Montana New Hire Reporting Form  
                                                          
                          https://dphhs.mt.gov/CSED
                                                                                 
      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/CSED/employerinfo/newhirereporting                   

          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  12/2017)