Form Bls 3020 - Multiple Worksite Report - Louisiana Workforce Commission
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Multiple Worksite Report - BLS 3020
Louisiana Workforce Commission
Form Approved, O.M.B. No. 1220-0134
OIS - Research and Statistics Div. - QCEW
Expiration Date: 07/31/2016
PO Box 94094
In Cooperation w ith the U.S. Department of Labor
Baton Rouge LA 70804-9094
Phone: (225) 342-3161
Louisiana
This report is mandatory under Louisiana Employment Security Law, Revised Statutes 23:1660, 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 Employer's Quarterly Wage and Tax Report
(Form LWC ES-4c).
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 LWC ES-4c.
CONTACT PERSON (for questions regarding this report)
NAME: ________________________________________ PHONE: _____________________________________________
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