“I” NHES 0085 R-12/17 
 IRE  OR 
 YPE OF H
MPLOYEE
 E *T “W”            
     
 FORM                                   
ORK TA TE
W S            
  ” for W-2 
W  
ONTRACTOR
C
  IRST AY OF ORK
P D W
ROGRAM *F
           
 REPORTING  :1-855-253-9072
IRE  03302-2092  
H AX   IP
 HIRE EW 2092 NDEPENDENT I
NH  224-0825 F                                                                                          *Z            
 -N REE  
OX 
 B  :(603) F      
1099  TATE
For “Type of Hire” write “
NEW ONCORD AX OLL : *S            
 :NHES PO  C F T I” for
O
T Note or “  
               *Required Fields
                                                      OWN
  
ETURN /T
 R                                  
ITY
 *C
                      
DDRESS  
                        A  

  OME (NOT PO BOX) 
 *H
  
 )_________________________
 :___________________________  
 :______________________________ N            (:  :_____________________________  
O   
 )_______________________________
O O AME
N  N ERSON N
CCOUNT  :____________________________________             ( P  
:
A  _______________________________________ O 
:  N  
 
ELEPHONE AX ONTACT  MPLOYEE 
AME DDRESS T F C
DENTIFICATION I N A             *E
MPLOYER  
 E **(or Independent Contractor) 
                      Note: All new hires must be reported within 20 days of the date hired. ** Independent contractors are reportable if contractor operates business as a sole proprietor and you expect to reimburse  individual more than $2,500 for services for one or more contracts in a calendar year. (EMP308.02(a)(3)).  Indicate contractor’s name, home or business address, social security number and first day of work.  Online “New Hire” filing link can be found on homepage http://www.nhes.nh.gov/ 
                     
EDERAL MPLOYER MPLOYER MPLOYER MPLOYER MPLOYER 
F  NHES                                                                                                                                                                                    E  E _____________________________________________________ E E E
                    # 
             
OCIAL 
                   *S ECURITY 
 S (Not Fein)