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:
Report for week ending Saturday: _________ Page ____ of ____
Report Submitted By: _______________________________ Telephone: _________________________
Worker's Weekly Claim
Total of all
* Provide explanation below.
Q #2 Ans
Q #9 Ans
D - G)
** Foward signed VDOL form B-2
with B-6 STC form.
(Last Name First)
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