Form Bls 3020 - Multiple Worksite Report - Pennsylvania Dept Of Labor And Industry
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Multiple Worksite Report - BLS 3020
Pennsylvania Dept of Labor and Industry
Form Approved, O.M.B. No. 1220-0134
Center for Workforce Information & Analysis
Expiration Date: 05/31/2016
651 Boas St Rm 220
In Cooperation w ith the U.S. Department of Labor
Harrisburg PA 17121-0750
Phone: 1-800-238-9412
Pennsylvania
This report 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 Employer's
Report for Unemployment Compensation (Form UC-2).
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 UC-2.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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