NEW HIRE DIRECTORY INFORMATION 888-219-7801 EXT 100
PO BOX 3510 IN TOPEKA 296-5025
TOPEKA, KS 66601-3510
FAX 888-219-7798
KANSAS DEPARTMENT OF HUMAN RESOURCES IN TOPEKA 291-3423
NEW HIRE REPORT
SECTION ONE
EMPLOYEE CERTIFICATION
PRINT OR TYPE
NAME SOCIAL SECURITY
NUMBER
HOME ADDRESS
STREET
CITY STATE ZIP
ARE YOU CURRENTLY OR HAVE YOU BEEN ORDERED BY A COURT TO PAY CHILD SUPPORT? YES NO
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF KANSAS THAT THE FOREGOING IS TRUE AND CORRECT.
____________________________________ _______________________________________________________________
DATE SIGNED MM-DD-YY EMPLOYEE'S SIGNATURE
SECTION TWO
EMPLOYER CERTIFICATION
EMPLOYER Wichita State University FEIN 4 8
-
6 0 2 9 9 2 5
BUSINESS OR TRADE NAME FEDERAL EMPLOYER’S ID NUMBER
HOME ADDRESS 1845 Fairmount
STREET SUITE
Wichita KS 67260
CITY STATE ZIP
TELEPHONE
VOICE FAX
CONTACT
NAME TITLE
SECTION THREE
REPORTING OPTIONS
IF THE EMPLOYEE ANSWERS
YES TO THE CHILD SUPPORT QUESTION IN SECTION ONE, THIS REPORT MUST BE SUBMITTED TO THE
ADDRESS OR FAX AT THE TOP OF THIS REPORT WITHIN 20 DAYS OF HIRING, REHIRING OR RETURN TO WORK OF THE EMPLOYEE.
IF THE EMPLOYEE ANSWERS NO TO THE QUESTION, THIS REPORT MUST BE RETAINED. AT THE END OF THE QUARTER
ALL NEW
EMPLOYEES ANSWERING YES
AND NO MUST BE REPORTED ON THE QUARTERLY NEW HIRE SUMMARY, K-CNS 110.
INSTEAD OF COMPLETING THIS REPORT FOR EACH NEW EMPLOYEE TO DETERMINE IF THE EMPLOYEE IS SUBJECT TO A CHILD SUPPORT
ORDER, EMPLOYERS MAY ELECT TO REPORT
ALL NEWLY HIRED, REHIRED AND RETURNING EMPLOYEES WITHN 20 DAYS. IF YOU CHOOSE
TO VOLUNTARILY REPORT
ALL EMPLOYEES WITHIN 20 DAYS, IT WILL BE UNNECESSARY TO FILE BOTH THIS REPORT, K-CNS 104, AND THE
QUARTERLY NEW HIRE SUMMARY, K-CNS 110.
EMPLOYERS MAY USE THE FEDERAL FORM W-4, EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE TO
VOLUNTARILY REPORT ALL EMPLOYEES. THE EMPLOYER MUST
COMPLETE BOXES 8 AND 10 ON THE W-4.
COPIES OF THE WITHHOLDING CERTIFICATE MUST BE SUBMITTED WITHIN 20 DAYS OF HIRE, REHIRE OR
RETURN TO WORK. EMPLOYEE INFORMATION IN BOXES 1 AND 2 MUST BE LEGIBLE AND COMPLETE.
K-CNS 104 (6-98)
