Form Bls 3020 - Multiple Worksite Report - 2013
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1
2Multiple Worksite Report - BLS 3020
Form Approved, O.M.B. No. 1220-0134; Expiration Date: 05/31/13
In Cooperation with the U.S. Department of Labor
STATE OF NEW MEXICO
PAGE
1 OF
2
This report is authorized by law, 29 U.S.C. 2.
Your voluntary cooperation is
1
needed to make the results of this survey complete, accurate, and timely.
The
totals on this form must match the corresponding totals on your Employer’s
Quarterly Wage and Contribution Report (Form ES903A).
2
QUARTERLY REPORT INFORMATION
U.I. NUMBER
QUARTER ENDING
DUE DATE
Please update address and contact
information in the address block shown
at the left.
SEE INSTRUCTIONS ON THE BACK OF THIS PAGE
3
WORKSITES
NUMBER OF EMPLOYEES
QUARTERLY
BUSINESS NAME
(division, subsidiary, etc)
(subject to UI laws)
WAGES
OFFICE
STREET ADDRESS
(physical location)
During the Pay Period Which Includes
OF WORKSITE
USE
th
CITY, STATE, AND ZIP CODE
the 12
of the Month
(subject to UI laws)
WORKSITE DESCRIPTION
(plant name, store number, etc)
Round to the nearest dollar
.00
COMMENTS:
.00
COMMENTS:
.00
COMMENTS:
.00
COMMENTS:
.00
COMMENTS:
.00
COMMENTS:
Note:
The totals MUST agree (except
TOTALS |
|
|
|
.00
for rounding) with your
-------------------------------------------------
Form ES903A.
_____________________________________________________________________________________________________
CONTACT PERSON (for questions regarding this report).
Please print.
NAME: ________________________________________
TITLE: ______________________________________________
VOICE PHONE: (____)______________ Ext.________
FAX NUMBER: (____)______________
DATE: _____________
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