Multistate Employer Notification Form For New Hire (W4) Reporting

Multistate Employer Notification Form For New Hire (W4) Reporting - 2013 Page 2

OMB Control No: 0970-0166

Expiration Date: 06/30/2013

4. PRINT your company’s address, including city, state, and zip code. This is the address associated with

the FEIN in Item 1. If your company’s FEIN address is a foreign address, PRINT the Country Name and the

Country’s Postal Code.

Employer Address:

City:

State:

Zip Code:

(For foreign addresses only) Country Name:

Country Postal Code:

5. Print your company’s phone number, including area code. This is the phone number associated with

the FEIN in Item 1.

Phone Number:

(

)

Ext. _____________________

6. Print the FEIN, name, state, and zip code of any subsidiary of your company that has its own FEIN and

for which you will be reporting New Hire information.

Subsidiary Information: (Please list any additional subsidiaries on a separate sheet.)

FEIN:

Name:

State/Zip Code:

FEIN:

Name:

State/Zip Code:

7. Print the two-character abbreviation for the State or U.S. Territory to which your company has chosen to

report new hire information. NOTE: The State that you designate must be a State in which you have one or more

employees. Refer to the state listing shown in Item 9.

8. Enter the effective date (MM/DD/YYYY) on which your company will begin sending new hire (W-4)

reports to the entry shown in Item 7.

Effective Date:

Multistate Employer Notification Form For New Hire (W4) Reporting - 2013 Page 2