Form Bls 3020 - Multiple Worksite Report - Workforce West Virginia
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Multiple Worksite Report - BLS 3020
Workforce West Virginia
Form Approved, O.M.B. No. 1220-0134
Research, Information & Analysis Division
Expiration Date: 05/31/2016
112 California Ave Room 208
In Cooperation w ith the U.S. Department of Labor
Charleston WV 25305-0112
Phone: (304) 558-2658
West Virginia
This report is mandatory under West Virginia Unemployment Compensation Law Section 21 A -10-11, 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 Report
(Form WVUC-A-154-A).
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)
Total:
______
______
______ $ ___________.00
with your Form WVUC-A-154-A.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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