Bls-3023-nvm

BLS 3023-NVM

Industry Verification Form, BLS 3023 NVM

Form Approved, O.M.B. No. 1220-0032

In cooperation with the U.S. Department of Labor

1	This report is mandatory under Section 320.5 of the Utana Unemployment Insurance Code and Section 320-1 Title 22 of the Utana Code of Regulations, 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.
2	The questions on this form concern the work locations of the business using Unemployment Insurance account number 1234567890 IN UTANA. ABC ENTERPRISES RESIDENTIAL SERVICES CO. ATTN: WALTER sMITH 1234 MAIN STREET SUITE 123 SOMECITY UA 12345-6789
3	Are the company name and mailing address shown in Item 2 correct for the business using the listed Unemployment Insurance account?  YES  NO….Please print corrections to the right of the address in Item 2 above.  Company permanently out of business or moved out of uTANA Enter date closed or moved: ____________________________________ (Please complete this form and describe the business activity of these work locations before they were closed.)
4	Please provide a contact for us if we have questions about this report. (Please print) Name: _________________________________ Phone: (________)_____________________ Date: ___________ Title: ____________________________________________________ Fax: (________)_____________________ Company website:________________________________________________________________________________
5	Please return the completed form to this address within 14 days. For questions concerning this form, contact:
UTANA DEPARTMENT OF LABOR AND INDUSTRY DIVISION OF RESEARCH AND STATISTICS – ES-202 12345 CENTER STREET, ROOM 200 SOMECITY, UA 12345-9876 INTERNET: http://www.utana.dol.gov phone: 1-123-321-4321 fax: 123-321-4421
		Please continue on the back of this page.

Purpose and Use: The purpose of this report is to update information on the products or services of each worksite covered by the Unemployment Insurance Account Number shown in Item 2 above. The information will be used to ensure that we assign the correct North American Industry Classification System (NAICS) code to each worksite, and that our records contain the correct names and addresses. 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 Insurance program purposes, and other purposes in accordance with law.

Time of Completion: Time of completion is estimated to vary from 10 to 60 minutes with an average of 15 minutes per form. This estimate 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 survey, send them to the Bureau of Labor Statistics, Division of Occupational and Administrative Statistics, 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.

OFFICE USE FY02 11/01/01

UI EMPL OWN

1234567890 56 5

utana department of labor and industry

Instructions 1. Each page of this report shows an industry description and a list of individual work locations. Begin by reviewing the industry description at the top of the page. 2. Use the address, county or other geographic unit, approximate employment, and any other printed information to identify each work location. 3. Complete Parts A, B, and C for each work location. PART A: Check whether the location mainly serves the general public or other businesses, or mainly supports other locations of your company.  serves the general public or other businesses means that the products and services are intended for anyone: individual consumers, other businesses, institutions, and organizations.  Serves other locations of your company means that the location does not serve the general public, but instead operates in support of other locations of your company. These are usually special-purpose locations such as headquarters, regional management offices, warehouses, accounting offices, data processing offices, research and development laboratories, computer maintenance facilities, repair shops, security offices, employee recreation facilities, and similar facilities. PART B: See if the industry at the top of the page describes the main activity in the past 12 months at each work location. The answer can be "YES" even if the location's activities do not include everything listed in the description.  If Yes..Check "YES" and go on to the next location.  If No...Check "NO." Continue with Part C. PART C: If you answered "NO" to part B, describe the main business activity in the past 12 months at this location. Please be as detailed as possible so that we can assign an accurate industry code.  If this location deals in goods or products, what are the products, and what is done with them? For example, do you design, manufacture, sell directly to consumers, distribute to wholesalers, install, repair, or do something else with them? Is the merchandise new or used?  If you manufacture products, what are the primary materials and the main production methods?  If you provide services, please describe in detail what those services are, and whether your clients are businesses, individuals, or a combination of the two. If this is construction, is the work mostly residential or nonresidential? Closed or Sold Locations. If a location has been closed or sold:  Draw a line through the information above part A.  Write "Closed" or "Sold" and the date this took place.  In part C, describe the business activity at this location if it was different from the industry description at the top of the page.  If this location was sold, please provide the name of the company that made the purchase and that company's Unemployment Insurance account number, if you know it. Additional Locations Not Listed. Does the company have additional locations that use this Unemployment Insurance account number that are not listed on the following pages? If so, please attach a separate sheet with the following information for each location.  List the address.  Describe the business activity, using the guidelines provided for Part C above.  If you have purchased the location from another company, also provide the name of the company that sold the location and that company's Unemployment Insurance account number, if you know it 4. QUESTIONS? For questions concerning this form, contact the state agency listed on the front of this page. 5. RETURN THE FORM. Return the completed form within 14 days to the address in Item 5 on the front of this page.

