Mississippi New Hire Reporting Form
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1Mississippi New Hire Reporting Form
Mail completed form to:
Mississippi State Directory of New Hires
P.O. Box 312
Holbrook, MA 02343
Or fax completed form to:
1-800-937-8668
Effective October 1, 1997, all Mississippi employers (or independent contractors) are required to report certain
information about personnel who have been newly hired, rehired, or have returned to work. Reports must be made
within 15 calendar days from date of hire. Employers must either (1) complete this form, or (2) submit a copy of
the worker’s IRS W-4 form with the “other information section” completed on this form, or (3) submit the
information by magnetic tape or floppy diskette. To submit new hire reports electronically, call 1-800-241-1330 to
obtain information.
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)
!! - !!!!!!!
State Employer Identification Number (SEIN):
*Employer Name: _________________________________________ DBA: ___________________________
*Address: _________________________________________________________________________________
__________________________________________________________________________________________
(Please indicate the address where the Income Withholding Order will be sent)
*City: ___________________________
*State: _________
*Zip Code: ____________ +4: _________
Contact Name: _____________________________
Phone: ___________________________
Email: ____________________________________
Below, please complete one entry for each new employee
EMPLOYEE INFORMATION
!!!
!!
!!!!
*Social Security Number:
-
-
Gender
: Male
Female
(circle one)
*First Name: ________________________________________
Middle: __________________________
*Last Name: ________________________________________
*Employee Address: ________________________________________________________________________
_________________________________________________________________________________________
*City: ___________________________
*State: _________
*Zip Code: ____________ +4: _________
Date of Birth: _____/_____/_______
*Date of Hire: _____/_____/_______
State of Hire _______
Employee Salary: ____________________ Payment Frequency
: Weekly Bi-weekly Monthly Annually
(circle one)
Is this employee eligible for medical insurance
? Yes
No
(circle one)
For information please visit our website at
or call us toll-free at 1-800-241-1330
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