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Florida New Hire Reporting Form
Florida New Hire Reporting Center
PO Box 6500
Tallahassee, FL 32314-6500
capital letters and avoid contact with the edges of the boxes.
The following will serve as an example:
EMPLOYER INFORMATION
Federal Employer ID Number (FEIN) (Please use the same FElN that appears on your quarterly wage reports you submit to the State):
Is (will) medical insurance be available to employee? Y/N
Florida Employer Unemployment Compensation (UCT-6) Number:
*optional information
Employer Name:
Employer Address:
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone:
Extension:
Employer Fax:
Contact Name:
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
Employee First Name:
Middle Initial:
Employee Last Name:
Employee Address:
Employee City:
Employee State:
Zip Code (5 digit):
Reports must be submitted within 20 days of date of hire or rehire
REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING
Questions? Call us at (850) 656-3343 or toll-free 1 (888) 854-4791
Rev (01/10)
To ensure the highest level of accuracy, please print neatly in
Send completed forms to:
FAX: (850) 656-0528 or toll-free fax 1 (888) 854-4762
Date of Hire:
Date of Birth:
ABC
123
*
*
STF BXRB1001
Social Security number disclosure is mandatory based on Title 42 United States Code sections
666(a)(13), 653a, and 654a(e), and on Section 409 . 2577, Florida Statutes. W
e collect social
security numbers for child support purposes . For more information go to
http://dor. myflorida. com/dor/privacy. html