Department Of Labor Employer'S Weekly Report Of Participants

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VERMONT DEPARTMENT OF LABOR
P.O. Box 189, Montpelier, VT 05601-0189
EMPLOYER'S WEEKLY REPORT OF PARTICIPANTS
SHORT-TIME (STC) COMPENSATION PLAN
VDOL Employer Number:
STC Plan Number:
Company Name:
Unit Name:
Report for week ending Saturday: _________ Page ____ of ____
Report Submitted By: _______________________________ Telephone: _________________________
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
Other paid
Worker's Weekly Claim
KEYS
Are STC
hours*
Total of all
Did
hours
STC hours
worker
worked
All Q
(columns
accept all
* Provide explanation below.
the same
Q #2 Ans
#3-8 =
Q #9 Ans
D - G)
work
as plan?
"No"?
offered?
[Round down
Participant Name
** Foward signed VDOL form B-2
to nearest
Hourly
hour]
with B-6 STC form.
SSN
(Last Name First)
Wage
EMPLOYER CERTIFICATION: I certify that a) the above information concerning the status/earnings of the employers participating in the STC plan noted above are true and correct to
the best of my knowledge; b) records supporting all details considered in this submission will be available for inspection for 3 years from the week ending date indicated above; and
c) I understand I will be liable to repay any improperly paid STC benefit that results from a finding of intentional misleading or false information.
_______________________________________
____________________________
_______________________
B-145 STC (9/09)
Authorized Employer Representative Signature
Signature Name Printed
Date

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