OMB Control No: 0970-0166
Expiration Date: 07-31-2022
MULTISTATE EMPLOYER REGISTRATION FORM FOR NEW
HIRE REPORTING
Employers who have employees working in two or more states may use this form to register to submit their new hire reports to one
state or make changes to a previous registration. Multistate employers may also visit https://ocsp.acf.hhs.gov/OCSE/ to register or
make changes electronically.
Federal law (42 USC 653A(b)(1)(A)) requires employers to supply the following information about newly hired employees to the State
Directory of New Hires in the state where the employee works:
■ Employee's name, address, Social Security number, and the date of hire (the date services for remuneration were first
performed by the employee)
■ Employer's name, address, and Federal Employer Identification Number (FEIN)
If you are an employer with employees working in two or more states, AND you will transmit the required information or
reports magnetically or electronically, you may use this form to designate one state where any employee works to transmit
ALL new hire reports to the State Directory of New Hires.
If you are no longer a multistate employer OR you are a multistate employer but no longer report to a single state, check “No Longer a
Multistate Employer” in the box below.
No Longer a Multistate Employer (If checked, complete items 1-4 and 6-7 and return the form via email (preferred), fax, or
mail (see last page for return information).
If you need help completing this form, call the Multistate Employer Help Desk at 1-800-258-2736, Option #1 (8:00 a.m.- 5:00 p.m. ET).
Please note that all fields are required unless otherwise noted as optional.
1. Enter your company's Federal Employer
Identification Number (FEIN) without hyphen.
This is the nine-digit number used by the IRS to
identify your company.
FEIN:
2. Enter today's date in MM/DD/YYYY format.
Date:
3. Enter your company's name. This is the name associated with the FEIN in item 1.
Employer Name:
Enter your company's address, including city, state, and ZIP code. This is the address associated with the FEIN in
item 1. If your company's FEIN address is a foreign address, print the country's name and Postal code.
Employer Address:
City: State:
ZIP code:
(For foreign addresses only)
Country Name: Country Postal Code:
Subsidiary Information: Please go to www.acf.hhs.gov/css/resource/multiple-fein-spreadsheet to access the
Multiple FEIN Spreadsheet, enter information about all your company's subsidiaries, and submit it with this form.
Subsidiaries are companies wholly controlled by your company.
We need the below information about your company's subsidiaries.
FEIN Organization
Name
Address
Line1
Address
Line2
Address
Line3
City State Province Country ZIP/
Postal
Code
Address Delivery Type (Optional)
■ Payroll/Income
Withholding Order
■ National Medical Support
Notice
■ Verification of
Employment
■ Workers Compensation
4. Enter the name of the state or U.S. territory your company designated to report new hire information to.
NOTE: The state you choose must be a state in which you have one or more employees. Refer to the state listing
shown in item 5.
5. Check the box next to the additional states or U.S. territories where your company has employees working. Do not
put a check next to the state or territory you selected in item 4. You must select at least one state or territory in this
list to register as a multistate employer.
6. Enter your name, title, work phone number, work email address (do not use Gmail, Yahoo, MSN, or Hotmail email
addresses), and work fax number.
Company's Business Contact Name:
Phone: Fax (optional):
Email:
7. BE SURE TO SIGN THIS FORM. By completing this form, I certify that the information provided is accurate and that I
am authorized to complete this form on my company's behalf.
Signature of the person
completing this form:
Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware Dist. of Col Florida Georgia Guam
Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan
Minnesota Mississippi Missouri Montana Nebraska Nevada
New Hampshire New Jersey New Mexico New York North Carolina North Dakota
Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island
South Carolina South Dakota Tennessee Texas Utah Vermont
Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
All States and
Territories
Submitting this form to the U.S. Department of Health and Human Services meets the requirement to supply written notice
about your choice to report new hire information to only one state and to identify that state (42 USC 653A(b)(1)(B)).
Email (preferred) the completed form to:
[email protected]
Fax the completed form to:
Multistate Employer Registration
Fax: 410-277-9325
Mail the completed form to:
Department of Health and Human Services
Administration for Children and Families
Office of Child Support Enforcement (OCSE)
Multistate Employer Registration
PO Box 509
Randallstown, MD 21133
For general information about the employer's role in the child support program, visit OCSE's Employer Services website at: http://
www.acf.hhs.gov/css/employers.
Please note: If your company merges with or acquires another company, or has other changes that may affect this reporting
requirement, send a revised form with the new or updated information. You may also update this information online at
https://ocsp.acf.hhs.gov/OCSE/.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub.L. 104-13):
Public reporting burden for this collection of information is estimated to average .050 hours, per response, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information, unless it displays a currently valid OMB control number.