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Illinois Department of Revenue
Station 369
UI-WIT-X
Amended Illinois Income Tax Withholding Return
for Household Employers
for the year 20__ __
Step 1: Identify yourself and your spouse
1a ___ ___ ___ - ___ ___ - ___ ___ ___ ___ 1b ___ ___ - ___ ___ ___ ___ ___ ___ ___
4 ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Your Social Security number (SSN)
Federal employer’s identification number
Your spouse’s Social Security number (SSN)
2 _______________________________________________________________
5 ____________________________________________________________
Your name (first, middle initial, last)
Your spouse’s name (first, middle initial, last)
3 _______________________________________________________________
Street address
_______________________________________________________________
City
State
ZIP
Step 2: Identify your household employees and list the Illinois Income Tax that you withheld for each
Column A
Column B
Column C
Column D
Column E
Column F
Name (first and last)
Social Security number
Originally reported
Originally reported
Corrected amount
Corrected amount
total yearly wages
Illinois Income Tax withheld
total yearly wages
Illinois Income Tax withheld
6 ____________________
$___________________
$___________________ $___________________ $ _ __________________
__ __ __-__ __-__ __ __ __
7 ____________________
$___________________
$___________________ $___________________ $ _ __________________
__ __ __-__ __-__ __ __ __
8 ____________________
$___________________
$___________________ $___________________ $ _ __________________
__ __ __-__ __-__ __ __ __
9 ____________________
$___________________
$___________________ $___________________ $ _ __________________
__ __ __-__ __-__ __ __ __
10 ____________________
$___________________
$___________________ $___________________ $ _ __________________
__ __ __-__ __-__ __ __ __
11
$ ___________________
$___________________ $___________________ $ _ __________________
W rite the totals from attachment (if more than 5 employees).
12
$___________________
$ _ __________________
Write the total amounts in Column D and Column F.
13
13 _ __________________
If Line 12, Column F is less than Line 12, Column D, subtract Column F from Column D. This is your refund.
14
14 _ __________________
If Line 12, Column F is greater than Line 12, Column D, subtract Column D from Column F. This is your tax due.
Make your payment payable to “Illinois Department of Revenue”. You must write your SSN or FEIN and the form number “UI-WIT-X” on your payment.
Step 3: Sign below
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.
__________________________________________________________________
__ __ / __ __ / __ __ __ __
(______)________________
Household employer’s signature (full name)
Month
Day
Year
Daytime telephone number
Step 4: Mail to
IllInoIS DEpARTMEnT oF REvEnUE
SpRIngFIElD Il 62776-0001
This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information could
Form UI-WIT-X (R-06/08)
result in a penalty. This form has been approved by the Forms Management Center.
IL-492-3745
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