Form 1 Employer Services Agreement and Profile Form

Employer Services Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Department of Health and Human Services
Administration for Children and Families
Office of Child Support Enforcement

Employer Services Agreement and Profile

By completing and providing the information contained in the “Employer Services Profile
Form," the employer or third party processor agrees that it will:
Not impersonate any individual, entity, or association, conceal or provide misleading
information about my identity while transmitting files.
Provide true, accurate, current, and complete information about the entity identified in
the “Profile Form.”
Provide written notice to the Office of Child Support Enforcement, at least 30 days
in advance, of its intent to no longer send Employer Services files.
Not use any information obtained as a result of involvement with the Employer Services for
employment decisions.
By checking "Accept", you certify that you have read and understood, and agree to the terms of
this agreement.

Accept

Decline

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Employer Services Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Employer Services Profile Form

Employer Services
Required *

General Information
Enter general information about your organization and participation in Employer Services.
Start Date: *
(MM/DD/YYYY)

FEIN: *
(Primary Federal Employer Identification Number. Format: 123456789)

Organization Type: *

Organization Name: *

Organization Short Name:
(Supply a shortened name, abbreviation, or acronym
for your organization.)

Address Information
Address Line 1: *

Address Line 2:

Address Line 3:

City: *

State: *

Zip Code:

*
Format: 12345 or 123456789

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Employer Services Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Required *

Contact Information
Enter business, technical support, and alternate contact information.

Business Contact Information
Enter business contact information.
Contact Name: *

Contact Phone Number: *
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format 1231231111)

Contact E-mail: *
(Format: name@somewhere.com)

Click if you want E-mail notifications sent to this E-mail address

Technical Support Contact Information
Enter technical support contact information.
Contact Name:

Contact Phone Number:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact E-mail:
(Format: name@somewhere.com)

Click if you want E-mail notifications sent to this E-mail address

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Employer Services Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Alternate Contact Information
Enter alternate contact information.
Contact Name:

Contact Phone Number:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact E-mail:
(Format: name@somewhere.com)

Click if you want E-mail notifications sent to this E-mail address

Alternate Contact Information
Enter alternate contact information.
Contact Name:

Contact Phone Number:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact E-mail:
(Format: name@somewhere.com)

Click if you want E-mail notifications sent to this E-mail address

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Employer Services Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Server Information
Please provide the public source IP addresses used by your organization to access the internet. In most cases, the addresses
will be those of your company's internet proxy servers, or the public IP address of the computer that will be used to access
Employer Services. Verify addresses with your network administrator.

IP Address Information
Public Source IP Address:
Public Source IP Address:
Public Source IP Address:

File Information
Your organization must submit Employer Services files as .csv, .txt, .xls, and .xlsx files only. The file names must only contain
alphanumeric characters, no characters such as spaces or parentheses. If your organization submits multiple files on one
day, each file name must be unique. A suggested approach is to append a date and a sequence number to the file name.
(Example: 123456789.DI.06092012.33.xls)
We will only process files if your organization has a profile and registered user in the system.

Public reporting burden for this collection of information is estimated to average 0.08 hours, 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.

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