Form R0909 - New Hire Reporting Program-Report Form
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1New Hire Reporting Program-Report Form
If you use this form to report, please make and keep extra copies for future
reporting.
Employer name and address:
DOL State Id:
Federal Id:
Employee Information
Independent Contractor Information
Information
SSN:
1.
Name:
Address:
City:
Zip:
State:
Date
of
Date of Hire:
termination:
Birth Date:
Home Phone:
Work Phone:
Occupation:
Income freq:
(Weekly, Bi-Weekly, Monthly)
Gross Income Amt:
Ins. Avail for Employee
(YIN):
CostIAmt:
Dep Covered
Ins. Avail for Dependent
(YIN):
Date of contract
Date payments exceeded $2,500
Date Contracts end
Total amount of Contract
Information
SSN:
1.
Name:
Address:
City:
Zip:
State:
Date
of
Date of Hire:
termination:
Birth Date:
Home Phone:
Work Phone:
Occupation:
Income freq:
(Weekly, Bi-Weekly, Monthly)
Gross Income Amt:
Ins. Avail for Employee
(YIN):
CostIAmt:
Dep Covered
Ins. Avail for Dependent
(YIN):
Date of contract
Date payments exceeded $2,500
Date Contracts end
Total amount of Contract
Mail to:
DSER-New Hire Reporting Program
or FAX to:
(207) 287-6882
State House Station
11
(800) 437-9611
Augusta, ME
04333-0011
R0909
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Parent category: Business