The following information is required:
Employer's Federal Employer Identification Number (FEIN)
Employer's Name
Employer's Address
Employee's Name (First, Middle, Last)
Employee's Address
Employee's Social Security Number
Employee's Date of Hire
Additional information may be required if reporting electronically. Please click here for electronic reporting specifications.
Have you been discriminated against by a potential or current employer -- as a job applicant or current employee? To best protect your legal rights you should discuss your situation with an employment lawyer. Meet with a local employment attorney sooner rather than later to protect your rights.