Thank you for your cooperation!

INDUSTRY DESCRIPTION UI Number 1234567890 in Utana Page 1 of 1 Our records show that the main activity of the businesses listed below is: 238131 RESIDENTIAL structural framing and sheathing using materials other than structural steel or concrete. May include new work, additions, alterations, maintenance, and repairs. EXAMPLES: * Framing contractors for residential buildings working in steel or wood * Residential post frame contractors * Residential steel framing contractors * Fabrication of wood frame components such as trusses on residential sites. DOES NOT INCLUDE finish carpentry, installing structural steel, or installing precast concrete framing or structural elements.
RESIDENTIAL SERVICES CO 345 LEXINGTON BLVD RICHMOND UT 12657	COUNTY: REDMOND Approximate Employment: 10 RESIDENTIAL FRAMING	OFFICE USE 00001 3 001 238131 5 000
A. Does this location mainly serve the general public or other businesses, or does it mainly support other locations of your company?  Mainly serves the general public or other businesses (5)  Mainly supports other locations of your company (8)
B. Does the industry description block above show the main business activity at this location?  YES  NO...Continue with part C.
C. If you checked NO, describe your business and list your main products or services at this location. Show the approximate percentage of each.
______% ______%
RESIDENTIAL SERVICES CO 459 OX ROAD, SUITE 209 DANVILLE UA 12778-0004	COUNTY: LOGAN Approximate Employment: 15 WOOD FRAMING – RESIDENTIAL	OFFICE USE 00002 3 003 238131 5 000
A. Does this location mainly serve the general public or other businesses, or does it mainly support other locations of your company?  Mainly serves the general public or other businesses (5)  Mainly supports other locations of your company (8)
B. Does the industry description block above show the main business activity at this location?  YES  NO...Continue with part C.
C. If you checked NO, describe your business and list your main products or services at this location. Show the approximate percentage of each.
______% ______%
RESIDENTIAL SERVICES CO 33446 HIGHWAY 24 HARRISONBURG UA 11278	COUNTY: ROCKINGHAM Approximate Employment: 11 HARRISONBURG LOCATION	OFFICE USE 00003 3 005 238131 5 000
A. Does this location mainly serve the general public or other businesses, or does it mainly support other locations of your company?  Mainly serves the general public or other businesses (5)  Mainly supports other locations of your company (8)
B. Does the industry description block above show the main business activity at this location?  YES  NO...Continue with part C.
C. If you checked NO, describe your business and list your main products or services at this location. Show the approximate percentage of each.
______% ______%
RESIDENTIAL SERVICES CO 2097 WASHINGTON AVE WASHINGTON UA 11349-3754	COUNTY: WASHINGTON Approximate Employment: 20 WASHINGTON SUPPLY/STORAGE FACILITY	OFFICE USE 00004 3 007 238131 5 000
A. Does this location mainly serve the general public or other businesses, or does it mainly support other locations of your company?  Mainly serves the general public or other businesses (5)  Mainly supports other locations of your company (8)
B. Does the industry description block above show the main business activity at this location?  YES  NO...Continue with part C.
C. If you checked NO, describe your business and list your main products or services at this location. Show the approximate percentage of each.
______% ______%

Continue on the next page. If this is the last page, return the completed form to the address in Item 5 on the front page.

thank you for your cooperation

Please return the completed form to this address within 14 days.

UTANA DEPARTMENT OF LABOR AND INDUSTRY

DIVISION OF RESEARCH AND STATISTICS – ES-202

12345 CENTER STREET, ROOM 200

SOMECITY, UA 12345-9876 INTERNET: http://www.utana.dol.gov

phone: 1-123-321-4321 fax: 123-321-4421