State of Illinois 
Department of  Employment Security 

New Hire Reporting Form 

Employers must report each new hire, including independent contractors, within 20 days. 

                                   Please print or type 
                                   EMPLOYER NAME AND ADDRESS 

Federal Employer ID Number - FEIN                     - 

Company Name 

Street Address 

Street Address 

City                               State                                Zip Code                    - 

                  EMPLOYER ADDRESS FOR CHILD SUPPORT WAGE WITHHOLDING ORDERS 

Street Address 

Street Address 

City                               State                                Zip Code                    -

                                   NEW EMPLOYEE NAME AND ADDRESS 
Social Security Number                                                  Date of Hire (MM-DD-YYYY) -          - 

First Name                                            MI                Last Name 

Street Address 

City                               State                                Zip Code                    - 

Is new hire an independent contractor?            N o              Y es 

                                   NEW EMPLOYEE NAME AND ADDRESS 
Social Security Number                                                 Date of Hire (MM-DD-YYYY)  -          - 

First Name                                            MI                Last Name 

Street Address 

City                               State                                Zip Code                    - 

Is new hire an independent contractor?            N o    Y es 

                  Report new hires online, or by returning your completed form either by FAX 1-217-557-1947, 
                       or by U.S. mail  IDES, P.O.  Box 19212, Springfield, IL 62794-9212. 
                                   Assistance: 1 800 327-HIRE (4473)