Illinois Ui Ha Form – Fill Out and Use This PDF

Enter your 7-digit Illinois Unemployment Insurance Account Number.

Enter the nine digit Federal Employer's Identification number (FEIN) assigned to you by the Internal Revenue Service.

Enter your first name, middle initial and last name.

Enter the street address including the city, state and zip code where you want to receive this form.

- use one line for each employee

Print the last and first name(s) of your household employee(s).

Complete this item by copying your employee’s social security number from his or her Social Security card.

Enter the total wages paid to each employee for each quarter of the year. If no wages were paid for that quarter, please enter "0".

Wages include (a) salaries, commissions and bonuses, tips reported to the employer, separation pay, vacation pay, prizes, sick pay, payments on account of retirement; (b) the reasonable cash value of remuneration paid other than cash, such as goods, meals and lodging; and (c) any remuneration for services performed within the State which is considered wages under the Federal Unemployment Tax Act.

If you had more than eight household employees during 2012, use an additional sheet of paper and include the information in Step 2 for each additional worker. Total each Column C through F on the attachment, and write the totals on Line 15 in the appropriate column.

Add Lines 6 through 15 within each column. This is the total wages paid for each quarter.

Copy totals from line 16a above.

Write in the total wages paid in excess of the unemployment insurance taxable wage base amount for each worker. For 2012, the taxable wage base amount is $13,560 for each worker.

An employer must pay unemployment insurance contributions on only the first $13,560 in wages for each employee.

Example: You have one household employee that you pay $5,000 each quarter. During the first and second quarter, the wages paid to the employee total $10,000, so you would enter “0” in each column for the first and second quarters. During the third quarter, the total amount paid to the employee reaches $15,000 which exceeds the $13,560 unemployment insurance taxable wage base by $1,440. So the amount to be entered on Line 17 for the third quarter, is $1,440 ($15,000-$13,560). The fourth quarter wages of $5,000 must be entered on Line 17 for the fourth quarter since the wage base was met during the third quarter.

Subtract Line 17 from Line 16b and enter the result on Line 18. These are your taxable wages.

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

Quarter totals: Enter the amount from Line 19 or 20 in each column. This is your contribution due for each quarter.

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 2012 total

unemployment insurance contributions due.

If you have stopped employing workers, write the date of the last day you employed workers.

This report must be signed by the person named in Step 1, Line 2. If signed by any other person, a Power of Attorney must be attached.

MAIL YOUR COMPLETED REPORT ALONG WITH YOUR CHECK TO:

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 more than $13,560 in the calendar year and those on vacation or paid

sick leave. Exclude workers on strike.

Write the amount shown on line 22. This is your total 2012 unemployment insurance contribution.

Write the amount of any previous payment made to the Illinois Department of Employment Security for the liability shown on Line 27.

Subtract Line 28 from Line 27.

This is the amount of unemployment insurance contribution due.

Make your check payable to the

ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY PO BOX 3637

SPRINGFIELD IL 62708-3637

If you do not file a processable return or pay the tax you owe by the due date, you will owe penalty and interest.

For other related forms or help with questions regarding unemployment insurance, please call the Unemployment Insurance Hotline toll-free at 1 800 247-4984 (option 2).

The TTY number for the hearing impaired is (866) 212-8831.

UI-HA back 2 of 2 (12/12)

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.