Household Employee Form

HOUSEHOLD EMPLOYEE FORM
TaxPayer’s Name*

First NameLast Name
Household employee definition: If you work for someone at their home and he/she controls what work is done, how you did the work, you made less than $2700 per household, and you did not have to purchase any expenses, you are considered a household worker and not self-employed.

*Some examples of workers who do household work are: Babysitters, Caretaker, Cleaning people, Domestic workers, Drivers, Health Aides, Housekeepers, Groundkeepers, Maids, Nannies, Private Nurses, Yard Workers, etc.

If any person you worked for paid you more than $1000 in any quarter or $2700 or more for the entire year, the employer must provide a w2, but if you worked for multiple people and they paid you less than $2700, please give us the total amount you were paid from all employers that year combined.

Household Employee Questions
How do you keep track of the income generated from the employers?*
You may choose more than one answer
Who is responsible for purchasing supplies and/or expenses?*
Who controls the work and how it is performed for the employer?*
Initial that the information provided is correct*

You must list all your employers that you worked for in their homes.*

	Employer’s First & Last Name (Person Who Paid You)	Services Provided to the Employer	The Entire Amount Received from the Employer During the Tax Year	Method of Payment Received
1
2
3
4
5
6
7
8
9
10
11

Provide One of Your Employer’s Information from the previous question as part of our Due Diligence Process*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
By signing this form, you agree that all the information provided is true and correct to the best of your abilities regarding your work as a household employee. You understand the difference between self-employed and household employee. You understand that you are responsible for keeping a record of payment for services provided for at least 3 years. You have been advised by your tax preparer that the IRS may require additional verification as proof of income at a later date and it is your responsibility to provide it is requested Taxpayer's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

HOUSEHOLD EMPLOYEE FORM