Rhode Island New Hire Reporting Form
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1Rhode Island New Hire Reporting Form
Mail completed form to:
Rhode Island New Hire Reporting Directory
P.O. Box 335
Holbrook, MA 02343
Or fax completed form to:
1-888-430-6907
Beginning October 1, 1997, an employer who hires or rehires an employee on or after October 1, 1997, must report the
hiring or rehiring of the employee to the department or its designee. If reporting on a W-4 or its equivalent records are to
be sent no later than fourteen (14) days after hire or rehire, and twice a month if reporting electronically or magnetically.
To submit new hire reports electronically, register at or call 1-888-870-6461 to obtain information.
TO ENSURE ACCURACY, PLEASE PRINT OR TYPE NEATLY IN UPPERCASE LETTERS AND NUMBERS, USING A DARK BALL-POINT PEN
Below, please complete all employer information (*)
EMPLOYER INFORMATION
-
*Federal Employer Identification Number (FEIN):
(Please the same FEIN for which listed employee(s) quarterly wages will be reported under)
*Employer Name: _________________________________________ DBA: ___________________________
*Employer Address: _________________________________________________________________________
_________________________________________________________________________
*City: ___________________________
*State: _________
*Zip Code: ____________ +4: _________
Payroll Address:
)__________________________________________________________
(if different than above
_________________________________________________________________________
City: ___________________________
State: _________
Zip Code: _____________ +4: _________
Contact Name: _____________________________
Phone: ___________________________
Email: ____________________________________
Fax:
____________________________
Below, please complete one entry for each new employee (*)
EMPLOYEE INFORMATION
- -
*Social Security Number:
*First Name: ________________________________________ Middle Name: __________________________
*Last Name: ________________________________________
*Employee Address: ________________________________________________________________________
_________________________________________________________________________
*City: ___________________________
*State: _________
*Zip Code: ____________ +4: _________
*Date of Hire: ______/______/_______
Date of Birth: ______/______/________
State of Hire ________
Does employee qualify for health insurance
? Yes
No
(circle one)
If yes, provide the date the employee qualifies for health insurance: ______/______/________
THIS FORM MAY BE REPRODUCED AS NECESSARY.
For more information on new hire reporting please visit our website at
or
call us toll-free at 1-888-870-6461
Rev 02/2012
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Parent category: Business