In-Home Employment Tax Declaration

In-Home Employment Tax Declaration
Please complete this form to declare employment and tax details for household employees.
Employer Full Name
First NameLast Name
Employer Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer Email Address
example@example.com
Employee Full Name
First NameLast Name
Employee Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employee Email Address
example@example.com
Employee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last 4 Digits of Employee's Social Security Number
Employment Start Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employment End Date (if applicable)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Work Performed
Total Wages Paid (USD)
Total Taxes Withheld (USD)
Additional Notes or Comments
Employer Signature
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Employee Signature
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Should be Empty: