Mississippi New Hire Reporting Form 

Mail completed form to:   Mississippi State Directory of New Hires 
                          PO Box 437 
                          Norwell, MA 02061  

Or fax completed form to: 1-800-937-8668

Effective October 1, 1997, all Mississippi employers (or independent contractors) are required to report certain 
information about personnel who have been newly hired, rehired, or have returned to work. Reports must be made 
within 15 calendar days from date of hire.  Employers must either (1) complete this form, or (2) submit a copy of 
the worker’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.  To submit new hire reports electronically, call 1-800-241-1330 to 
obtain information.    

Below, please complete all employer information 

EMPLOYER INFORMATION 

*Federal Employer Identification Number (FEIN):  !! -  !!!!!!!
(Please the same FEIN for which listed employee(s) quarterly wages will be reported under) 

State Employer Identification Number (SEIN):  !! -  !!!!!!!

*Employer Name: _________________________________________  DBA: ___________________________
*Address: _________________________________________________________________________________
__________________________________________________________________________________________
(Please indicate the address where the Income Withholding Order will be sent) 
*City: ___________________________      *State: _________      *Zip Code: ____________    +4: _________
Contact Name: _____________________________                                   Phone: ___________________________
Email: ____________________________________

Below, please complete one entry for each new employee 

EMPLOYEE INFORMATION 

*Social Security Number: !!! !! !!!! -           -                              Gender(circle one):    Male     Female

*First Name: ________________________________________                         Middle: __________________________ 
*Last Name: ________________________________________
*Employee Address: ________________________________________________________________________
_________________________________________________________________________________________
*City: ___________________________      *State: _________      *Zip Code: ____________    +4: _________
Date of Birth: _____/_____/_______      *Date of Hire: _____/_____/_______           State of Hire _______
Employee Salary: ____________________ Payment Frequency (circle one): Weekly   Bi-weekly   Monthly   Annually
Is this employee eligible for medical insurance (circle one)?   Yes     No

For information please visit our website at www.ms-newhire.com or call us toll-free at 1-800-241-1330