Form Bls 3020 - Multiple Worksite Report - Alaska Dept Of Labor & Workforce Development
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Multiple Worksite Report - BLS 3020
Alaska Dept of Labor & Workforce Development
Form Approved, O.M.B. No. 1220-0134
Research & Analysis Section
Expiration Date: 07/31/2016
P.O. Box 120017
In Cooperation w ith the U.S. Department of Labor
Juneau AK 99812-9966
Phone: (907) 465-4510
Alaska
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 Contribution Report (Form 07-1004).
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
NUMBER OF
QUARTERLY WAGES
OFFICE
(division, subsidiary, etc.)
STREET ADDRESS
EMPLOYEES
OF WORKSITES
(physical location)
USE
CITY, STATE, AND ZIP CODE
(subject to UI Law s) During the Pay Period
(subject to UI law s)
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)
Total:
______
______
______ $ ___________.00
0
0
0
$ 0
with your Form 07-1004.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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