PDF document
- 1 -
       UI-HA Report for Household Employers Instructions 

You may file on-line at https://mytax.illinois.gov 
                                                                                               Line 15  If              you had more than eight household employees during     2023, use 
                                                                                                        an additional sheet   of paper and include the           information   in   Step 2 
Step 1                                                                                                  for each additional worker. Total each Column C through F on the 
Line 1a Enter your 7-digit Illinois Unemployment Insurance Account Number.                              attachment, and write the totals on Line 15 in the appropriate 
                                                                                                        column. 
Line 1b Enter the nine digit Federal Employer's Identification number (FEIN) 
        assigned to you by the Internal Revenue Service.                                       Line 16a Add Lines  7through 15            within  each column. This is   the total 
Line 2  Enter your first name, middle initial and last        name.                                     wages paid for each quarter. 

Line 3  Enter the street address            . 

Line 4  Enter the city, state and zip code.                                                    Step 3 

                                                                                               Line 16b Copy totals from line 16a above. 
Step 2                                                                                         Line 17  Write in the total wages paid in excess of the unemployment 
                                                                                                        insurance taxable wage base amount for                each worker. For            
Lines  7through 1         5  - use one line for each employee                                                                                                                      2023, 
                                                                                                        the taxable wage base amount   is $1            3,271  for each worker. 
        Column A                                                                                        An employer must pay unemployment insurance contributions on                      
                                                                                                        only the first $1 ,                                   
        Print the last and first name(s)   of your household employee(s).                                                          3 271 in wages for each employee. 

        Column B                                                                                        Example: You               have one household   employee that you pay 
                                                                                                        $5,000 each quarter.   During the first and second quarter, the 
        Complete this item by entering             your employee’s social security 
                                                                                                        wages paid to the employee total $10,000, so you would enter “0” 
        number.                                                                                                                                                                           
                                                                                                        in each column for the first and second quarters During  .           the   third  
        Columns   C through   F (quarters)                                                              quarter, the total amount paid   to the employee reaches $15,000 
                                                                                                        which exceeds the $13,              271  unemployment insurance taxable 
        Enter the total wages paid            to   each employee for each quarter  of   the   
                                                                                                        wage base by $1,729. So the amount   to be entered on Line 17 
        year.   If no wages were paid for that          quarter, please enter "0". 
                                                                                                        for the third quarter,   is $1,     729   ($15,000-$13,  271).   The fourth 
        Wages include (a) salaries, commissions            and    bonuses,  tips reported               quarter wages   of $5,000 must be entered on           Line 17   for  the   
        to the employer, separation pay, vacation pay,             prizes, sick pay,                    fourth quarter since the wage base was met during the third 
        payments on account   of retirement; (b)          the reasonable    cash value                  quarter. 
        of remuneration paid other than            cash, such as  goods,  meals  and     
                                                                                                                                1st quarter      2nd quarter   3rd quarter    4th quarter 
        lodging; and (c) any remuneration for            services performed   within the     
        State which   is considered wages           under the Federal   Unemployment                    Ex Line 17              $  0             $  0          $1, 729        $5,000 
        Tax          Act. 

UI-HAinstructions  (2/2024) 



- 2 -
Step 3 continued 

Line 18    Subtract Line 17 from Line 16b and enter the result on Line 18.                  Step 6 
           These are your taxable wages. 
                                                                                            Line 30    If you have stopped employing workers, write the date of the last 
Lines 19 and 20                                                                                        day you employed workers. 

