Michigan Department of Treasury                                                                                                                      Michigan New Hire
3281(Rev. 9-12)                                                                                                                                      Operations Center
                                                                                                                                                     P.O. Box 85010
State of Michigan New Hire Reporting Form                                                                                                            Lansing, MI 48908-5010
Federal law requires public (State and local) and private employers to report all newly hired or rehired employees who are working                   Phone: (800) 524-9846
in Michigan to the State of Michigan. 1This form is recommended for use by all employers who do not report electronically.                           Fax:   (877) 318-1659

OO A newly hired employee is an individual not previously employed by you, and       OO Employers who report electronically and have employees working in two or 
    a rehired employee is an individual who was previously employed by you but              more states may register as a multi-state employer and designate a single state 
    separated from employment for at least 60 consecutive days.                             to which new hire reports will be transmitted. Information regarding multi-state 
OO Reports must be submitted within 20 days of hire date (i.e., the date services           registration is available online at: http://www.acf.hhs.gov/programs/cse/
    are first performed for pay).                                                           newhire/employer/private/newhire.htm#multi or call (410) 277-9470.
                                                                                     OO
OO This form may be photocopied as necessary. Many employers preprint employer              Reports will not be processed if mandatory information is missing. Such reports 
    information on the form and have the employee complete the necessary                    willl be rejected and you must correct and resubmit them.
    information during the hiring process.                                           OO For optimum accuracy, please print neatly in all capital letters and avoid contact 
OO When reporting new hires with special exemptions, please use the MI-W4 form.             with the edge of the box. See sample below.
OO Online and other electronic reporting options are available at:  
    www.mi-newhire.com.                                                                     A B  C  1  2 3  

                                                                                                           Social Security Number:
   EMPLOYEE Information (Mandatory) 
                                                                                                                                                                                 
 First Name:                                                                                               Middle Initial:

 Last Name:

 Address:

 City:                                                                                                     State:

 Zip Code:                                                                                                 Hire Date:

OPTIONAL           Date of Birth:                                                  Driver’s License No:
                    
                                                                                                           Federal Employer Identification Number (FEIN):
   EMPLOYER Information (Mandatory)
                                                                                                                                                                                
   Employer Name:

   Address:

   City:                                                                                                   State:

   Zip Code:

OPTIONAL           Contact Name:
                          
                   Contact Phone:                                                                          Contact Fax:

                   Contact Email:
                          
   1 Ref: Social Security Act section 453A and the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (P.L. 104-193), effective October 1, 1997.