Alaska New Hire Reporting Form {04-1050}

Alaska New Hire Reporting Form Send completed form to: MS 13 New Hire Reporting Section CHILD SUPPORT SERVICES DIVISION 550 W 7th AVE STE 310 ANCHORAGE AK 99501-6699 Contact Name Or fax to: (907) 787-3197 (907) 269-6685 1 (877) 269-6685 (907) 269-6089 Message Line: Toll free in Alaska: For information call: Contact Title Employer Information Submission Date (Year / Month / Date) Contact Phone Number Contact Fax Number Contact Email address Employer Federal Identification Number (FEIN) Employer AK Department of Labor Number Do you provide Health Insurance to your Employee? 000 Employer Name Yes Employer - Doing Business As / Also Known As No Employer Payroll Mailing Address City State Zip Code Employer Physical Address "Same" if same as mailing address City State Zip Code Employee Information Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Year Month Day Year Month Day Employee Employee Date of Birth / Rehire Date of Hire * 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 Employee Date of Hire Year Month Day / Rehire Employee First Name M.I. Employee Date of Birth Employee Last Name Year Month Day Employee Social Security Number * Employee Street Address City State Zip Code Year Employee Date of Hire Month Day Employee Date of Birth Year Month Day / Rehire CSSD 04-1050 (Rev 06/04/14) American LegalNet, Inc. www.FormsWorkFlow.com New Hire Reporting ­ continued Employer Name Employer Federal Identification Number (FEIN) Submission Date (Year / Month / Date) Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Year Employee Date of Hire Month Day Employee Date of Birth Year Month Day / Rehire Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Year Employee Date of Hire Month Day Employee Date of Birth Year Month Day / Rehire Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Employee Date of Hire Year Month Day / Rehire Employee Date of Birth Year Month Day Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Year Employee Date of Hire Month Day Employee Date of Birth Year Month Day / Rehire Employee Social Security Number * Employee First Name M.I. Employee Last Name Employee Street Address City State Zip Code Year Employee Date of Hire Month Day Employee Date of Birth Year Month Day / Rehire CSSD 04-1050 (Rev 06/04/14) American LegalNet, Inc. www.FormsWorkFlow.com