Montana New Hire Reporting Form  
                                                          
      https://dphhs.mt.gov/cssd/employerinfo/newhirereporting
                                                                                 
      EMPLOYER SECTION – REQUIRED INFORMATION
Federal ID Number:                                                                           
Business Name:                                                                               
Mailing Address:                                                                             
Address Line 2:                                                                              
City:                                 State:              Zip Code:                          
Business Phone:                      Ext.                 Fax Number:                        
Email Address  (optional)                                                                    

       If  the above business address is new,  please mark this    D           box

      EMPLOYEE SECTION  –  REQUIRED INFORMATION 

       If your company  address  is outside of  the United States,  report online. 

       If the individual  does not have a Montana address          ,  report online. 

Social Security  Number:                       Date of Hire   :                              
Last Name:                                   First Name:                        MI:          
Mailing Address:                                                                             
Address Line 2                                                                               
City:                                  State:                        Zip Code:               

Home  Address:                                                                               
Address Line 2:                                                                              
City:                                  State:                        Zip Code:               

                          Optional Employee Information 

Home Phone:                            Date of Birth:
Work Phone:                            State of Hire:                                        
Is Health Insurance Available:   D   Yes     D   No 
Date Health  Insurance Is Available:                                                         

Want the convenience          of reporting   your new hires online?              

Go to:https://dphhs.mt.gov/cssd/employerinfo/nhrs                               

          New Hire Reporting Helpline: 1-888-866-0327 or 406-444-9290 
                    Fax to: 1-888-272-1990 / Local Fax: 406-444-0745 
                    Or  Mail To:   Montana New  Hire Reporting  
                                           PO Box 8013  
                                     Helena,  MT 59604-8013                    (REV  08/2021)