Form Ui-Ha - Report For Household Employers

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State of Illinois
Illinois Department of Employment Security
Form UI-HA
Report for Household Employers
File on-line at https://taxnet.ides.state.il.us
Step 1: Tell us about yourself
1a
________________________________
b
___ ___–___ ___ ___ ___ ___ ___ ___
Federal employer’s identification number
Illinois account number (Unemployment Insurance)
2
___________________________________________________________________
Your name (first, middle initial, last)
3
___________________________________________________________________
Street Address
___________________________________________________________________
City
State
Zip
Step 2: Report your household employee information
5
For unemployment insurance reporting, complete Columns A-F
6
A
B
C
D
E
F
Name
Social
1/2013
2/2013
3/2013
4/2013
(last, first)
Security No.
QTR. ending Mar. 31
QTR. ending June 30
QTR. ending Sept. 30
QTR. ending Dec. 31
7
_____________________________ ______________ __________________ __________________ _________________
_________________
8
_____________________________ ______________ __________________ __________________ _________________
_________________
9
_____________________________ ______________ __________________ __________________ _________________
_________________
10
_____________________________ ______________ __________________ __________________ _________________
_________________
11
_____________________________ ______________ __________________ __________________ _________________
_________________
12
_____________________________ ______________ __________________ __________________ _________________
_________________
13
_____________________________ ______________ __________________ __________________ _________________
_________________
14
_____________________________ ______________ __________________ __________________ _________________
_________________
15
Other (attach)
________________________ __________________
______________________
______________________
______________________
_____________________
16a
Column totals: Add Lines 7 through 15 in each column
______________________
______________________
______________________
_____________________
Step 3: Figure your unemployment insurance
contribution due for each quarter
1st quarter
2nd quarter
3rd quarter
4th quarter
16b
Column totals: Copy totals from line 16a above.
______________________
______________________
______________________
_____________________
17
Write the total wages paid in excess of the taxable
wage base amount ($12,900 per employee for 2013).
______________________
______________________
______________________
_____________________
18
Subtract Line 17 from Line 16b.
______________________
______________________
______________________
_____________________
19
If Line 16a is less than $50,000, multiply Line 18 by
______________________
______________________
______________________
_____________________
your 2013 contribution rate or 5.400%, whichever is less.
20
If Line 16a is $50,000 or more, multiply Line 18 by
______________________
______________________
______________________
_____________________
your 2013 contribution rate.
21
Quarter totals: Enter the amount from Line 19 and/or 20.
______________________
______________________
______________________
_____________________
22
22
_________________
Grand total: Add the quarter totals from Line 21 (Columns C, D, E and F) and write the result on Line 22.
PLEASE RETURN THIS PAGE AND PAGE 2 OF THIS FORM
UI-HA front 1 of 2 (12/13)

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