D D EMPLOYER SECTION 150 REQUIRED INFORMATION Federal ID NumberBusiness Name Mailing Addressddress Line 2CityStateZip CodeBusiness PhoneExt Fax NumberEmail Address optionalIf the a ID: 855251
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1 D D eporting Form EMPLOYER SECTIO
D D eporting Form EMPLOYER SECTION – REQUIRED INFORMATION Federal ID Number:Business Name: Mailing Address:ddress Line 2:City:State:Zip Code:Business Phone:Ext. Fax NumberEmail Address (optional)If the above businessaddressisnew, please mark thisboxEMPLOYEE SECTION REQUIRED INFORMATIONIf your company address is outside of the United Statesreport onlineIf the individual does not have a Montana addressreport onlineSocial Security NumberDate of HireLast Name:First Name:MI:Mailing Address:Address Line 2City:StateZip Code:Home Address: Address Line 2:City:State:Zip Code:Optional Employee InformationHome Phone:Date of Birth:Work Phone:State of Hire:Is Health Insurance Available:YesDate HealtInsurance Is Available: Want the convenience of reporting your new hires online? New Hire Reporting Helpline: 1-888-866-0327 or 406-444-9290Fax to: 1-888-272-1990 / Local Fax: 406-444-0745 Mail ToMontana New Hire Reporting PO Box 8013 Helena, MT 596048013 REV 12/2017