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: