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   ofBirth: _____/_____/_______                   *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