Form 1 MSE Form

OMB Control No: 0970-0166

Expiration Date: xx-xx-xxx

MULTISTATE EMPLOYER NOTIFICATION 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. Complete Items 1-5, enter your contact information in Item 10, and mail, fax, or e-mail this form to the address, fax number, or e-mail address located on the last page.

□ No Longer a Multistate Employer – (If checked, complete Items 1-5 and Item 10, and return the form to the address, fax number, or e-mail address located on the last page.)

If you need help completing this form, call the Multistate Employer Help Desk at 410-277-9470 (8:00 am – 5:00 pm ET).

_1. Print your company’s Federal Employer 2. Print today’s date in MM/DD/YYYY format, for
Identification Number. This is the nine-digit example, 09/23/2014.
number used by the IRS _{to identify your
company.}

Federal Employer

_{Identification Number (FEIN): _________________ Date / /}

3. Print your company’s name. This is the name associated with the FEIN in Item 1.

Employer Name:

4. Print 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 name and Postal code.

_{Employer Address:}

_______________________________________________________________

_______________________________________________________________

_{City: _____________________________ State: ____ ZIP Code: ________}

_{(For foreign addresses only) Country Name: Country Postal Code: ______}

5. Print your company’s phone number, including area code. This is the phone number associated with the FEIN in Item 1.

_{Phone Number: ( ) Ext.}

6. Print the FEIN, name, state, and ZIP Code of any subsidiary of your company that has its own FEIN and for which you will be reporting new hire information.

Subsidiary Information: (Please list any additional subsidiaries on a separate sheet.)

_{FEIN: FEIN:}

_{Name: Name:}

_{State/ZIP Code: State/ZIP Code:}

_{FEIN: FEIN:}

_{Name: Name:}

_{State/ZIP Code: State/ZIP Code:}

7. Print the name of the state or U.S. territory your company designated to report new hire information. 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 9.

______________________________________

8. Enter the effective date (MM/DD/YYYY) that your company will begin sending new hire reports to the entry shown in Item 7.

Effective Date: / /

9. Put a check mark in 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 7. You must select at least one state or territory in this list to register as a multistate employer.

 Alabama	 Florida	 Kentucky	 Montana	 Ohio	 Texas
 Alaska	 Georgia	 Louisiana	 Nebraska	 Oklahoma	 Utah
 Arizona	 Guam	 Maine	 Nevada	 Oregon	 Vermont
 Arkansas	 Hawaii	 Maryland	 New Hamp.	 Pennsylvania	 Virgin Islands
 California	 Idaho	 Massachusetts	 New Jersey	 Puerto Rico	 Virginia
 Colorado	 Illinois	 Michigan	 New Mexico	 Rhode Island	 Washington
 Connecticut	 Indiana	 Minnesota	 New York	 S. Carolina	 W. Virginia
 Delaware	 Iowa	 Mississippi	 N. Carolina	 S. Dakota	 Wisconsin
 Dist. of Col.	 Kansas	 Missouri	 N. Dakota	 Tennessee	 Wyoming

10. Print your name, title, work phone number (if different from the company phone number entered in Item 5), work e-mail address, and work fax number. BE SURE TO SIGN THIS FORM. 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)).

Contact Name: Title:

Phone: ( ) Fax: ( )

_E-mail:

Providing your e-mail address helps us communicate with you more effectively in the future.

Signature of person

_{completing this form:}

Send the completed form to: Fax the completed form to:

Department of Health and Human Services Multistate Employer Notification

Administration for Children and Families Fax: 410-277-9325

Office of Child Support Enforcement

Multistate Employer Notification E-mail the completed form to:

PO Box 509

Randallstown, MD 21133 [email protected]

_{For gen}eral information about the employer’s role in the child support program, visit OCSE’s Employer Services website at: _{http://www.acf.hhs.gov/programs/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

Public reporting burden for this collection of information is estimated to average 3 minutes 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.