Form BLS 3021 BLS 3021 Report of Federal Employment and Wages

Report of Federal Employment and Wages- BLS 3021

Form Approved, O.M.B. No. 1220-0134; Expiration Date: 03/31/07

In Cooperation with the U.S. Department of Labor

SECOND REQUEST STATE OF UTANA PAGE 1 OF 2

This report is authorized by law, 5 U.S.C. 8501-8509, and is required by each federal agency with employees covered by the UCFE program. Your cooperation is needed to make the results of this survey complete, accurate, and timely.

1

QUARTERLY REPORT INFORMATION

:

:

:

2

SEE INSTRUCTIONS ON THE BACK OF THIS PAGE

WORKSITES

UCFE NUMBER

QUARTER ENDING

DUE DATE

WORKSITE NAME

STREET ADDRESS (physical location)

CITY, STATE, AND ZIP CODE

WORKSITE DESCRIPTION (site name, base number, etc)

NUMBER OF EMPLOYEES

(subject to UCFE laws)

During the Pay Period Which Includes

the 12^th of the Month

QUARTERLY

WAGES

OF WORKSITE

(on all payrolls)

Round to the nearest dollar

Please update address and contact information in the address block shown at the left.

3

OFFICE

USE

APR

MAY

JUN

.00

COMMENTS:

.00

COMMENTS:

.00

COMMENTS:

.00

COMMENTS:

.00

.00

COMMENTS:

COMMENTS:

TOTALS | | | | .00

_____________________________________________________________________________________________________

CONTACT PERSON (for questions regarding this report). Please print.

NAME: ________________________________________ TITLE: ______________________________________________

VOICE PHONE: (____)______________ Ext.________ FAX NUMBER: (____)_______________ DATE: _____________

UCFE NUMBER: 1234567890 IN UTANA PAGE 2 OF 2

INSTRUCTIONS

DUE DATE: Please return this form or a computer-generated fascimile by JULY 31, 2005.

Please follow these steps to prepare your Report of Federal Employment and Wages. Contact the Agency listed in Step 5 if you have any questions or if you need additional information.

1. Review the agency name, contact name, and mailing address and make any necessary corrections (Section 2).

2. The Worksites list (Section 3) shows the individual worksites (business locations) that appear in our files for this state.
Please read across the row for each worksite and do the following:

 NAME/ADDRESS/Description: Review the name and physical location address for each worksite and make any necessary corrections. Review the description below the physical location to be sure it uniquely identifies each worksite (site name, base number, etc.). If there is no printed description, please enter a unique identifier for the site.

 EMPLOYMENT: Enter employment for each month of the quarter. Employment is the total number of full-time, part-time, and intermittent civilian employees who worked during or received pay for the pay period which includes the 12^th of the month. Include all employees who were subject to Unemployment Compensation for Federal Employees (UCFE) and employees paid for various types of leave (annual, sick, etc.) taken during the pay period including the 12^th.

 WAGES: Enter wages paid during the quarter (on all payrolls) for each worksite. Round wages to the nearest dollar.

 COMMENTS: Explain any large changes in employment or wages. Changes might result from layoffs, bonuses, seasonal increases or decreases, or similar events.

 CLOSED: If a worksite has been closed, or is otherwise inactive, use the Comments section to show the date closed.

3. Is the list in Section 3 complete? That is, does the agency operate any worksites in this state that do not appear on the form, such as newly-opened worksites?

MISSING WORKSITES: Provide the following information for each additional worksite. You may use available blank lines or attach a separate page. If you are not sure how to report a worksite or employee, please call the office listed in
Step 5 of these instructions.

a. The agency name, street or physical location address (NO POST OFFICE BOXES), city, state, and zip code

b. A unique description or identifier for each worksite (e.g., site name, base number, or similar description)

c. The number of employees for each month of the quarter, and quarterly wages

d. The county, township, city, independent city, or similar geographic area in which the worksite is located

e. The main business activity at the worksite

In addition, if any of these worksites were transferred from another agency, please provide:

f. The name of the agency that transferred the worksite

g. The effective date of the transaction

4. Complete the Totals section at the end of the list. For each month, sum the number of employees at all worksites. Then sum the wages for the quarter at all worksites.

5. Using the enclosed envelope, return your completed form to:

Utana State Department of Labor

Labor Market Information Services – QCEW/UCFE REPORT

288 West Main Street

Somecity, UA 22989-3182

Voice phone: (123) 456-7890 or 1-800-123-4567; Fax: (123) 456-7990

GENERAL INFORMATION

PURPOSE OF THIS REPORT

This Report of Federal Employment and Wages (RFEW) collects employment and wages by individual work location in this State. Data from the RFEW enable our agency to monitor and analyze conditions of business activities by geographic area and industry in this State. The information collected on this form by the Bureau of Labor Statistics and the State agencies cooperating in its statistical programs will be used for statistical and Unemployment Compensation for Federal Employees program purposes, and other purposes in accordance with law.

We estimate that this form will take from 10 minutes to 60 minutes to complete per response, with an average of 22 minutes. This includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing this information. If you have any comments regarding these estimates or any other aspect of this form, send them to the Bureau of Labor Statistics, Division of Administrative Statistics and Labor Turnover, Room 4840, 2 Massachusetts Avenue N.E., Washington, D.C. 20212. You are not required to respond to the collection of information unless it displays a currently valid OMB number.