Rhode Island New Hire Reporting Form 

                             Mail completed form to:                       Rhode Island New Hire Reporting Directory 
                                                                           P.O. Box 485 
                                                                           Norwell MA 02061 

                             Or fax completed form to:                     1-888-430-6907 

Beginning October 1, 1997, an employer who hires or rehires an employee on or after October 1, 1997, must report the  
hiring or rehiring of the employee to the department or its designee. If reporting on a  W-4 or its equivalent records are to  
be sent no later than fourteen (14) days after hire or rehire, and twice a month if reporting electronically or magnetically.  
To submit new hire reports electronically, register at  www.ri-newhire.com or call 1-888-870-6461 to obtain information.  
 TO ENSURE ACCURACY,  PLEASE PRINT OR TYPE             NEATLY IN UPPERCASE LETTERS AND NUMBERS, USING   A DARK BALL-POINT PEN 

 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) 

 *Employer Name: _________________________________________ DBA: ___________________________ 
 *Employer  Address: _________________________________________________________________________ 
                           _________________________________________________________________________ 
 *City: ___________________________     *State: _________      *Zip Code: ____________    +4: _________ 
    Payroll  Address:       (if different than above   )__________________________________________________________ 
                           _________________________________________________________________________
   City: ___________________________      State: _________        Zip Code: _____________    +4: _________ 
   Contact Name: _____________________________                             Phone: ___________________________ 
   Email: ____________________________________                             Fax:                ____________________________ 

 Below,  please complete one entry for each new employee (*) 
    EMPLOYEE INFORMATION 

 *Social Security Number:      -                       -

 *First Name: ________________________________________ Middle Name: __________________________
 *Last Name: ________________________________________
 *Employee  Address: ________________________________________________________________________
                           _________________________________________________________________________ 
 *City: ___________________________     *State: _________      *Zip Code: ____________    +4: _________
 *Date of Hire: ______/______/_______      Date of Birth: ______/______/________     State of Hire ________
 Does employee qualify for health insurance (circle one)?   Yes     No   
 If yes, provide the date the employee qualifies for health insurance: ______/______/________
                                     THIS FORM MAY BE REPRODUCED  AS NECESSARY. 

            For more information on new hire reporting please visit our website at             www.ri-newhire.com 
                                      or call us toll-free at 1-888-870-6461 

                                                                                                                  Rev 02/2012