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STATE OF TENNESSEE NEW HIRE REPORTING Effective October 1 1997 all Tennessee employers are required to report certain information about employees who have been newly hired rehired or have returned to work. I. Name Last Home Address Do not use Employer City not leave blank State Zip Code Employee Date of Hire Federal EIN ADDITIONAL INFORMATION Store or Outlet Number Gender M/F Earned Income Tax Credit Available Y/N Date of Birth Employee Left Your Employment Y/N if unknown leave blank Does your company offer Medical Insurance Y/N Has this employee left your employment before you filed this report Corporate or Payroll if different from business address REPORTS WILL NOT BE PROCESSED WITHOUT MANDATORY INFORMATION Send Reports To Tennessee New Hire Reporting Program P. Employers must either 1 complete this form or 2 submit a copy of the employee s IRS W-4 form 3 other form with required information at a minimum or 4 submit the information by Internet magnetic tape or diskette. This form may be reproduced as necessary. Reports made on this form must be within 20 calendar days of hire or if you wish to help the Department of Labor and Workforce Development within 5 days of date of hire. TO ENSURE ACCURACY PLEASE PRINT or TYPE NEATLY IN UPPER-CASE LETTERS AND NUMBERS USING A DARK BALL-POINT PEN REQUIRED INFORMATION EMPLOYEE DATA Social Security Number First M. Employers must either 1 complete this form or 2 submit a copy of the employee s IRS W-4 form 3 other form with required information at a minimum or 4 submit the information by Internet magnetic tape or diskette. This form may be reproduced as necessary. Reports made on this form must be within 20 calendar days of hire or if you wish to help the Department of Labor and Workforce Development within 5 days of date of hire. This form may be reproduced as necessary. Reports made on this form must be within 20 calendar days of hire or if you wish to help the Department of Labor and Workforce Development within 5 days of date of hire. TO ENSURE ACCURACY PLEASE PRINT or TYPE NEATLY IN UPPER-CASE LETTERS AND NUMBERS USING A DARK BALL-POINT PEN REQUIRED INFORMATION EMPLOYEE DATA Social Security Number First M. Employers must either 1 complete this form or 2 submit a copy of the employee s IRS W-4 form 3 other form with required information at a minimum or 4 submit the information by Internet magnetic tape or diskette. This form may be reproduced as necessary. Reports made on this form must be within 20 calendar days of hire or if you wish to help the Department of Labor and Workforce Development within 5 days of date of hire. TO ENSURE ACCURACY PLEASE PRINT or TYPE NEATLY IN UPPER-CASE LETTERS AND NUMBERS USING A DARK BALL-POINT PEN REQUIRED INFORMATION EMPLOYEE DATA Social Security Number First M. .

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