Dws-Ui Form 6 - Utah New Hire Registry Reporting
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1DWS-UI
Form 6
Rev. 0214
UTAH NEW HIRE REGISTRY REPORTING FORM
Submit this completed form within 20 days of a
You may photo copy this original form for
new employee’s first day of work to:
future use
See important instructions on second page
Utah New Hire Registry
PRINT legibly in ink or TYPE all entries
P.O Box 45247
Please write all entries in CAPS
Salt Lake City UT 84145-0247
All required items MUST be completed
Or
Contact Person _________________________
FAX to 801-526-4391
Phone number _________________________
Today’s Date (mm/dd/yyyy) ________________________
REQUIRED EMPLOYER INFORMATION
Federal Employer ID Number (FEIN) ____________________________________________________
Employer’s Business Name ____________________________________________________________
Employer’s Street Address ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
City
State
ZIP
REQUIRED EMPLOYEE INFORMATION
Social Security Number
____________________________________________________________
Employee’s first name
____________________________________________________________
Employee’s middle initial ____________
Employee’s last name
____________________________________________________________
Employee’s home address ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
City
State
ZIP
Date of hire/rehire (mm/dd/yyyy) ______________________________________________________
OPTIONAL INFORMATION: Employee’s birthdate (mm/dd/yyyy) ___________________________
•
140 East 300 South
Salt Lake City, Utah 84111
•
•
•
801-526-9235
or toll free 800-222-2857
FAX 801-526-9236
Relay Utah 711
•
•
Spanish Relay Utah 1-888-346-3162
Equal Opportunity Employer/Programs
jobs.utah.gov
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