Please return the completed form either by mail or fax to:
MN Department of Human Services
Fax number: 651-431-7545
MN Department of Human Services
Fax number: 651-431-7545
CSD-Table Maintenance
PO BOX 64946
St. Paul, MN 55164-0946
___ New registration
___ Change to existing registration
Federal Identification Number (FEIN)/Taxpayer ID (Required):
________________________________
Federal Identification Number (FEIN)/Taxpayer ID (Required):
________________________________
Employer name ______________________________________________
Address ______________________________________________
City ____________________________________
State _________________ Zip __________
City ____________________________________
State _________________
Zip __________
Are you self employed? ___Yes ___No
If yes, are your Social Security Number and FEIN the same? ___Yes ___No
If yes, are your Social Security Number and FEIN the same?
___Yes ___No
Corporate name ______________________________________________
Alternate Corporate name ______________________________________________
Address ______________________________________________
City ____________________________________
State _________________ Zip ___________
City ____________________________________
State _________________
Zip __________
Phone number ______ ______ ________
Fax number ______ ______ ________
Phone number ______ ______ ________
Fax number ______ ______ ________
Are child support payments issued on your behalf by another company?
___Yes ___No (If yes, please complete the following):
Company name ______________________________________________
Address ______________________________________________
City ____________________________________
State _________________ Zip ___________
City ____________________________________
State _________________
Zip __________
Phone number ______ ______ ________
Fax number ______ ______ ________
Phone number ______ ______ ________
Fax number ______ ______ ________
If you have additional worksites or FEIN/Taxpayer ID numbers not listed here, please provide
the information on a separate sheet of paper.
Would you like to receive income withholding paperwork at an address other than the corporate address listed above?
___Yes ___No (If yes, please complete the following):
Company name ______________________________________________
Address ______________________________________________
City ____________________________________
State _________________ Zip ___________
City ____________________________________
State _________________
Zip __________
Phone number ______ ______ ________
Fax number ______ ______ ________
Phone number ______ ______ ________
Fax number ______ ______ ________
Form completed by:
Name _________________________________ Title __________________________________
Name _________________________________
Title __________________________________
Phone number ______ ______ ________
Fax number ______ ______ ________
Phone number ______ ______ ________
Fax number ______ ______ ________