Form Bls 3020 - Multiple Worksite Report - Indiana Dept Of Workforce Development
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Multiple Worksite Report - BLS 3020
Indiana Dept of Workforce Development
Form Approved, O.M.B. No. 1220-0134
Research & Analysis - QCEW
Expiration Date: 08/31/2019
10 N Senate Ave Rm 211 SE
In Cooperation w ith the U.S. Department of Labor
Indianapolis IN 46204-2277
Phone: (800) 784-0360
Indiana
This report 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 Contributions Report (Form UC-1).
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 UC-1.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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