Form Bls 3020 - Multiple Worksite Report - New York State Department Of Labor
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Multiple Worksite Report - BLS 3020
New York State Department of Labor
Form Approved, O.M.B. No. 1220-0134
Division of Research and Statistics
Expiration Date: 08/31/2019
P.O. Box 15001
In Cooperation w ith the U.S. Department of Labor
Albany NY 12240
Phone: (518) 485-8145
New York
This report is mandatory under Section 531 of the New York labor law, 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 Combined Withholding, Wage Reporting and UI Return
(Form NYS-45).
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 NYS-45.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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