Quarterly Report Of Wages And Withholdings For Employers Of Household Workers
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1QUARTERLY REPORT OF WAGES AND WITHHOLDINGS
FOR EMPLOYERS OF HOUSEHOLD WORKERS
APPROVED EXTENSION TO:
Instructions for completion are available on the back of this form
.
PLEASE TYPE ALL INFORMATION
DELINQUENT IF
YR
QTR
NOT POSTMARKED
________________________
_____________________
QUARTER ENDED
DUE
OR RECEIVED BY
EMPLOYER ACCOUNT NUMBER
DO NOT ALTER THIS AREA
P1
C
T
S
W
A
DEPT.
USE
Mo.
Day
Yr.
WIC
EFFECTIVE
ONLY
DATE
A. NUMBER OF EMPLOYEES full-time and part-time who
worked during or received pay subject to UI wages for
payroll period which includes the 12th of the month.
1ST MONTH
2ND MONTH
3RD MONTH
B.
No Payroll This Quarter
C.
SOCIAL SECURITY NUMBER
D.
EMPLOYEE NAME
(FIRST, MIDDLE INITIAL, LAST)
E.
TOTAL SUBJECT WAGES
F.
PIT WAGES
G.
PIT WITHHELD
C.
SOCIAL SECURITY NUMBER
D.
EMPLOYEE NAME
(FIRST, MIDDLE INITIAL, LAST)
E.
TOTAL SUBJECT WAGES
F.
PIT WAGES
G.
PIT WITHHELD
C.
SOCIAL SECURITY NUMBER
D.
EMPLOYEE NAME
(FIRST, MIDDLE INITIAL, LAST)
E.
TOTAL SUBJECT WAGES
F.
PIT WAGES
G.
PIT WITHHELD
C.
SOCIAL SECURITY NUMBER
D.
EMPLOYEE NAME
(FIRST, MIDDLE INITIAL, LAST)
E.
TOTAL SUBJECT WAGES
F.
PIT WAGES
G.
PIT WITHHELD
H. GRAND TOTAL SUBJECT WAGES
I.
GRAND TOTAL PIT WAGES
J. GRAND TOTAL PIT WITHHELD
K . I declare that the information herein is true and correct to the best of my knowledge and belief .
Signature __________________________________ Title ______________________ Phone (____ )_________Date ____________
(Employer, Accountant, Preparer, etc.)
You have received this Report of Wages and Withholdings for Employers of Household Workers, DE 3B HW, in lieu of the
Quarterly Wage and Withholding Report, DE 6, because you have elected to pay taxes for your Household Workers on an
annual basis. This form will be mailed to you quarterly and an Annual Payroll Tax Return For Employer Of Household
Workers, DE 3 HW, will be mailed to you in the fourth quarter. This annual process is only available to employers who pay
$20,000 or less in household wages during the calendar year. If your wage estimate is understated and you do pay more than
$20,000 in wages in the calendar year, please follow the instructions on the back of this form under the “QUESTION” topic.
You must file this report even if you had no payroll by marking Item B, and indicating “0” in each of the three boxes in Item A,
and in the Grand Total Boxes, Items H, I, and J.
DE 3B HW Rev. 3 (1-97) (INTERNET)
MAIL TO: State of California / Employment Development Department / P.O. Box 826221 / MIC 28B / Sacramento, CA 94280-0001
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