Form BLS 3020 BLS 3020 Multiple Worksite Report

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Multiple Worksite Report − BLS 3020

Form Approved, O.M.B. No. 1220−0134
In Cooperation with the U.S. Department of Labor
STATE OF UTANA

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This report is authorized by law, 29 U.S.C. 2. Your voluntary 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 Contribution
Report (Form QCR−1234).

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QUARTERLY REPORT INFORMATION

ABC ENTERPRISES
SPECIAL EVENT CATERERS
1234 MAIN STREET, SUITE 123
SOMECITY UA 12345−6789

U.I. NUMBER
:
QUARTER ENDING :
:
DUE DATE

1234567890
JUNE 30, 2012
JULY 31, 2012

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

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WORKSITES

OFFICE
USE

SEE INSTRUCTIONS ON THE BACK OF THIS PAGE

BUSINESS NAME (division, subsidiary, etc.)
STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE
WORKSITE DESCRIPTION (plant name, store number, etc)

NUMBER OF EMPLOYEES

*MWR WEB INFORMATION *
*ID: 123456789012
*
*Password: 99999999 *
**********************

(subject to UI laws)
During the Pay Period Which Includes
the 12th of the Month
APR

MAY

JUN

QUARTERLY
WAGES
OF WORKSITE

(subject to UI laws)
Round to the nearest dollar

GO PAPERLESS! REPORT YOUR DATA ON THE WEB.
Instructions: http://www.bls.gov/cew/cewmwr05.htm

00001
000002
722320
001

SPECIAL EVENT CATERERS
345 LEXINGTON BLVD
RICHMOND UA 12657
STORE #001

00002
000010
722320
003

SPECIAL EVENT CATERERS
459 OX ROAD SUITE 209
DANVILLE UA 12778−0004
STORE #002

00003
000005
722320
005

SPECIAL EVENT CATERERS
33446 HIGHWAY 24
HARRISONBURG UA 11278
LOCATION #003

.00
COMMENTS:

.00
COMMENTS:

.00
COMMENTS:

.00
COMMENTS:

.00
COMMENTS:

Note: The totals MUST agree (except
for rounding) with your Form QCR−1234.

TOTALS
.00
−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−−

_______________________________________________________________________________________________

CONTACT PERSON (for questions regarding this report).

Please print.

NAME: ___________________________________________

TITLE: _____________________________________________

VOICE PHONE: (____)______________ Ext.___________

FAX NUMBER: (____)______________

DATE: ____________

U.I. NUMBER:

1234567890 IN UTANA

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INSTRUCTIONS

DUE DATE: Please return this form or a computer−generated facsimile by JULY 31, 2012.

Please follow these steps to prepare your Multiple Worksite Report. Contact the Agency listed in Step 5 if you have any
questions or if you need additional information, or see http://www.bls.gov/cew/cewmwr00.htm
1. Review the business name, contact name, and mailing address and make any necessary corrections (Section 2).
2. The Worksites list (Section 3), beginning in the second row, shows the individual worksites (business locations) that
appear in our files for the U.I. Number. 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 (plant name, store 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− and part−
time employees who worked during or received pay for the pay period which includes the 12th of the month.
Include all employees who were subject to Unemployment Insurance laws.
WAGES: Enter wages paid during the quarter that are subject to State Unemployment Insurance laws, including the
portion that exceeds the State's taxable wage base. Round wages to the nearest dollar.
COMMENTS: Explain any large changes in employment or wages. Changes might result from store closings, strikes,
layoffs, bonuses, seasonal increases or decreases, or similar events.
CLOSED OR SOLD: If a worksite has been sold, closed, or is otherwise inactive, use the Comments section to show:
(a) the date closed or sold; (b) if sold, the name of the company that bought the business at that worksite; and (c) the
purchaser's U.I. Number, if you know it.
3. Is the list in Section 3 complete? That is, does the business operate any worksites using this U.I. Number that do not
appear on the form, such as newly−opened worksites or newly−acquired 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 business 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., plant name, store 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 you purchased any of these worksites from another company, please provide:
f. The name of the company that sold the worksite
g. The effective date of the sale, and
h. The seller's U.I. Number, if you know it.
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. Except for rounding, these figures MUST agree with the totals on your

.
.
.
.
.

Quarterly Contributions Report.

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

UTANA DEPARTMENT OF LABOR AND INDUSTRY
DIVISION OF RESEARCH AND STATISTICS − QCEW MWR REPORT
12345 CENTER STREET, ROOM 200
SOMECITY, UA 12345−9876
PHONE: 1−123−321−4321
FAX: 123−321−4421
INTERNET: http://www.utana.dol.gov

PURPOSE OF THIS REPORT

GENERAL INFORMATION

This Multiple Worksite Report (MWR) collects employment and wages by individual work location in this State. If you operate businesses from more than
one location under the Unemployment Insurance Account Number (U.I. Number) shown above, the MWR supplements your Quarterly Contributions
Report. Data from the MWR 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 Insurance program purposes, and other purposes in accordance with law.

PAPERWORK REDUCTION ACT STATEMENT

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. The OMB control number for this survey is
1220−0134. Without a currently valid OMB control number, BLS would not be able to conduct this survey.