Multistate Employer Notification Form For New Hire (W4) Reporting

OMB Control No: 0970-0166

Expiration Date: 06/30/2013

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:

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.

Multistate Employer Notification Form For New Hire (W4) Reporting - 2013 Page 3

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