Ohio New Hire Reporting
Ohio Revised Code section 3121.89 to 3121.8910 requires all Ohio employers, both public and private, to report all contractors
and newly hired employees to the state of Ohio within 20 days of the contract or hire date. Information about new hire reporting
and online reporting is available on our website: www.oh-newhire.com
To ensure the highest level of accuracy, please print neatly in
capital letters and avoid contact with the edges of the boxes.
The following will serve as an example:
A
B
Send completed forms to:
Ohio New Hire Reporting Center
PO Box 15309
Columbus, OH 43215-0309
Fax: (614) 221-7088 or toll-free fax (888) 872-1611
EMPLOYER INFORMATION
Employer Name:
Employer Address (Please indicate the address where the Income Withholding Orders should be sent).
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone (optional):
Employer Fax (optional):
EMPLOYEE OR CONTRACTOR INFORMATION
Social Security Number (SSN) (Check here if using FEIN for the Contractor)
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip Code (5 digit):
REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING
Questions? Call us at (614) 221-5330 or toll-free (888) 872-1490
C
1
2
3
Extension:
State of Hire:
Date of Hire:
Date of Birth: Is this a Contractor?
Email:
JFS 07048 (Rev. 12/2013) Ohio Department of Job and Services
Yes
No
Date payments will begin for Contractor:
Length of time the Contractor will be performing services:
months
Reset Form
IT 4
Rev. 5/07
Notice to Employee
1. For state purposes, an individual may claim only natural de- For further information, consult the Ohio Department of Taxa-
pendency exemptions. This includes the taxpayer, spouse tion, Personal and School District Income Tax Division, or
and each dependent. Dependents are the same as defined your employer.
in the Internal Revenue Code and as claimed in the taxpayer’s
federal income tax return for the taxable year for which the
3. If you expect to owe more Ohio income tax than will be
taxpayer would have been permitted to claim had the tax-
withheld, you may claim a smaller number of exemptions;
payer filed such a return.
or under an agreement with your employer, you may have
an additional amount withheld each pay period.
2. You may file a new certificate at any time if the number of your
exemptions increases.
4. A married couple with both spouses working and filing a
joint return will, in many cases, be required to file an indi-
You must file a new certificate within 10 days if the number of
vidual estimated income tax form IT 1040ES even though
exemptions previously claimed by you decreases because:
Ohio income tax is being withheld from their wages. This
(a) Your spouse for whom you have been claiming exemp-
result may occur because the tax on their combined in-
tion is divorced or legally separated, or claims her (or his)
come will be greater than the sum of the taxes withheld
own exemption on a separate certificate.
from the husband’s wages and the wife’s wages. This
(b) The support of a dependent for whom you claimed ex-
requirement to file an individual estimated income tax form
emption is taken over by someone else.
IT 1040ES may also apply to an individual who has two
(c) You find that a dependent for whom you claimed exemp-
jobs, both of which are subject to withholding. In lieu of
tion must be dropped for federal purposes.
filing the individual estimated income tax form IT 1040ES,
the individual may provide for additional withholding with
The death of a spouse or a dependent does not affect your
his employer by using line 5.
withholding until the next year but requires the filing of a new
certificate. If possible, file a new certificate by Dec. 1st of the
year in which the death occurs.
please detach here
IT 4
Department of
Rev. 5/07
Employee’s Withholding Exemption Certificate
hio
Taxation
Print full name Social Security number
Home address and ZIP code
Public school district of residence School district no.
(See The Finder at tax.ohio.gov.)
1. Personal exemption for yourself, enter “1” if claimed ...............................................................................................................
2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) ............................................
3. Exemptions for dependents .......................................................................................................................................................
4. Add the exemptions that you have claimed above and enter total ...........................................................................................
5. Additional withholding per pay period under agreement with employer ..................................................................................
$
Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.
Signature Date
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N
Page 1 of 3
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form.
Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 07/17/17 N
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
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