Form Bls 3020 - Multiple Worksite Report - California Employment Development Dept
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Multiple Worksite Report - BLS 3020
California Employment Development Dept
Form Approved, O.M.B. No. 1220-0134
Labor Market Information Division
Expiration Date: 08/31/2019
P.O. Box 826220
In Cooperation w ith the U.S. Department of Labor
Sacramento CA 94299-9977
Phone: (916) 262-1856
California
This report is mandatory under Section 320.5 of the California Unemployment Insurance Code and Section 320-1
Title 22 of the California Code of Regulations, and is authorized by law, 29 U.S.C. 2. Your cooperation is needed to
make the results of this survey complete, accurate, and timely. The totals on this form must match the
corresponding totals on your Quarterly Contribution Return and Report of Wages (Form DE9, DE9C).
BUSINESS MAILING ADDRESS
Please print.
QUARTERLY REPORT INFORMATION
Business Name: __________________________________________
U.I. NUMBER: ______________________
QUARTER ENDING: ___ / ___ / ___
Street Address: ___________________________________________
DUE DATE: ___ / ___ / ___
City: ___________________________ ST: ______ ZIP: __________
WORKSITES
BUSINESS NAME
(division, subsidiary, etc.)
NUMBER OF
QUARTERLY WAGES
OFFICE
STREET ADDRESS
(physical location)
EMPLOYEES
OF WORKSITES
USE
(subject to UI Law s) During the Pay Period
(subject to UI law s)
CITY, STATE, AND ZIP CODE
Which Includes the 12th of the Month
Round to the nearest dollar
WORKSITE DESCRIPTION
(plant name, store number, etc.)
Month 1
Month 2
Month 3
.00
.00
.00
.00
.00
.00
Note: The totals MUST agree (except for rounding)
0
0
0
$ 0
Total:
______
______
______ $ ___________.00
with your Form DE9, DE9C.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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