__________________________________________________
Multiple Worksite Report - BLS 3020
Ohio Department of Job and Family Services
Form Approved, O.M.B. No. 1220-0134
Bureau of Labor Market Information
Expiration Date: 05/31/2016
PO Box 182428
In Cooperation w ith the U.S. Department of Labor
Columbus OH 43218-2428
Phone: (888) 296-7541 OPTION #6
Ohio
This report is mandatory under Ohio Unemployment Compensation Law, Section 4141.20, 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 Unemployment Compensation Quarterly Tax
Return (JFS 20125).
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)
Total:
______
______
______ $ ___________.00
with your JFS 20125.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________