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