           For each quarter, calculate your unemployment insurance  
           contribution. Within each column, complete either Line 19   or 20,          
           whichever   is applicable.                                                       Step 7 

                                                                                            Line 31    This report must be signed by the person named in Step 1, Line 2. 
Line 21    Quarter totals: Enter the amount from Line 19 or   20 in   each column.          
                                                                                                       If signed by any other person, a Power of Attorney must be 
           This   is your contribution due for each quarter.                                           attached. 
Line 22.   Grand total. Add the quarterly totals from Line 21     (Columns   C,     D, E   
           and   F) and enter the result on Line  22. This  is   your total  
           unemployment insurance contributions for 2023.                                    MAIL YOUR COMPLETED REPORT ALONG WITH YOUR CHECK TO: 

                                                                                                 ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY 
Step 4                                                                                           PO BOX 19300 
                                                                                                  SPRINGFIELD IL 62794-9300 
Line 23-26 Enter the total number of employees (full or part time) who are 
           covered by unemployment insurance and        who   performed      services     
           during   or received pay for the payroll period  including  the   12th   of   
           each month   of the quarter. Include      workers  who have earned                                      General Instructions 
           more than $13,   271    in the calendar year and those on vacation       or   
           paid sick leave. Exclude workers on strike. 
                                                                                            What if I do not file or pay by the due date? 
                                                                                            If you do not file a processable return or pay the tax you owe by the due 
                                                                                            date, you will owe penalty and interest. 
Step 5 
Line 27    Write the amount shown on line 22. This is your 
           total unemployment insurance contribution for 2023.                              What if I need to correct information I reported? 
                                                                                            Where may I obtain help or more information? 
Line 28    Write the amount   of any previous  payment  made      to   the Illinois   
                                                                                            For other related forms   or help with questions regarding unemployment   
           Department   of Employment Security     for the  liability shown  on      
                                                                                            insurance, please call the Unemployment Insurance Hotline toll-free at   
           Line      27. 
                                                                                            (800)247-4984. 
Line 29    Subtract Line 28 from Line     27.                                               The TTY number for the hearing impaired  is   (866) 212-8831. 
           This   is the amount   of unemployment insurance      contribution due. 

           Make your check payable   to the    Illinois Department of  
           Employment Security. 

UI-HAinstructions  (2/2024) 



- 3 -
     State   of Illinois                                                                                                          Illinois Department of Employment Security 
     Form UI-HA  2023                                    Report for Household Employers                                           File  on-line      at https://mytax.illinois.gov 
Step 1: Tell us about yourself 
1a ________________________________                          b ___ ___–___ ___ ___ ___ ___ ___ ___ 
   Illinois account number (Unemployment Insurance)          Federal employer’s identification number 
2  ___________________________________________________________________ 
   Your name (first, middle initial, last) 
3  ___________________________________________________________________ 
   Street Address 
4  ___________________________________________________________________ 
   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             1/2023                   2/2023                       3/2023                    4/2023 
   (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 ($13,             271  per employee for 2023).             ______________________  ______________________    ______________________  _____________________ 
18  Subtract Line 17 from Line 16b.                                             ______________________  ______________________    ______________________  _____________________ 
19  IfLine    16a   is less than $50,000, multiply Line  18  by                 ______________________  ______________________    ______________________  _____________________ 
    your 202   3          contribution rate   or 5.400%, whichever   is less. 
20  If Line 16a is $50,000 or more, multiply                                    ______________________  ______________________    ______________________  _____________________ 
    Line 18 by your 2023 contribution rate. 
21  Quarter totals: Enter the amount from Line 19 and/or 20.                    ______________________  ______________________    ______________________  _____________________ 
22  Grand total:           Add the quarter totals from Line 21 (Columns C, D, E and F) and write the result on Line 22.                                    22   _________________ 

UI-HAfront        1 of 2 (2/2024)                                             PLEASE RETURN THIS PAGE AND PAGE 2 OF THIS FORM 



- 4 -
Step 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 
30 Write the date you stopped employing workers.                                                                                                                                   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 

Filing deadline: April 15, 2024 
You may   file and pay on-line   at https:// mytax.illinois.gov  
Mail your completed report along with your check to: 

            ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY 
            PO BOX 19300 
            SPRINGFIELD IL 62794-9300 

                                    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. 
UI-HAback         /2 of 2 (22024) 
                                                           PLEASE RETURN THIS PAGE AND PAGE 1 OF THIS FORM 






PDF file checksum: 3718599706

(Plugin #1/10.13/13.0)