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 
Send completed forms to:                                     To ensure the highest level of accuracy, please print neatly in 
Fax  -(888) 223-1462     or mail -                           capital letters and avoid contact with the edges of the boxes.  
Louisiana Directory of New Hires                             The following will serve as an example: 
PO Box 138078
Sacramento, CA 95813-8078                                            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: (First day employee works for pay)

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