Form Uis1 Dom - Report To Determine Liability For Domestic Employment Under The Unemployment Insurance Act

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UIS1 DOM (Rev. 03/01)

STATE OF ILLINOIS

DEPARTMENT OF EMPLOYMENT SECURITY

REPORT TO DETERMINE LIABILITY FOR DOMESTIC EMPLOYMENT

UNDER THE UNEMPLOYMENT INSURANCE ACT

If you or your organization paid a domestic worker or combination of domestic workers cash wages totaling at least $1,000 in a calendar quarter during the

current or preceding four years, Illinois law considers you or your organization an employer liable for Unemployment Insurance contributions. Cash wages include

payment by check, but do not include payments in kind, such as room and board. A domestic worker is an individual who performs domestic service in a private

home, local college club, or local chapter of a college sorority or fraternity. Common types of domestic employees are: liveSin companions, housekeepers,

butlers, maids, chauffeurs and baby sitters. Baby sitting, laundry or other services performed outside the home of the person or organization for which the

services are provided do not constitute domestic service.

If, on the basis of paying for domestic service, you or your organization is an employer for Unemployment Insurance purposes, please complete this form

and mail to: IDES REVENUE BUREAU, 33 South State Street, Chicago, Illinois 60603-2802. The Department will establish an employer account

number for you or your organization and provide the materials necessary to meet the responsibilities of an employer under the Illinois Unemployment Insurance

law. If you need assistance in filling out this form, you may contact the office shown above at telephone number (312) 793S4880 or (800) 247S4984.

1. Please enter your name or your organization's name, address, telephone number and contact person for additional information.

Name _____________________________________________________________________________________________________________________

b. Address and Telephone Number______________________________________________________________________________________________

(Street & Number or Rural Route)

____________________________________________________________________________________________________________________________

(City or Town)

(County)

(State) (ZIP Code)

(Area Code) (Telephone Number)

c. Person to contact for additional information _______________________________________________________________________________________

(Name)

(Telephone Number if Different from Above)

2. Did you pay cash wages of $1,000 or more in any quarter in the current or preceding four years? __________________ YES ___________________ NO

If YES, please indicate the earliest quarter:

“

1st S January through March

2nd S April through June

Year _____________________________ Quarter (check one):

“

3rd S July through September

4th S October through December

3. Enter the Date of Hire _____________________ and First Pay Date _______________ for the first DOMESTIC worker you or your organization hired

during the year indicated in question 2.

4. Enter the Federal Employer Identification Number (FEIN) under which you or your organization file Social Security Returns for DOMESTIC workers:

‘‘SS‘‘‘‘‘‘‘

If you or your organization do not have a FEIN, contact the nearest office of the U.S. Internal Revenue Service and request Form SSS4 (FEIN Application),

Publication 926 (Household Employer's Tax Guide) and Circular E (Employer's Tax Guide).

CERTIFICATION: I hereby certify that the information contained in this report is true and correct.

Signed by _________________________________________________________________________ Date __________________________________________

If you are submitting this report for yourself, you must sign it. Reports submitted for an organization must be signed by a person authorized to sign for the organization.

Please keep a copy of the completed form for your records. To have correspondence sent to another address, please use the UI-1M, Special Mailing Form.

S S S DO NOT WRITE IN THE AREA BELOW. FOR DEPARTMENT USE ONLY. S S S

This state agency is requesting information that is nec-

Source _____________Rec’d Date ___________

essary to accomplish the statutory purpose as outlined

under ILCS 405/100S3200. Disclosure of this informa-

Area

Industry

A/C _____________________ N/L ___________

tion is REQUIRED. Failure to Disclose this informa-

tion may result in statutorily prescribed liability and

Liab Date __________ Qtr _______ Sec _______

sanction, including penalties and/or interest.