Form Bls 3020 - Multiple Worksite Report
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Multiple Worksite Report - BLS 3020
Job Service North Dakota
Form Approved, O.M.B. No. 1220-0134
Labor Market Information Center
Expiration Date: 08/31/2019
1000 East Divide Avenue
In Cooperation w ith the U.S. Department of Labor
Bismarck ND 58502-5507
Phone: (701) 328-1279
North Dakota
This report is mandatory under Section 52-02-02 of the North Dakota Century Code, Section 27-02-03-01 of the
North Dakota Administrative Code, 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 Contribution and Wage Report (Form SFN 41263).
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 SFN 41263.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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