New Hire Reporting Form - 2002

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Virginia New Hire Reporting Form
Federal and state legislation (Virginia Statute 63.2-1946), effective October 1, 1997 requires all Virginia employers, both public
and private, to report to the Commonwealth of Virginia all newly hired, rehired, or returning to work employees. Information about
new hire reporting and online reporting is available on our website:
To ensure the highest level of accuracy, please print neatly in
Send completed forms to:
capital letters and avoid contact with the edges of the boxes.
Virginia New Hire Reporting Center
The following will serve as an example:
PO Box 25309
Richmond, VA 23260-5309
A
B
C
1
2
3
Fax: (804) 771-9709 or toll-free fax 1 (800) 688-2680
EMPLOYER INFORMATION
Federal Employer ID Number (FEIN)
(Please enter the same FEIN used to report the employee’s quarterly wages.):
-
Employer Name:
Employer Address (Please indicate the address where an Income Withholding Order should be sent).
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone (optional) :
Extension:
Employer Fax (optional) :
Email Address:
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
-
-
Employee First Name:
Middle Initial:
Employee Last Name:
Employee Address:
Employee City:
Employee State:
Zip Code (5 digit):
Date of Hire (optional):
Date of Hire (optional):
Date of Birth (optional):
Is medical insurance available to employee? (optional):
Y/N
Reports must be submitted within 20 days of date of hire or rehire.
REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING
Rev (06/02)
Questions? Call us at (804) 771-9733 or toll-free 1 (800) 979-9014

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