Department Of Labor Employer'S Weekly Report Of Participants printable pdf download

Department Of Labor Employer'S Weekly Report Of Participants

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:

Company Name:

Unit Name:

Report for week ending Saturday: _________ Page ____ of ____

Report Submitted By: _______________________________ Telephone: _________________________

Other paid

Worker's Weekly Claim

KEYS

Are STC

hours*

Total of all

Did

hours

STC hours

worker

worked

All Q

(columns

accept all

* Provide explanation below.

the same

Q #2 Ans

#3-8 =

Q #9 Ans

D - G)

work

as plan?

"No"?

offered?

[Round down

Participant Name

** Foward signed VDOL form B-2

to nearest

Hourly

hour]

with B-6 STC form.

SSN

(Last Name First)

Wage

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

Date