Form De 3bhw - Employer Of Household Worker(S) Quarterly Report Of Wages And Withholdings
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1
2EMPLOYER OF HOUSEHOLD WORKER(S)
QUARTERLY REPORT OF WAGES AND WITHHOLDINGS
APPROVED EXTENSION TO:
Instructions for completion are available on the back of this form
.
PLEASE PRINT OR TYPE ALL INFORMATION IN BLACK INK - DO NOT ALTER PREPRINTED 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 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
0.00
0.00
0.00
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 Employer of Household Worker(s) Quarterly Report of Wages and Withholdings (DE 3BHW) in lieu of the
Quarterly Contribution Return and Report of Wages (Continuation) (DE 9C) 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 Employer of Household Worker(s)
Annual Payroll Tax Return (DE 3HW) 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
“QUESTIONS” 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. If you no longer have household worker(s) and would like to inactivate your
employer account number, please complete a Change of Employer Account Information (DE 24), available on our Web site at
or call our Taxpayer Assistance Center at (888) 745-3886. See the back of this
form for further instructions.
MAIL TO: State of California / Employment Development Department / P.O. Box 826221 / MIC 28B / Sacramento, CA 94230-6221
DE 3BHW Rev. 8 (9-10) (INTERNET)
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CU
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