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Blank Arizona New Hire Reporting PDF Template

The Arizona New Hire Reporting Form is a crucial document that employers must complete when hiring new employees in the state. This form helps ensure compliance with state regulations and assists in tracking new hires for various purposes, including child support enforcement. Accurate completion and timely submission are essential for maintaining proper records and avoiding potential penalties.

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Overview

The Arizona New Hire Reporting Form is an essential tool for employers in the state, designed to ensure compliance with state and federal regulations regarding new employees. When you hire someone, this form must be completed and submitted promptly. It captures important information about both the employer and the employee, including the Federal Employer Identification Number (FEIN), the employer's contact details, and the new hire's Social Security Number, name, and address. Additionally, it asks for the employee's date of birth and date of hire, along with questions about medical insurance benefits. This information not only helps in tracking employment but also plays a crucial role in child support enforcement and other state benefits. Employers can send the completed form by mail or fax, making the process straightforward and accessible. Understanding how to fill out this form accurately is vital for any business operating in Arizona.

Form Example

Arizona New Hire Reporting Form

Mail completed form to: Arizona New Hire Reporting Center

P.O Box 402

Holbrook, MA 02343

Or fax completed form to: 1-888-282-0502 toll-free fax

EMPLOYER INFORMATION

Federal Employer Identification Number (FEIN): _______________________________________________________

(Please use the same FEIN for which listed employee(s) quarterly wages will be reported under.)

Employer Name: _________________________________________ DBA: ___________________________________

Contact Name: __________________________ Telephone: _________________ Email: ________________________

Address: _______________________________________________________________________________________

(Please indicate the address where the Income Withholding Order will be sent)

City: _________________________________ State: __________ Zip Code: _________________ +4: _____________

Complete one entry for each new employee

EMPLOYEE INFORMATION

Social Security Number: _____________-_____________-_____________

Employee First Name: __________________________________ Middle: ____________________________________

Employee Last Name: ______________________________________________________________________________

Employee Address: ________________________________________________________________________________

City: ________________________________________ State: ____________ Zip Code: ____________ +4: _________

*Date of Birth: ________________________________	*Date of Hire: ___________________________
*Is medical insurance an employee benefit?	Yes ____	No ____
*Is this employee eligible for an insurance benefit?	Yes ____	No ____

* OPTIONAL

EMPLOYEE INFORMATION

Social Security Number: _____________-_____________-_____________

Employee First Name: __________________________________ Middle: ____________________________________

Employee Last Name: ______________________________________________________________________________

Employee Address: ________________________________________________________________________________

City: ________________________________________ State: ____________ Zip Code: ____________ +4: _________

*Date of Birth: ________________________________	*Date of Hire: ___________________________
*Is medical insurance an employee benefit?	Yes ____	No ____
*Is this employee eligible for an insurance benefit?	Yes ____	No ____

* OPTIONAL

For information please visit our web-site at www.az-newhire.com

or call us toll-free at 1-888-282-2064

The Arizona New Hire Reporting Center is an authorized agent of the Arizona Department of Economic Security

Rev 03/2010

↓ PDF Form

Document Characteristics

Fact Name	Description
Purpose	The Arizona New Hire Reporting Form is used to report newly hired employees to the state.
Governing Law	This reporting requirement is governed by the Arizona Revised Statutes, specifically A.R.S. § 23-722.
Submission Methods	Employers can submit the completed form by mail or fax. The mailing address is P.O. Box 402, Holbrook, MA 02343, and the fax number is 1-888-282-0502.
Employer Identification	Employers must provide their Federal Employer Identification Number (FEIN) on the form, which should match the FEIN used for reporting quarterly wages.
Employee Information	Each entry on the form requires detailed information about the new employee, including their Social Security Number, name, address, date of birth, and date of hire.
Insurance Benefits	The form includes questions about medical insurance benefits, specifically whether the employee is eligible for such benefits.
Contact Information	Employers must provide contact information, including a name, telephone number, and email address for communication regarding the form.

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