Nc New Hire Reporting - Residential Services, Inc.

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STATE OF NORTH CAROLINA
NEW HIRE REPORTING
Effective October 1, 1997, North Carolina employers are required to report certain
information about employees who have been newly hired, rehired, or have returned to
work. Employees must either (1) complete this form OR (2) submit a copy of the
employee’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. Call 1-888-514-4568
to obtain information on submitting new hire reports electronically. This form may be
reproduced as necessary. Reports must be sent within 20 calendar days of date of hire.
TO ENSURE ACCURACY, PLEASE PRINT NEATLY IN UPPER-CASE
LETTERS AND NUMBERS, USING A DARK, BALL-POINT PEN
Employee Information:
Social Security Number:
__ __ __--__ __--__ __ __ __
Name:
___________________________
____
First
M.I.
__________________________________
Last
Address:
____________________________________________________________
________________________________________________________________________
Employer Information:
Federal EIN:
56-1101520
State EIN:
68-25-69
Employer Name:
Residential Services, Inc.
Payroll Address:
P.O. Box 730,
200 Weaver Street
Carrboro, NC 27510
Other Information:
Employee Date of Birth: __ __--__ __--__ __
Date of Hire: __ __--__ __-__ __
REPORTS WILL NOT BE PROCESSED WITHOUT MANDATORY INFORMATION
Send Reports to: North Carolina New Hire Reporting Program
P.O. Box 9004
Raleigh, NC 27675-9004
Fax: (919) 877-1019
RSI-PER 03-23

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