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Print Form Alaska New Hire Reporting Form Reset - clears all fields
Send completed form to: Or fax to: (907) 787-3197
MS 1 3New Hire Reporting Section
CHILD SUPPORT SERVICES DIVISION
th
550 W 7 AVE STE 310 Message Line: (907) 269-6685
ANCHORAGE AK 99501-6699 Toll free in Alaska: 1 (877) 269-6685
For information call: (907) 269-6089
Contact Name Contact Title
Employer Information
Submission Date (Year / Month / Date) Contact Phone Number Contact Fax Number Contact Email address
2014-06-04
Employer Federal Identification Number (FEIN) Employer AK Department of Labor Number Do you provide Health Insurance to your Employee?
000 Yes No
Employer Name Employer - Doing Business As / Also Known As
Employer Payroll Mailing Address City State Zip Code
AK
Employer Physical Address “Same” if same as mailing address City State Zip Code
AK
Employee Information
Employee Social Security Number * Employee First Name M.I. Employee Last Name
Employee Street Address City State Zip Code
AK
Year Month Day Year Month Day
Employee Employee
Date of Hire / Rehire 2014 0 0 Date of Birth 0 0
* You are required to provide the social security numbers of your newly hired or rehired employees pursuant to AS 25.27.075(b). The Child Support Services
Division will use the social security numbers only for the purpose of establishing and enforcing child support.
Employee Social Security Number * Employee First Name M.I. Employee Last Name
Employee Street Address City State Zip Code
AK
Year Month Day Year Month Day
Date of Hire / Rehire 2014 Date of Birth
Employee 0 0 Employee 0 0
Employee Social Security Number * Employee First Name M.I. Employee Last Name
Employee Street Address City State Zip Code
AK
Year Month Day Year Month Day
Employee Employee
Date of Hire / Rehire 2014 0 0 Date of Birth 0 0
CSSD 04-1050 (Rev06/04/14 )
