Form 1 Employer Services Agreement and Profile

OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

Department of Health and Human
ServicesAdministration for Children and
Families Office of Child Support
Enforcement
Employer Services Profile
Description of Service
After completing the registration process and receiving your activation code, you can access thePortal to:
1. Supply and update information about your organization such as addresses, contactnames,
phone numbers, and email addresses.
2. Report lump sum payments for employees who may owe past-due child support.
3. Report employee terminations.
4. Register as a multistate employer if you have employees in more than one state andchoose
to report all new and rehired employees to only one of those states.
Instructions
Fill out all the required fields in this form and email it to the Portal Help Desk. One of our teammembers may
contact you if additional information is necessary to complete the registration process.
Note
If you are a multistate employer and want to register only to report new hires to one state or update
information in the Multistate Employer Registry, download and complete the MultistateEmployer
Registration form on our website and follow the instructions.
Disclaimer
By completing and supplying the information in this form, you agree to:
1. Not impersonate any individual, entity, or association; conceal; or supply misleading
information about my identity while transmitting files.
2. Supply true, accurate, current, and complete information about the entity identified inthis form.
3. Not use any information obtained because of involvement with Employer Services for
employment decisions.
A third-party provider certifies that it has authorization to update information on OCSE’s Child Support Portal on behalf
of clients.
Security
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The employer, company, or government agency shall have appropriate procedures in place to promptly
report confirmed or suspected information security or privacy incidents, including, but not limited to,
unauthorized use or disclosure of Personally Identifiable Information (PII) involving confidential child support
information submitted through OCSE to your organization. As soon as reasonably practicable after discovery,
but in no case later than one hour after discovery of the incident, the employer, company, or government
agency shall report confirmed or suspected incidents to OCSE as specified in this paragraph. The requirement
for the employer, company, or government agency to report confirmed or suspected incidents involving PII
to OCSE is based on federal guidance/requirements from the Office of Management and Budget (OMB),
Health and Human Services (HHS), the Federal Information Security Modernization Act of 2014 (FISMA), and
the United States Computer Emergency Readiness Team (US-CERT).
Incidents must be reported via email to OCSE using the security mailbox address:
ocsesecurity@acf.hhs.gov

By selecting Accept, you certify that you have read, understood, and agree to the terms of thisagreement.

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Employer Services Profile
Required *

General Information
Enter general information about your organization and participation in Employer Services.
Date: *
(The date you are completing the form using MM/DD/YYYY format.)
FEIN: *
(Primary Federal Employer Identification Number – enter as nine numeric characters with no hyphen
after the second number.)
Organization Type: *

(Select Employer if you manage your own company's employee reporting.
Select Third Party if you are a payroll company or manage multiple employee reporting
clients.)

Organization Name: *

Organization Short Name:
(Enter abbreviation for your organization. Maximum 25 characters.)

Address Information
Address Line 1: *

Address Line 2:

Address Line 3:

City: *

ZIP Code (5 digits): *

State: *

Is this the Payroll/Income Withholding Order address?

Yes

ZIP Code Ext:

No

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Required *

Contact Information
Enter business, technical, and alternate contact information. If you have multiple contacts for child support purposes, you can add their
information on the Portal.

Business Contact Information
MI:

First Name: *

Last Name: *

Email: *
(Format: name@somewhere.com)

Select if you want email notifications sent to this address.
Yes

Does this email address belong to a shared email box? *

No

Phone Number: *
(Enter numeric characters only. Include area code. Format: 1231231111)

Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format 1231231111)

Select other contact types that apply:
Alternate
Verification of Employment

General

Multistate/MSER

National Medical Support Notice

Payroll/Income Withholding Order

Lump Sum

Technical

Accounts Payable

Technical Contact Information
This person is a network or system administrator who can help provide corporate IP address information or batch system
information, if applicable.
First Name:

MI:

Last Name:

Email:
(Format: name@somewhere.com)

Does this email address belong to a shared email box?

Yes

No

Phone Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

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Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Select other contact types that apply:
Business

General

Multistate/MSER

Verification of Employment

National Medical Support Notice

Payroll/Income Withholding Order

Lump Sum

Accounts Payable

Alternate

Alternate Contact Information
This is the person child support agencies may contact regarding case-specific questions.
First Name:

MI:

Last Name:

Email:
(Format: name@somewhere.com)

Select if you want email notifications sent to this address.
Does this email address belong to a shared email box?

Yes

No

Phone Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Phone Ext:

Fax Number:
(Enter numeric characters only. Include area code. Format: 1231231111)

Select other contact types that apply:
Business

General

Multistate/MSER

Verification of Employment

National Medical Support Notice

Payroll/Income Withholding Order

Lump Sum

Accounts Payable

Technical

Communication Preference
Communication Preference: *
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IP Address Information
The federal Office of Child Support Enforcement (OCSE) requires a public Internet Protocol (IP) address from external partners to allow
secure access to the Child Support Portal. OCSE independently verifies the IP address and organization name with the American
Registry for Internet Numbers (ARIN), a regional internet registry for the United States. For moreinformation, visit the ARIN website.
Enter the public IP addresses your organization uses to access the internet. In most cases, the IP address is your company's I
internet proxy server or the public IP address of the computer used to access OCSE's Child Support Portal. To locate your public
IP address, search on the internet for "What Is My Public IP Address." You must verify the addresses with your network administrator.
Public IP Addresses: *

By completing this section, you certify your organization holds exclusive use of the static IP addresses assigned by an
Internet Service Provider vendor. If the static IP address assigned to your organization changes, you must contact the
Portal Help Desk.
Name of Internet Service Provider: *

(Example: Comcast, AT&T, or Verizon. Enter
your company name if you own your IP
address and it isverifiable on ARIN website.)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary
information collection is for OCSE to register and authenticate authorized users of the Employer Services applications on OCSE’s
Child Support Portal. Public reporting estimated burden for this collection of information is 0.08 hours per respondent, including
the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. As
provided by 42 U.S.C. § 653(m)(2), any confidential information collected for this program is accessed only by authorized users.
A federal agency may not conduct or sponsor an information collection without a valid OMB Control Number. No individual or
entity is required to respond to, nor shall an individual or entity be subject to a penalty for failure to comply with a collection of
information subject to the requirements of the Paperwork Reduction Act of 1995, without a current valid OMB Control Number.
If you have any comments on this collection of information, please contact OCSEFedSystems@acf.hhs.gov.

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