Ohio Department of Job and Family Services 
                                                          OHIO NEW HIRE      REPORTING 
  Ohio Revised Code section 3121.89 to 3121.8910 requires all Ohio employers, both public and private, to report all contractors 
  and newly hired employees to the state of Ohio within 20 days of the contract or hire date.  Information about new hire reporting 
  and online reporting is available on our website: www.oh-newhire.com 
 
    Send completed forms to:                                                 To ensure the highest level of accuracy, please print neatly in 
    Ohio New Hire Reporting Center                                           capital letters and avoid contact with the edges of the boxes.  
    PO Box 15309                                                             The following will serve as an example: 
    Columbus, OH    43215-0309 
    Fax:  (614) 221-7088 or toll-free fax (888) 872-1611                               A         B     C             1 2     3 
                                
                                                          EMPLOYER INFORMATION  
                       
    Federal Employer ID Number (FEIN) (Please use the same FEIN as the listed employee’s quarterly wages will be reported under): 
 
    Employer Name: 
 
    Employer Address (Please indicate the address where the Income Withholding Orders should be sent). 
 
    Employer City:                                                                                 Employer State:     Zip Code (5 digit): 
 
    Employer Phone (optional):                                    Extension:           Employer Fax (optional): 
 
    Email: 
 
                                              EMPLOYEE OR CONTRACTOR INFORMATION  
 
    Social Security Number (SSN)                                        (Check here if using FEIN for the Contractor) 
 
                                                                                           State of Hire: 
    First Name:                                                                                                              Middle Initial: 
 
    Last Name: 
 
    Address: 
 
    City:                                                                                            State:          Zip Code (5 digit): 
 
    Date of Hire:                             Date of Birth:                      Is this a Contractor? 
 
                                                                                     Yes         No 
                                                                                                                              
    Date              payments will begin for Contractor:                   Length of time the Contractor will be performing services: 
                                           
                                                                                       months 
 
                           REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING 
JFS 07048 (Rev. 12/2013)                      Questions?  Call us at (614) 221-5330 or toll-free (888) 872-1490