Louisiana New Hire/Rehire     Form 
  Effective October 1, 1997 Act 97 of the 1997 LA Legislative Session requires all Louisiana Employers, both public and private, 
 to report all newly hired or rehired employees to the State of Louisiana within 20 days of hire.  Information about new hire 
 reporting and online reporting is available on our Web site: www.LA-newhire.com 
                                                              To ensure the highest level of accuracy, please print neatly in 
  Send completed forms to: 
  Louisiana New Hire Reporting                                capital letters and avoid contact with the edges of the boxes.  
  P.O. Box 142513                                             The following will serve as an example: 
  Austin, TX 78714-2513
  Toll-Free Fax:  (888) 223-1462                                   A B                             C     1       2     3
 
                                                   EMPLOYER INFORMATION  
  Federal Employer ID Number (FEIN):                               State ID Number (required if available): 
 
  Employer Name: 
 
  Employer Address:  
 
  Employer City:                                                                Employer State:               Zip Code (5 digit):
 
  Employer Phone (optional):                          Extension:    Employer Fax (optional): 
 
  Email (optional): 
 
                                                   EMPLOYEE INFORMATION 
  Employee Social Security Number (SSN):                           Date of Hire:
 
  Employee First Name:                                             Middle Name: 
 
  Employee Last Name: 

  Employee Address: 
 
  Employee City:                                                       Employee State:                        Zip Code (5 digit): 

  Occupation              (required if available):                                                       Date of Birth (optional):
                                              
                   REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING 
                                                   Questions?  Call us at toll-free (888) 223-1461