Form De 3bhw Quarterly Report Of Wages And Withholdings For Employers Of Household Workers
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1QUARTERLY REPORT OF WAGES AND WITHHOLDINGS
FOR EMPLOYERS OF HOUSEHOLD WORKERS
APPROVED EXTENSION TO:
Instructions for completion are available on page 2 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
DEPT. P1
C
T
S
W
A
USE
Mo. Day
Yr.
WIC
ONLY EFFECTIVE
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 Quarterly Report of Wages and Withholdings for Employers of Household Workers (DE 3BHW) in lieu of the
Quarterly Wage and Withholding Report (DE 6), 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 Annual Payroll Tax Return for Employers of Household Workers (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 page 2 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.
MAIL TO: State of California / Employment Development Department / P.O. Box 826221 / MIC 28B / Sacramento, CA 94230-6221
DE 3BHW Rev. 5 (3-06) (INTERNET)
Page 1 of 2
CU
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