Form CSSD04-1050 "Alaska New Hire Reporting Form" - Alaska

What Is Form CSSD04-1050?

This is a legal form that was released by the Alaska Department of Health and Social Services - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 31, 2012;
  • The latest edition provided by the Alaska Department of Health and Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CSSD04-1050 by clicking the link below or browse more documents and templates provided by the Alaska Department of Health and Social Services.

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Download Form CSSD04-1050 "Alaska New Hire Reporting Form" - Alaska

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Alaska New Hire Reporting Form
Send completed form to:
Or fax to:
(907) 787-3197
MS 13 New Hire Reporting Section
Message Line:
(907) 269-6685
CHILD SUPPORT SERVICES DIVISION
Toll free in Alaska:
1 (877) 269-6685
th
550 W 7
AVE STE 310
For information call:
(907) 269-6089
ANCHORAGE AK 99501-6699
Contact Name
Contact Title
Employer Information
Submission Date (Year / Month / Date)
Contact Phone Number
Contact Fax Number
Contact Email address
Employer Federal Identification Number (FEIN)
Employer AK Department of Labor Number
Do you provide Health Insurance to your Employee?
000
Yes
No
Employer Name
Employer - Doing Business As / Also Known As
Employer Payroll Mailing Address
City
State
Zip Code
Employer Physical Address “Same” if same as mailing address
City
State
Zip Code
Employee Information
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
* You are required to provide the social security numbers of your newly hired or rehired employees pursuant to AS 25.27.075(b). The Child Support Services
Division will use the social security numbers only for the purpose of establishing and enforcing child support.
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
CSSD 04-1050 (Rev 12/31/12)
Alaska New Hire Reporting Form
Send completed form to:
Or fax to:
(907) 787-3197
MS 13 New Hire Reporting Section
Message Line:
(907) 269-6685
CHILD SUPPORT SERVICES DIVISION
Toll free in Alaska:
1 (877) 269-6685
th
550 W 7
AVE STE 310
For information call:
(907) 269-6089
ANCHORAGE AK 99501-6699
Contact Name
Contact Title
Employer Information
Submission Date (Year / Month / Date)
Contact Phone Number
Contact Fax Number
Contact Email address
Employer Federal Identification Number (FEIN)
Employer AK Department of Labor Number
Do you provide Health Insurance to your Employee?
000
Yes
No
Employer Name
Employer - Doing Business As / Also Known As
Employer Payroll Mailing Address
City
State
Zip Code
Employer Physical Address “Same” if same as mailing address
City
State
Zip Code
Employee Information
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
* You are required to provide the social security numbers of your newly hired or rehired employees pursuant to AS 25.27.075(b). The Child Support Services
Division will use the social security numbers only for the purpose of establishing and enforcing child support.
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
CSSD 04-1050 (Rev 12/31/12)
New Hire Reporting – continued
Employer Name
Employer Federal Identification Number (FEIN)
Submission Date (Year / Month / Date)
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
Employee Social Security Number *
Employee First Name
M.I.
Employee Last Name
Employee Street Address
City
State
Zip Code
Year
Month
Day
Year
Month
Day
Employee
Employee
/
Date of Hire
Rehire
Date of Birth
CSSD 04-1050 (Rev 12/31/12)
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