West Virginia New Hire Reporting Form printable pdf download

West Virginia New Hire Reporting Form

WEST VIRGINIA NEW HIRE REPORTING FORM

Send Completed Form to:

West Virginia New Hire Reporting Program

Fax form to:

1-877-625-4675

PO BOX 2473

Or:

304-346-9518

Charleston, WV 25329

For information:

1-877-625-4669

Or:

304-346-9513

EMPLOYER INFORMATION

Federal Employer

_______________________________________________________________

Identification Number

_______________________________________________________________

Employer Name

_______________________________________________________________

Mailing Address

_______________________________________________________________

City/State/Zip Code+4

_______________________________________________________________

Contact Name/Phone

EMPLOYER ADDRESS FOR INCOME WITHHOLDING NOTICES

(Include if address is different than above)

_______________________________________________________________

Address

_______________________________________________________________

City/State/Zip Code +4

EMPLOYEE INFORMATION

Social Security Number ____________-_______-____________

______________________________________________________________

Employee Name

______________________________________________________________

Employee Address

______________________________________________________________

City/State/Zip Code

Date of Hire*(MM/DD/YYYY) ___________________ Date of Birth*(MM/DD/YYYY) ___________

*Providing this optional data enhances our ability to perform services more efficiently

West Virginia New Hire Reporting Form