Form 1 Employer Services Agreement and Profile Form

OMB Control No: 0970-0370
Expiration Date: MM-DD-YYYY

Department of Health and Human Services
Administration for Children and Families
Office of Child Support Enforcement

Employer Services Agreement and Profile
Description of Service
After completing the registration process and receiving your activation code, you can access the
Portal to:
1. Supply and update information about your organization such as addresses, contact
names, phone numbers, and email addresses.
2. Report lump sum payments for employees who may owe past-due child support.
3. Report employee terminations.
4. Register as a multistate employer if you have employees in more than one state and
choose to report all new and rehired employees to only one of those states.
Instructions
Fill out all the required fields in this form and email it to the Portal Help Desk. One of our team
members may contact you if additional information is necessary to complete the registration
process.
Note
If you are a multistate employer and want to register only to report new hires to one state or
update information in the Multistate Employer Registry, download and complete the Multistate
Employer Registration form on our website and follow the instructions.
Disclaimer
By completing and supplying the information in this form, you agree to:
1. Not impersonate any individual, entity, or association; conceal; or supply misleading
information about my identity while transmitting files.
2. Supply true, accurate, current, and complete information about the entity identified in
this form.
3. Not use any information obtained because of involvement with Employer Services for
employment decisions.
By selecting Accept, you certify that you have read, understood, and agree to the terms of this
agreement.
Accept

Decline

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Employer Services Profile
Required *

General Information
Enter general information about your organization and participation in Employer Services.
Date: *
(MM/DD/YYYY)

FEIN: *
(Primary Federal Employer Identification Number Format: 123456789)

Organization Type: *

(Select Employer if you manage your own company's employee reporting.
Select Third Party if you are a payroll company or manage multiple employee reporting
clients.)

Organization Name: *

Organization Short Name:
(Enter abbreviation for your organization. Maximum 25 characters.)

Address Information
Is this the Payroll/Income Withholding Order address?

Yes

No

Address Line 1: *

Address Line 2:

Address Line 3:

City: *

State: *

ZIP Code (5 digits): *

ZIP Code Ext:

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Required *

Contact Information
Enter business, technical, and alternate contact information. If you have multiple child support contacts, you can add their
information on the Portal.

Business Contact Information
MI:

First Name: *

Last Name: *

Email: *
(Format: [email protected])

Select if you want email notifications sent to this address.
Yes

Does this email address belong to a shared email box? *

No

Phone Number: *
(Enter numeric characters only. Include area code. Format: 1231231111)

Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format 1231231111)

Select other contact types that apply:
Alternate

General

Multistate/MSER

Technical

Verification of Employment

National Medical Support Notice

Payroll/Income Withholding Order

Technical Contact Information
A network or system administrator who can help provide corporate IP address information or batch system
information, if applicable.
First Name:

MI:

Last Name:

Email:
(Format: [email protected])

Select if you want email notifications sent to this address.
Does this email address belong to a shared email box?

Yes

No

Phone Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

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Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Select other contact types that apply:
Business

General

Multistate/MSER

Alternate

Verification of Employment

National Medical Support Notice

Payroll/Income Withholding Order

Alternate Contact Information
First Name:

MI:

Last Name:

Email:
(Format: [email protected])

Select if you want email notifications sent to this address.
Does this email address belong to a shared email box?

Yes

No

Phone Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Select other contact types that apply:
Business

General

Multistate/MSER

Verification of Employment

National Medical Support Notice

Payroll/Income Withholding Order

Technical

Communication Preference
You must select a preferred method of communication for your organization: email, fax, or phone.
Communication Preference: *

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IP Address Information
The federal Office of Child Support Enforcement (OCSE) requires a public Internet Protocol (IP) address from external
partners to allow secure access to the Child Support Portal. OCSE independently verifies the IP address and organization
name with the American Registry for Internet Numbers (ARIN), a regional internet registry for the United States. For more
information, visit the ARIN website.
Enter the public IP addresses your organization uses to access the internet. In most cases, the IP address is your company's
internet proxy server or the public IP address of the computer used to access OCSE's Child Support Portal. To locate your
public IP address, search on the internet for "What Is My Public IP Address." You must verify the addresses with your network
administrator.
Public IP Addresses: *

By completing this section, you certify your organization holds exclusive use of the static IP addresses assigned by an
Internet Service Provider vendor. If the static IP address assigned to your organization changes, you must contact the
Portal Help Desk.
Name of Internet Service Provider: *

(Example: Comcast, AT&T, or Verizon. Enter your
company name if you own your IP address and it is
verifiable on ARIN website.)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub.L. 104-13):
Public reporting burden for this collection of information is estimated to average 0.08 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.

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