Pennsylvania New Hire Reporting Program                      New Hire Reporting Form                        COMMONWEALTH OF PENNSYLVANIA
Center for Workforce Information & Analysis                                                                             Department of Labor & Industry

                                                                                      New Hire Information that Must Be Reported
                                                                    Required Employer Information:          Required New Hire Employee 
                                                                                                            Information:
                                                                    Employer Federal Employer               Employee Social Security Number
                                                                    Identification Number (FEIN)            The number assigned to the individual by 
 1. Instructions for completing this form.                          If your company has more than one FEIN, the Social Security Administration. 
    Unless noted as optional, all fields on this form are required. please use the same FEIN used to report Please verify for accuracy.
    Please type or print legibly in black or blue ink only.         your quarterly wage information when 
                                                                    reporting new hires. 
   This form may be duplicated as needed.
                                                                    Employer Company Name                   Employee Full Legal Name
 The table at right provides details on the information             Legal name associated with the FEIN.    First, middle and last name
 to be submitted using this form.                                                                           Nicknames are NOT acceptable
                                                                    Employer Street Address                 Employee Street Address
 2. Submitting this form.                                           Address to which income withholding     Permanent address of the new hire  
                                                                    orders should be sent.                  employee. 
   By Fax:  866-748-4473 (TOLL FREE) 
                                                                    P.O. Boxes are not acceptable           P.O. Boxes are not acceptable
                       or 717-657-HIRE (717-657-4473) (Local)
   By Mail:            Commonwealth of Pennsylvania
                                                                    Employer City, State and Zip Code       Employee City, State of Hire 
                       New Hire Reporting Program
                                                                    Self-explanatory.                       and Zip Code
                       P.O. Box 69400
                                                                                                            Self-explanatory.
                       Harrisburg, PA 17106-9400
                                                                    Employer Contact Person Name            Employee Date of Hire
 3. Questions?                                                      Employer’s representative authorized to The first day the new hire employee  
Contact New Hire Customer Service at:                               answer questions on the New Hire Report,  performs services for wages or any  
888-PAHIRES (888-724-4737) for more information.                    should they be contacted by our program other form of compensation. 
                                                                    for additional information. This can be This cannot be more than three years 
                                                                    someone from the payroll company.       from the current date.
 4. Save time and postage costs. 
                                                                    Employer Contact Person Phone Number Employee Date of Birth
    Online reporting is fast, free and paperless.                   Phone number for the Employer           Optional – the date of birth for the  
   For more information about how to get started, please visit      Contact Person.                         new hire employee.

                                                                    Note: Multi-state employers MAY NOT use this form to report their new hire information.  
    www.pacareerlink.state.pa.us
                                                                    Multi-state employers MUST report by electronic means (Internet, SFTP), and MUST 
 Or contact our customer service at 888-PAHIRES (888-724-4737)      include the state of hire for each new hire employee being reported. Contact New Hire 
                                                                    Customer Service at 888-PAHIRES (888-724-4737) for more information.

                                                                                                   New Hire Reporting: Lending a Hand to Pennsylvania’s Children
CWIA-25  06-12 (Page 1)

Pennsylvania New Hire Reporting Program                     New Hire Reporting Form                                                                                                             COMMONWEALTH OF PENNSYLVANIA
Center for Workforce Information & Analysis                                                                                                                                                      Department of Labor & Industry
REQUIRED EMPLOYER INFORMATION:                                                                                    REQUIRED EMPLOYEE INFORMATION: (Please type or print LEGIBLY in blue or black ink ONLY) 
(Please type or print LEGIBLY in blue or black ink ONLY)                                                                                                                                         ONE EMPLOYEE PER BOX
Employer FEIN:                                                                                                    Employee Social Security Number

Employer Name:                                                                                                    Legal Name (First)               (Middle)                                     (Last)

Employer Address (Street, City, State, Zip):
PO Box’s are not acceptable                                                                                       Street Address (Post Office Box is not acceptable)    Apartment Number (if available)

Employer Contact Name:                                                                                            Zip Code                            City                                                     State

Employer Contact Phone Number:
                                                                                                                  Date of Hire (MM/DD/YYYY)                                   Date of Birth (MM/DD/YYYY)
                                                                                                                  (Must be within 3 years of current date)
Employer Contact Fax Number:
                                                                                                                                                                                                 ONE EMPLOYEE PER BOX
Employer Contact Email:
                                                                                                                  Employee Social Security Number

Please fax this form to:
866-PAHIRES (866-748-4473) (TOLL FREE)                                                                            Legal Name (First)               (Middle)                                     (Last)
Or 717-657-HIRE (717-657-4473) (Local)
                                                                                                                  Street Address (Post Office Box is not acceptable)    Apartment Number (if available)
Or mail this form to:
          Commonwealth of Pennsylvania                                                                            Zip Code                            City                                                     State
          New Hire Reporting Program
          P.O. Box 69400                                                                                          Date of Hire (MM/DD/YYYY)                                   Date of Birth (MM/DD/YYYY)
          Harrisburg, PA 17106-9400                                                                               (Must be within 3 years of current date)
                                                                                                                                                                                                 ONE EMPLOYEE PER BOX
Questions?
Contact New Hire Customer Service at 888-PAHIRES (888-724-4737)                                                   Employee Social Security Number
Or by email at:  RA-LI-CWDS-NewHire@pa.gov    
                                                                                                                  Legal Name (First)               (Middle)                                     (Last)
                      This form may be duplicated as needed
                                                                                                                  Street Address (Post Office Box is not acceptable)    Apartment Number (if available)
                       Save time and postage costs.
               Online reporting is fast, free and paperless.
                                                                                                                  Zip Code                            City                                                     State
          For more information about how to get started, please visit 

          www.pacareerlink.state.pa.us                                                                            Date of Hire (MM/DD/YYYY)                                   Date of Birth (MM/DD/YYYY)
                                                                                                                  (Must be within 3 years of current date)
Or contact our customer service at 888-PAHIRES (888-724-4737)                                                     New Hire Reporting: Lending a Hand to Pennsylvania’s Children
CWIA-25  06-12 (Page 2)