"New Hire Reporting Form - Georgia New Hire Reporting Program" - Georgia (United States)

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Georgia New Hire Reporting Form
Send completed forms to:
To ensure the highest level of accuracy, please print neatly in
Georgia New Hire Reporting Program
capital letters and avoid contact with the edges of the boxes.
PO Box 38480
The following will serve as an example:
Atlanta, GA 30334-0480
A
B
C
1
2
3
Fax: (404) 525-2983 or toll-free fax 1 (888) 541-0521
EMPLOYER INFORMATION
Federal Employer ID Number (FEIN)
(Please use the same FEIN that appears on your quarterly wage reports you submit to the State):
Multiple medical insurance: Y/N
If available/offered: Y/N
Primary Insurance Company Name (if available to the employee):
Employer Name:
Employer Address: (Please indicate the address where the Wage Withholding Orders should be sent).
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone:
Extension:
Employer Fax:
E-mail:
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
Employee Starting Salary (Monthly):*
.00
Employee First Name:
Middle Initial:*
Employee Last Name:
Employee Address:
Employer City:
Employer State:
Zip Code:
Date of Hire:
Date of Birth:
Actual First Day of Work:*
Medical Insurance Company Name:*
*optional
Reports must be submitted within 10 days of date of hire or rehire
Questions? Call us at (404) 525-2985 or toll-free 1(888) 541-0469
Rev (09/03)
Georgia New Hire Reporting Form
Send completed forms to:
To ensure the highest level of accuracy, please print neatly in
Georgia New Hire Reporting Program
capital letters and avoid contact with the edges of the boxes.
PO Box 38480
The following will serve as an example:
Atlanta, GA 30334-0480
A
B
C
1
2
3
Fax: (404) 525-2983 or toll-free fax 1 (888) 541-0521
EMPLOYER INFORMATION
Federal Employer ID Number (FEIN)
(Please use the same FEIN that appears on your quarterly wage reports you submit to the State):
Multiple medical insurance: Y/N
If available/offered: Y/N
Primary Insurance Company Name (if available to the employee):
Employer Name:
Employer Address: (Please indicate the address where the Wage Withholding Orders should be sent).
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone:
Extension:
Employer Fax:
E-mail:
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
Employee Starting Salary (Monthly):*
.00
Employee First Name:
Middle Initial:*
Employee Last Name:
Employee Address:
Employer City:
Employer State:
Zip Code:
Date of Hire:
Date of Birth:
Actual First Day of Work:*
Medical Insurance Company Name:*
*optional
Reports must be submitted within 10 days of date of hire or rehire
Questions? Call us at (404) 525-2985 or toll-free 1(888) 541-0469
Rev (09/03)
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