BLS-3023-NCA (Non-CARS)

A

Industry Verification Form, BLS 3023 NCA
Form Approved, O.M.B. No. 1220−0032

UTANA DEPARTMENT OF LABOR AND INDUSTRY

In cooperation with the U.S. Department of Labor

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2

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.

The questions on this form concern the work location(s) using Unemployment Insurance account number 1234567890
IN UTANA.

ATTN: WALTER SMITH
RESIDENTIAL SERVICES INC
1234 MAIN STREET SUITE 300
SOMECITY UA 12345−1234

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4

We need the name and direct mailing address for the business using this Unemployment Insurance account, regardless of who prepares
this form. This information does not affect mailings for tax purposes. Are the name and mailing address shown in Item 2 correct for the
business using this Unemployment Insurance account?
YES
NO....Please print corrections or additions to the right of the printed address in Item 2.
COMPANY PERMANENTLY OUT OF BUSINESS OR MOVED OUT OF UTANA
Enter date closed or moved: __________________ SKIP to Item 7 on the back of this form
In addition to your mailing address, please tell us where your business is physically located (street and number). The physical location
address is the place where you conduct your business and receive deliveries, so it cannot be a Post Office Box.
Our records show that this business in Utana is physically located at:
1234 MAIN STREET
SUITE 300
SOMECITY UA 12345−6789
Is this address correct for the location in Utana?
[ ] YES−−> Continue with Item 5
[ ] NO −−> Please make changes to the right of the address here, in Item 4. Continue with Item 5

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6

Is the following information correct for the address in Item 4? UTANA COUNTY: WATERCRESS
YES...Continue with Item 6
NO....Please print corrections in this space and then continue with Item 6
Does the business using Unemployment Insurance account 1234567890 IN UTANA
have one physical location or more than one physical location in UTANA?
(Do not count client sites or offsite projects that
will last less than a year as separate locations.)
One physical location
More than one physical location......Please attach a separate sheet. For each site, list (1) business name (2) physical location address (3) number
of employees (4) county, and (5) answer Item 7.

PLEASE CONTINUE WITH ITEM 7 ON THE BACK OF THIS PAGE.

OFFICE USE

UI

EMPL

CTY

FY14

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11/01/13

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NAICS

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7 INSTRUCTIONS:

Describe the business using the Unemployment Insurance account number 1234567890 IN UTANA.
We need detailed information to assign the correct industry code to this business. In the space provided below, describe your business
activities, goods, products, or services in this state, as though you were tellling a prospective employee what you do. Then give us the
approximate percentage of sales or revenues resulting from each item. See examples below. Percentages should total 100%. If you are a
third party agent for the business named in Item 2, such as a payroll service or accountant, please review Item 7 with your client.
Goods or Products: What are they, and what do you do with them? Do you design, manufacture, sell directly to consumers, distribute to
wholesalers, install, repair, or do something else with them? What are these goods or products made of?
EXAMPLE 1: Major appliances: Sell to public 40%; Sell to retailers 30%; Repair 30% EXAMPLE 2: Install fiber optic cable 100%
Manufacturers: What are your main products? What are your most important materials? What are the main production methods?
EXAMPLE: Weaving cotton broadwoven fabrics 80%; Spinning cotton threads 20%
Services: Describe in detail the services you provide. To whom do you provide those services? If you offer consulting, brokerage,
management, or similar services, what are your major activities?
EXAMPLE 1: Hair cutting & styling 65%; Manicures 25%; Facials 10% EXAMPLE 2: Long distance trucking, less than truckload 100%
EXAMPLE 3: Marketing consulting: Planning marketing strategy 60%, Sales forecasting 40% EXAMPLE 4: Cleaning private homes 100%
Construction or Building Trades: Is the work mostly residential or nonresidential? Single− or multi−family? New or remodeling?
EXAMPLE: Electrical contractor: Wiring new homes 51%; Electrical refurbishing of office buildings 49%

List most
important
activities,
goods,
products,
or services

%
%
%
%
PLEASE PRINT CLEARLY

8 CONTACT INFORMATION

100%

%

Name: _______________________________________ Phone: (_____)____________
E−Mail Address: ________________________________________________________
Business Website Address: ___________________________________________________

Please return the completed form to this address within 14 days, using the postage−paid envelope provided.
For questions concerning this form, contact:

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

Thank you for your cooperation!
Purpose and Use: The purpose of this report is to update information on your products or services. The information will be used to ensure that we assign the correct industry code to
this business location, and that our records contain the correct name and address. 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 5 to 45 minutes with an average of 10 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 Administrative Statistics and Labor Turnover (NCA), 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. The OMB control number for this survey
is 1220−0032.

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