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Multi-State Employer Notification Form For New Hire Reporting - Department Of Health And Human Services Page 3

OMB Control No: 0970-0166

Expiration date: 04//30/2007

NOTE: COMPLETE THIS FORM ONLY IF YOUR COMPANY HAS EMPLOYEES IN MORE THAN ONE STATE

AND YOU CHOOSE TO REPORT ELECTRONICALLY OR MAGNETICALLY TO ONLY ONE STATE.

INSTRUCTIONS FOR COMPLETING THIS FORM:

Item 1. Enter your company’s Federal Employer Identification Number. This is the number used by the IRS to identify your

company.

Item 2. Enter today’s date in MM/DD/YYYY format, e.g., 09/23/1997.

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

Item 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 two-character Country Code, the Country Name,

and the Country Zip Code.

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

Item 6. Enter the FEIN the name, state, and zip code of any subsidiaries, divisions, autonomous operating units, etc. of your

company that have their own FEIN and for whom you will be reporting New Hire W-4 information. If there are more

than two entries, please list the others on a separate piece of paper.

Item 7. PRINT the two-character abbreviation for the State, U.S. territory, or U.S. possession to which your company has

chosen to report New Hire W-4 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 on the form.

Item 7a. Enter the effective date (MM/DD/YYYY) on which your company will begin sending New HireW-4 information to the

entry shown in Item 7.

Item 8. If your company has employees in States, U.S. territories, or U.S. possessions other than the entry shown in Item 7,

CIRCLE the applicable two-character State abbreviations shown in the State list

Item 9. PRINT your name, title, work phone number (if different from the Company phone number entered in Item 5), work

Email address, and work fax address. BE SURE TO SIGN THE FORM. The information in this Item is used to

acknowledge receipt of your notification and to contact you if any clarification is needed.

Send the completed form to:

Fax the completed form to:

Department of Health and Human Services

Administration for Children and Families

Office of Child Support Enforcement

Multistate Employer Notification

P.O. Box 509

1-410-277-9325

Randallstown, MD 21133

If you need assistance in completing this form, call 1-410-277-9470 (9:00 a.m. – 5:00 p.m. EST); for general information,

call 1-202-401-9267.

Multi-State Employer Notification Form For New Hire Reporting - Department Of Health And Human Services Page 3