
5. Employer‘s City
6. State
7. Zip Code
9. Employer‘s Fax ( ____ ) _____-________
8. Employer‘s Telephone ( ____ ) _____-________
10. New Hire Contact Person
11. New Hire Contact Person’s Email
EMPLOYEE INFORMATION
ITEMS 12-22 ARE REQUIRED INFORMATION
12. Social Security
13. First Day of Work for Pay
Number (SSN)
(MM/DD/YYYY)
14. Employee’s First Name
15. Employee’s Middle Name
16. Employee’s Last Name
17. Suffix (if Applicable)
18. Employee’s Home Address
19. Employee’s City
20. State
21. Zip Code
23. Employee Salary and Rate
22. Employee’s Date of Birth
$_______._____ per ____________
(MM/DD/YYYY)
24. Sex of Employee (circle one)
Male
Female
25. Are Health Care Benefits Available to the Employee? (circle one)
Yes
No
Employer must submit data within 20 calendar days of the new employee’s first day of work to:
District of Columbia New Hire Registry
P.O. Box 366
Holbrook, MA 02343
FAX: 877-892-6388
PHONE: 877-846-9523
FOR ADDITIONAL COPIES PLEASE PHOTO THIS ORIGINAL OR VISIT
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