Form Ui-Ha - Return For Household Employers - Illinois Department Of Employment Security - 2011 Page 2
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2Step 4: Number of employees who are covered for unemployment insurance
Write the total number of covered workers (full and part time) who performed services during or received pay for the payroll period including the
12th of each month of each quarter. If none, write “0”
23
1st quarter
A
January 12
__________
B
February 12
__________
C
March 12
___________
24
2nd quarter
A
April 12
__________
B
May 12
__________
C
June 12
___________
25
3rd quarter
A
July 12
__________
B
August 12
__________
C
September 12 ___________
26
4th quarter
A
October 12
__________
B
November 12 __________
C
December 12
___________
Step 5: Figure your total unemployment insurance contribution due
27
Write the amount from Line 22.
27
____________I ____
28
Write the amount of any previous payment to the Illinois Department of Employment Security for the liability shown on Line 27.
28
____________I ____
29
Subtract Line 28 from Line 27. Make your check payable to the Illinois Department of Employment Security.
29
____________I ____
Step 6: Complete if you are no longer employing workers
Write the date you stopped employing workers.
30
30
____/_____/____
month
day
year
Step 7: Sign below
Under penalties of perjury, I state that I have examined this report and, to the best of my knowledge, it is true, correct, and complete.
31
____________________________________________________________
____/____/__________
(_____) ______________
Household employer’s signature (full name)
month
day
year
Daytime telephone number
April 16, 2012
Filing deadline:
You may file and pay on-line at https://taxnet.ides.state.il.us
Mail your completed report along with your check to:
ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY
PO BOX 3637
SPRINGFIELD IL 62708-3637
This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined under 820 ILCS405/100-3200.
Disclosure of this information is REQUIRED. Failure to disclose this information may result in statutorily prescribed liability and sanction,
including penalties and or interest. This form has been approved by the Forms Management Center.
Form UI-HA back 2 of 2 (12/11)
PLEASE RETURN THIS PAGE AND PAGE 1 OF THIS FORM
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