Multistate Employer Notification Form For New Hire Reporting
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3OMB Control No: 0970-0166
Expiration Date: 07-31-2019
MULTISTATE EMPLOYER NOTIFICATION 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 also visit
https://ocsp.acf.hhs.gov/OCSE/
to register or make changes electronically.
Federal law (42 USC 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 may 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, check
“No Longer a Multistate Employer” in the box below. Complete Items 1-5, enter your contact information in Item 10, and
mail, fax, or e-mail this form to the address, fax number, or e-mail address 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, fax number, or e-mail address located on the last page.)
If you need help completing this form, call the Multistate Employer Help Desk at 410-277-9470 (8:00 am – 5:00 pm ET).
1. Print your company’s Federal Employer
2. Print today’s date in MM/DD/YYYY format, for
Identification Number. This is the nine-digit
example, 09/23/2014.
number used by the IRS 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:
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