GOVERNMENT OF THE DISTRICT OF COLUMBIA                                                      DEPARTMENT OF EMPLOYMENT SERVICES 
 
                                                        PFL30H 
                    NOTE: You must complete the UC30H before completing this form. 
 FORM ID: 
                                                  EMPLOYER’S ANNUAL                                                          POSTMARK DATE 
                                                                                                    
          DOES-PFL30H-2019         CONTRIBUTION AND WAGE                                            
                                                        REPORT                                                               (DO NOT USE THIS SPACE) 
 EMPLOYER ACCOUNT #:               EMPLOYER’S NAME AND ADDRESS                                     FEDERAL EIN: 

                                                                                                   YEAR ENDING: 
 TAX RATE: 

                                   SEE INSTRUCTIONS ON PAGE 2 
             Only use this form if you are a Household Employer who files UI taxes annually 
  1.      TOTAL WAGES PAID (to all covered workers this year – same amount reported on UC30H, line 2)     $_________________ 

  2.      CONTRIBUTION DUE (Multiply line 1 by the tax rate of 0.62% (0.0062)    $_________________ 

  3.      APPROVED CREDIT                                                                               $_________________  

  4.      SUBTOTAL (Subtract line 3 from line 2)                                                     $_________________ 

  5.      PLUS INTEREST DUE                                                                            $_________________  

  6.      PLUS PENALTY DUE                                                                            $_________________ 
  7.      EQUALS TOTAL REMITTANCE AMOUNT (Add line 4, 5 and 6)                                                 $_________________ 
          (Make check or money order payable to “DC Treasurer”) 
  
                                                  STATUS CHANGES            
  
  8.   ENTER THE APPROPRIATE INFORMATION BELOW IF ANY CHANGE HAS OCCURED: 

                                                  CERTIFICATION 
 I CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT AND ANY WAGE REPORTS 
 ATTACHED HERETO IS TRUE AND CORRECT AND THAT NO PART OF THE TAX WAS OR WILL BE 
 DEDUCTED FROM EMPLOYEES’ WAGES. 
                                                                                                                                         DATE: 
 SIGNATURE:                                                         TELEPHONE: 

 PRINT NAME:                                                        TITLE: 
  
              Office of Paid Family Leave – Tax Division | 4058 Minnesota Avenue NE| Washington DC 20019                                         
                                   Office: (202)-899-3700 | pfltaxdivision@dc.gov 
DOES-PFL30H-2019 Rev. 12/20/2019                                                                                                                     1 of 3 
 

Instructions  
 • All household employers using the PFL30H must also submit the UC30H.              
 • Filing the PFL30H does not exempt employers from the requirement to file wages using the 
   UC30H. The UC30H is used to file wages for both the UI and the PFL programs annually. Failure to 
   file wages on time using the UC30H could result in PFL penalties and interest.     
 • Please note that because 2019 was the first year for the District of Columbia’s Paid Family Leave 
   tax there were only three reportable tax quarters (Q2, Q3 and Q4). Due to this, you must exclude 
   the wages paid in Q1/2019 from PFL30H, Line 1.  
    
Line 1: TOTAL WAGES.  Enter the total gross wages paid (before deductions) including the cash value of all 
remuneration paid in any medium other than cash to all covered employees in the year. For most employers, the 
amount reported on the PFL30H, Line 1, will not equal the amount reported on the UC30H, Line 2, due to the 
exclusion of Q1/2019 wages. The amount reported on the PFL30H, Line 1, must never exceed the amount 
reported on the UC30H, Line 2. If the amount reported on the PFL30H, Line 1, is less than the amount reported 
on the UC30H, Line 2, due to an employee exception, then you must submit documents in compliance with 
DOES’ employer guidance for excepted employees. See “Process for Determining Employee Exceptions from 
PFL Coverage” available at https://does.dc.gov/page/dc-paid-family-leave. Employers who report a lower number 
on the PFL30H, Line 1, than on the UC30H, Line 2, due to claiming employee exceptions, and whose request 
for employee exceptions is denied by DOES, could be subject to interest and penalties on the difference in the 
amount paid. 
 
Line 2: CONTRIBUTION DUE. Amount of PFL taxes owed to DOES. Multiply the amount in Line 1 by 
0.0062. Example: $100,000 (Line 1) * 0.0062 = $620 (Line 2). 
 
Line 3: APPROVED CREDIT. The amount of your approved credit that will be applied toward your PFL             
contribution due. Credit applies automatically and should be considered prior to penalty and interest calculation. 
(Please contact PFL Tax Division to confirm the amount of any credit balance on the account). 
 
Line 4: SUBTOTAL. Subtract line 3 from line 2 
Example: An employer has a credit balance of $100.00. Total wages submitted is $100,000.00. 
Upon submission, the total PFL Tax debt = $620.00 but the amount owed = $520.00.  
 
Line 5: INTEREST DUE. Interest will be assessed at a rate of 1.5% if the contribution due on the report is not 
paid by the end of the month following the close of the period to which it pertains. (Please contact PFL Tax 
Division to confirm the amount of any interest due on the account). 
 
Line 6: PENALTY DUE. In addition to interest, a penalty of 10% of the contribution, but not less than 
$100.00, will be assessed if either the PFL30H or the UC30H is not filed, or if the contribution due is not paid 
by the end of the month following the close of the tax period to which it pertains. Separate payments must be 
made for the PFL tax and for UI tax. (Please contact PFL Tax Division to confirm the amount of any penalty 
due on the account). 
 
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    Office of Paid Family Leave – Tax Division | 4058 Minnesota Avenue NE| Washington DC 20019  
                                 Office: (202)-899-3700 | pfltaxdivision@dc.gov 
DOES-PFL30H-2019 Rev. 12/20/2019                                                                      2 of 3 
 

Line 7: TOTAL REMITTANCE AMOUNT. Add Lines 4, 5, and 6. Make check or money order payable to 
“DC Treasurer”. You must include your employer account number and the year on your check or money order. 
DO NOT send cash. 
 
 Mail PFL30H and PFL payment to: 
 Office of Paid Family Leave Tax Division Suite 4300A 
 4058 Minnesota Avenue, N.E. 
 Washington D.C. 20019 
 
Line 8: STATUS CHANGES. If any information pertaining to your employer account has changed since the 
last reporting period, please enter the changed information and provide supporting documentation where 
relevant. 

          Office of Paid Family Leave – Tax Division | 4058 Minnesota Avenue NE| Washington DC 20019 
                                 Office: (202)-899-3700 | pfltaxdivision@dc.gov 
DOES-PFL30H-2019 Rev. 12/20/2019                                                                       3 of 3