Kentucky New Hire Reporting Form
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1Kentucky New Hire Reporting Form
____________________________________________________
Send Completed Form to:
Fax form to: 1-800-817-0099
Kentucky New Hire Reporting Center
For more information: 1-800-817-2262
P.O. Box 2586
or
Atlanta GA 30301-2586
EMPLOYER INFORMATION
(Please Print or Type)
Federal Employer Identification Number ___________________
Employer Name _____________________________________________________________
Street Address (1) __________________________________________________________________
Street Address (2) __________________________________________________________________
(
This address is the payroll address for income withholding if it is different than employer’s site address)
City/State/Zip Code ________________________________________________________________
Contact Phone/Name _______________________________________________________________
EMPLOYEE INFORMATION
Employee Name ___________________________________________________________________
Social Security Number __________ - _________ - _________
Employee Address _________________________________________________________________
City/State/Zip _____________________________________________________________________
OPTIONAL FIELDS
State Employer Identification Number ___________ Is health Insurance Available to Employee? YES / NO
Date of Birth ___________________ Date of hire ____________________
State of hire ____________
EMPLOYEE INFORMATION
Employee Name __________________________________________________________________
Social Security Number __________ - _________ - _________
Employee Address ________________________________________________________________
City/State/Zip ____________________________________________________________________
OPTIONAL FIELDS
State Employer Identification Number ____________ Is health Insurance Available to Employee? YES / NO
Date of Birth ___________________ Date of hire ____________________
State of hire ____________
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Parent category: Business