DWS-UIC 6                                 State of Utah                             
 Rev. 07/2018 
                              Department of Workforce Services 
                            Unemployment Insurance – Contributions 
                        UTAH NEW HIRE REGISTRY REPORTING FORM 
 
 Submit this completed form within 20 days of a   You may photo copy this  
 new employee’s first day of work to:             original form for future use 
                                                  See important instructions on second page 
              Utah New Hire Registry             PRINT legibly in ink or TYPE   all entries 
              P.O. Box 45247                      Please write all entries in CAPS 
             Salt Lake City, UT 84145-0247 
                                                  All required items MUST be completed 
              OR 
              FAX to 801-526-4391 
                                                Contact Person:   

 Today’s Date (mm/dd/yyyy):                     Phone number:   
 
 REQUIRED EMPOYER INFORMATION 

 Federal Employer ID Number (FEIN):   

 Employer’s Business Name:   

 Employer’s Street Address:   

                             City                                         State      ZIP 
 
 REQUIRED EMPLOYEE INFORMATION 

 Social Security Number:     

 Employee’s first name:      

 Employee’s middle initial:                                              

 Employee’s last name:       

 Employee’s home address:   

                            City                                          State      ZIP 
 Date of hire/rehire (mm/dd/yyyy):   

 OPTIONAL INFORMATION: Employee’s birthdate (mm/dd/yyyy):   
 
                                     Equal Opportunity Employer Program 
             Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240.  Individuals  
              with speech and/or hearing impairments may call Relay Utah by dialing 711.  Spanish Relay Utah: 1-888-346-3162. 
 

                                     INSTRUCTIONS 
                                          
This form is used to report new hires by mail or fax. We strongly recommend entering new hire 
data on our web site at https://jobs.utah.gov/UI/Employer/EmployerHome.aspx. Larger employers 
may consider submitting new hire information by CD or by uploading a file on our website. For 
further information about electronic reporting, please refer to the New Hire Registry Handbook or 
visit our web site, https://jobs.utah.gov/UI/Employer/EmployerHome.aspx. You can contact us at 
801-526-9235 or 1-800-222-2857. 
 
The Form: You may download, complete, and print this form in Acrobat Reader, but you cannot 
electronically save a completed form, or retain your work on a partially completed form. 
Alternately, you may print the form and use a typewriter with a dark simple print font with 10 or 12 
pitch. If hand-printing, use black ink and print in CAPITAL LETTERS with clear character 
separation. 
 
REQUIRED ITEMS must be completed. Forms submitted with missing data will be returned. 

  Federal Employer ID Number: The 9-digit federal employer identification number used for 
   Federal tax reporting. Do not place a hyphen between numbers. 

  Employer’s Name: List the employer’s legal name. 

  Employer’s Address: The address where child support payment orders are sent. 

  Employee’s Social Security Number: The 9-digit number issued by the Social Security 
   Administration. Do not place hyphens between numbers. Forms and reports without a Social 
   Security Number will not be accepted. 

  Date of Hire/Rehire: This is the date that labor or services for compensation are first 
   performed by the employee. The date of rehire is the date labor or services for 
   compensation are first performed by an employee who was previously employed by the 
   employer, but has been separated from that employment for at least 60 consecutive days. 
 
SUBMISSION OF NEW HIRE REPORTS 
 
  You may choose the filing method that is most convenient for you. You may also submit a 
   copy of the employee’s W-4 Form   or a printed list. 
  An employer who fails to timely report the hiring or rehiring of an employee as required by 
   law is subject to a civil penalty of $25 to $500 for each such failure. 
  All required information must be provided within 20 calendar days of the employee’s first 
   day of work. 
  Submit all data using the address, fax number or web site at the top of this page.