PDF document

- 1 -

OMB Control No: 0970-0166
OMB Expiration Date: 07/31/2025

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 register online at
https://ocsp.acf.hhs.gov/OCSE/.

Note: If you are a third-party provider, your clients must have employees in two or more states to register as a
multistate employer.

Federal law (42 U.S.C. § 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 can 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, select the No
Longer a Multistate Employer check box below.

No Longer a Multistate Employer (If selected, complete items 1–4 and 7) and return the form to the email address
msedb@acf.hhs.gov or mail it to the address located on page 3.

If you need help completing this form, contact the Multistate Employer Help Desk at 800-258-2736 (8 a.m. – 5 p.m. ET,
Monday through Friday).

Note: All required fields are followed by a red asterisk .*

1. Enter your company's FEIN without a hyphen. 2. Enter today's date in MM/DD/YYYY format.
This is the nine-digit number used by the IRS to
identify your company.
FEIN *: Date :*

3. Enter your company's legal name used for child support documents. 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, enter the country's name and postal code.

Employer Address *:

City :* State *:

ZIP Code *:

(For foreign addresses only) Country Name: Country Postal Code:

- 2 -

4. Enter your name, title,  work  phone   number,  work email   address,   and work fax  number. 
   Name *:                                                       Title:
   Phone  *:                                                     Fax  (optional):
   Email  *:
      Is this also the address  for mailing Income    Withholding    for Support Orders (IWOs)?                 Yes       No  

   Subsidiary Information: Please go to the Organization FEIN Template at             https://www.acf.hhs.gov/css/training-
                                                                                                                                     
   technical-assistance/organization-fein-template      to  access     the FEIN Excel file, enter information  about all your 
   company's subsidiaries, and submit it with this form. Subsidiaries are companies wholly controlled by another 
                                                                                                                          
   company. 

5. Select the state or U.S. territory to submit new hires to.
                                                                                          
   Note: The state you designate must be a state where you have one or more employees.
                              
   State or U.S. territory  :*
                                                                                                                 
6. Select all other states and U.S. territories where you have one or more employees.* 
   Do not include the previously selected   reporting state.
                                                                        
   Select at least one state or territory to register as a multistate employer.

        All States and  Territories 
        Alabama                   Alaska               Arizona             Arkansas            California            Colorado 
        Connecticut               Delaware             District  of        Florida             Georgia               Guam 
                                                       Columbia 
        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 

7. Sign this form.

By completing this form,   I certify the information  provided  is   accurate and that I   am authorized to   complete this form on  
my company's behalf     . 

Signature   ofthe person completing   this form  *  :                                                     Date*:  

                                                                                                                                       2

- 3 -

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 U.S.C. § 653A(b)(1)(B)).
The completed form can be submitted by email or postal service .

Email the completed form to HHS Administration for Children and Families
msedb@acf.hhs.gov. Office of Child Support Enforcement 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
https://www.acf.hhs.gov/css/employers .
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 can also update this information online at
https://ocsp.acf.hhs.gov/OCSE/ .

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary information collection is for
multistate employers to register to submit their new hire reports to one state or make changes to a previous registration. Public reporting estimated
burden for this collection of information is estimated to average .050 hours to submit the MSER form 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), 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 OCSEFedSystems@acf.hhs.gov .

PDF file checksum: 3894348690

(Plugin #1/9.12/13.0)