Form 1 Employer Services Agreement and Profile

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

Employer Services Profile

OMB Control No: 0970-0370 Expiration Date: 02/28/2025

Description of Service

After completing the registration process and receiving your activation code, you can access the Portal to:

• Supply and update information about your organization such as addresses, contact names, phone numbers, and email addresses.

• Report lump sum payments for employees who may owe past-due child support.

• Report employee terminations.

• 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.

• Send secure messages and exchange documents containing sensitive information with child support agencies and OCSS through Communication Center. This reduces the need to encrypt emails.

Instructions

Fill out all the required fields in this form and email it to the Technical Operations Support. 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.

A third-party provider certifies that it has authorization to update information on OCSS Child Support Portal on behalf of clients.

Security

The employer, company, or government agency shall have appropriate procedures in place to promptly report confirmed or suspected information security or privacy incidents, including, but not limited to, unauthorized use or disclosure of Personally Identifiable Information (PII) involving confidential child support information submitted through OCSS to your organization. As soon as reasonably practicable after discovery, but in no case later than one hour after discovery of the incident, the employer, company, or government agency shall report confirmed or suspected incidents to OCSS as specified in this paragraph. The requirement for the employer, company, or government agency to report confirmed or suspected incidents involving PII to OCSS is based on federal guidance/requirements from the Office of Management and Budget (OMB), Health and Human Services (HHS), the Federal Information Security Modernization Act of 2014 (FISMA), and the United States Computer Emergency Readiness Team (US-CERT).

Incidents must be reported via email to OCSS using the security mailbox address:

the [email protected]

By selecting Accept, you certify that you have read, understood, and agree to the terms of this agreement.

Employer Services Profile

Required *

General Information

Enter general information about your organization and participation in Employer Services.

Date: *

(The date you are completing the form using MM/DD/YYYY format.)

FEIN: *

(Primary Federal Employer Identification Number – enter as nine numeric characters with no hyphen after the second number.)

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

Address Line 1: *

Address Line 2:

Address Line 3:

City: * ^{State: * ZIP Code (5 digits): * ZIP Code Ext:}

^{Is this the Payroll/Income Withholding Order address?} Yes No

Required *

Contact Information

Business Contact Information
First Name: *	MI:		Last Name: *
Email: *
				(Format: [email protected])
Select if you want email notifications sent to this address. oes this email address belong to a shared email box? * Yes No
Phone Number: *				Phone Ext:
(Enter numeric characters only. Include area code. Format: 1231231111)

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

^D

Fax Number:

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

Select other contact types that apply:

Alternate

Verification of Employment Lump Sum

General

National Medical Support Notice Accounts Payable

Multistate/MSER

Payroll/Income Withholding Order

Technical

This person is 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)

Phone Ext:

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Fax Number:

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

Select other contact types that apply:

Business

Verification of Employment Lump Sum

General

National Medical Support Notice Accounts Payable

Multistate/MSER

Payroll/Income Withholding Order

Alternate

Alternate Contact Information

This is the person child support agencies may contact regarding case-specific questions.

^{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: Phone Ext:

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

Fax Number:

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

Select other contact types that apply:

Business

Verification of Employment Lump Sum

General

National Medical Support Notice Accounts Payable

Multistate/MSER

Payroll/Income Withholding Order

Technical

Required *

Communication Preference

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

Required *

IP Address Information

The federal Office of Child Support Enforcement (OCSS) requires a public Internet Protocol (IP) address from external partners to allow secure access to the Child Support Portal. OCSS 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 the OCSS 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 that your organization holds exclusive use of the static IP addresses assigned by an Internet Service Provider vendor except if the IP address is associated with a home office. If the static IP address assigned to your organization or the IP address of the home office changes, then you must contact the Technical Operations Support.

^{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 the ARIN website.)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary

information collection is for OCSS to register and authenticate authorized users of the Employer Services applications on the OCSS’s Child Support Portal. Public reporting estimated burden for this collection of information is 0.08 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. As provided by 42 U.S.C. § 653(m)(2), any confidential information collected for this program is accessed only by authorized users. A federal agency may not conduct or sponsor an information collection without a valid OMB Control Number. No individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, without a current valid OMB Control Number. If you have any comments on this collection of information, please contact [email protected].

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