* Required field

Employer Legal/Registered Information

CSE Employer Number
Note: If you received an Employer Information Request form from DCSS, the CSE Employer Number is located on the top right of the form.

* 9 Digit Federal Identification Number (FEIN)
(Do not include the dash)

No FEIN, Employer reports with SSN
(Do not provide SSN)

* Employer Legal Name (Corp/Inc/LLC)

Sole Proprietor (Owner's Name)

Employer "Doing Business As" Name

Payroll/Garnishment Information

Attention (optional)

* Address

* City

* State

* Zip

* Phone Number
(include area code)

Ext.

E-mail Address

Fax Number
(include area code)

Health Benefits Information

Attention (optional)

Does your company provide health insurance?

Yes No

Address

Address same as payroll?

Yes No

City

State

Zip

Phone Number
(include area code)

Ext.

E-mail Address

Fax Number
(include area code)

Additional Information

A Professional Employer Organization is used (PEO)

PEO Company Name:

A third party is used to verify employment (provide information below)

Verifying Company Name:

Service ID:

This organization has more than one (1) FEIN (list additional Name/FEINs below or call 888-898-1743)

Company Name:

FEIN

Company Name:

FEIN

* Form Completed by

* Title

* Phone Number

Comments (600 characters maximum):

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