Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I: Employer Information. Fill in your LA Revenue Account Number or SSN, FEIN, and the Date of Application. Provide the Legal Name, Trade Name, Address, City, State, and ZIP code.
3. Move to Section II: Employee Information. Enter the Employee’s Name and SSN along with their Address, City, State, and ZIP code.
4. In Section III: Employer Declaration, confirm that all information is accurate by signing and dating the form.
5. Section IV will be completed by the Department of Health after submission. Ensure you leave this section blank for now.
6. Proceed to Section V: Employment Information. Fill out details such as Employment Start and End Dates, Hourly Rate of Pay, Average Hours Worked per Week, Position, Location of Employment (City and State), and Disability status.
7. Finally, complete Section VI: Calculation of Deduction for Tax Year by entering gross wages for qualified individuals during specified months.

Start filling out your form online today for free using our platform!