Form Bls 3020 - Multiple Worksite Report - Georgia Dept Of Labor
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Multiple Worksite Report - BLS 3020
Georgia Dept of Labor
Form Approved, O.M.B. No. 1220-0134
Workforce Statistics and Economic Research Division
Expiration Date: 05/31/2016
148 Andrew Young International Boulevard
In Cooperation w ith the U.S. Department of Labor
Atlanta GA 30303-1751
Phone: (404) 232-4909
Georgia
This report is mandatory under the Official Code of Georgia Annotated Section 34-8-121, 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 Employer's Quarterly Tax and Wage Report (Form
DOL-4).
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 DOL-4.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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