Multistate Employer Notification Form

OMB Control No: 0970-0166

Expiration Date: xx/xx/20xx

MULTISTATE EMPLOYER NOTIFICATION FORM

FOR NEW HIRE (W4) REPORTING

This form is provided to employers who have employees in two or more states and wish to register to submit their new hire reports to one state or to make changes to their previous registration.

Federal law requires employers to provide to the State Directory of New Hires of the state in which a newly hired employee works, a report that contains the name, address, and Social Security number of the employee, and the name, address and Federal Employer Identification Number (FEIN) of the employer (42 USC 653A(b)(1)(A)).

If you are an employer with employees in two or more states AND you will transmit the required reports magnetically or electronically, Federal law allows you to comply with the new hire reporting requirement by exercising one of the following options (42 USC 653A(b)(1)(B)):

Option #1: Send the new hire reports to the State Directory of New Hires of the state in which each

newly hired employee works.

OR

Option #2: Designate one state in which any employee works and transmit ALL new hire reports to the

State Directory of New Hires of that state. You must notify the Secretary of the U.S. Department

of Health and Human Services in writing of your choice to report to only one state and identify the chosen state (42 USC 653A(b)(1)(B)).

For Option #2: Complete this form to identify/register your entity as a multistate employer for new hire reporting.

If you are no longer a multistate employer –OR– you are a multistate employer but you no longer report to one state, check “No Longer a Multistate Employer” in the box below. Complete Items 1 – 5, provide your contact information in

Item 10, and mail or fax this form to the address or fax number 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 or fax number located on the last page.)

For assistance in completing this form, call the Multistate Employer Help Desk at 410-277-9470 (8:00 a.m. – 5:00 p.m. ET).

If you wish to register electronically, go to: http://151.196.108.21/OCSE

1. Print your company’s Federal Employer Identification 2. Print today’s date in MM/DD/YYYY

Number. This is the nine-digit number used by the IRS format, e.g., 09/23/2007.

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 the Country’s 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 two-character abbreviation for the State or U.S. Territory to which your company has chosen to

report new hire information. NOTE: The State that you designate 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) on which your company will begin sending new hire (W-4)

reports to the entry shown in Item 7.

Effective Date: / /

9. Please circle the States or U.S. Territories in which your company has employees, other than the State or Territory selected as your reporting State in item 7. You must indicate at least one State in this list to register as a multistate employer.

DO NOT INCLUDE THE STATE CODE ENTERED IN ITEM 7

AK=Alaska GA=Georgia MA=Massachusetts NE=Nebraska PR=Puerto Rico WA=Washington

AL=Alabama GU=Guam MD=Maryland NH=New Hamp. RI=Rhode Island WI=Wisconsin

AR=Arkansas HI=Hawaii ME=Maine NJ=New Jersey SC=S. Carolina WV=W. Virginia

AZ=Arizona IA=Iowa MI=Michigan NM=New Mexico SD=S. Dakota WY=Wyoming

CA=California ID= Idaho MN=Minnesota NV=Nevada TN=Tennessee

CO=Colorado IL=Illinois MO=Missouri NY=New York TX=Texas

CT=Connecticut IN=Indiana MS=Mississippi OH=Ohio UT=Utah

DC=Dist. of Col. KS=Kansas MT=Montana OK=Oklahoma VA=Virginia

DE=Delaware KY=Kentucky NC=N. Carolina OR=Oregon VI=Virgin Islands

FL=Florida LA=Louisiana ND=N. Dakota PA=Pennsylvania VT=Vermont

10. Print your name, title, work phone number (if different from the company phone number entered in Item 5), work email address and work fax number. BE SURE TO SIGN THE FORM. The information in this form is used to acknowledge receipt of your notification and to contact you if any clarification is needed.

Contact Name: Title

Phone: ( ) Fax

Email:

Providing your email address will help us communicate with you more effectively in the future.

Signature of person

completing this form:

Send the completed form to: Or 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

PO Box 509

Randallstown, MD 21133

For assistance in completing this form, call the Multistate Employer Help Desk at 410-277-9470

(8:00 a.m. – 5:00 p.m. ET). For general child support information, visit OCSE’s Employer Services website at:

http://www.acf.hhs.gov/programs/cse/newhire/employer/home.htm

Please note: If your company experiences a merger, acquisition, or other change that may affect this reporting

requirement, please send a revised form with the new information.

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.