State of Illinois                                        
                                                          
 Department of  Employment Security 
 
 New Hire Reporting Form 
                                                          
 Employers must report each new hire within 20 days.      Assistance: 1 800 327-HIRE (4473) 
                                    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                            - 

                                    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                            - 

                   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.