Form Bls 3020 - Multiple Worksite Report - Nebraska Dept Of Labor
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Multiple Worksite Report - BLS 3020
Nebraska Dept of Labor
Form Approved, O.M.B. No. 1220-0134
Office of Labor Market Information - QCEW
Expiration Date: 08/31/2019
PO Box 94600
In Cooperation w ith the U.S. Department of Labor
Lincoln NE 68509-4600
Phone: (800) 338-2376
Nebraska
This report is mandatory under Nebraska Employment Security Law, Section 48-612, 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 Nebraska Unemployment Insurance Combined Tax
Report (Form UI-11T).
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 UI-11T.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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