U.S. Department of Labor

Bureau of Labor Statistics

Data Collection Center

dccaddress2

dcccity2, dccst2 dcczip

Phone: dccphone Fax: faxphone

MP MF INT

► Information We Have For Your Firm:

Con_Firm	Contact: Attn: Payroll Manager2
Con_Address	Tel: con_tel Ext: con_ext
Con_City, Con_State Con_Zipcode	Fax: con_fax

►Report payroll information for the pay period that includes the 12th of the month.

FAX TO: faxphone2

Reference Month/Year: mon1 year1	1 Employee Count	2 Women Employee Count	3 Payroll, Excluding Commissions	4 Commissions	5 Total Hours, Including Overtime	6 Overtime Hours (Whole hours)
Report #: reptnum State: STC Location: REGlocation UI: ReptUI
Pay Type: pay-type1	All Workers	XXXXX
Production Workers	XXXXX
Pay Type: pay-type2	All Workers	XXXXX
Production Workers	XXXXX
Report #: reptnum State: STC Location: REGlocation UI: ReptUI
Pay Type: pay-type1	All Workers	XXXXX
Production Workers	XXXXX
Pay Type: pay-type2	All Workers	XXXXX
Production Workers	XXXXX
Report #: reptnum State: STC Location: REGlocation UI: ReptUI
Pay Type: pay-type1	All Workers	XXXXX
Production Workers	XXXXX
Pay Type: pay-type2	All Workers	XXXXX
Production Workers	XXXXX
Report #: reptnum State: STC Location: REGlocation UI: ReptUI
Pay Type: pay-type1	All Workers	XXXXX
Production Workers	XXXXX
Pay Type: pay-type2	All Workers	XXXXX
Production Workers	XXXXX

This report is authorized by law 29 U.S.C.2. We request your cooperation to make the results of this survey comprehensive, accurate, and timely. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.

Please note this report is mandatory in North Carolina, under Section 96-4(i) of the North Carolina Employment Security Law; in Oregon, under the Oregon Revised Statute 657.660; in Washington, under the Revised Code of Washington sections 50.12.010, 50.12.070, and 50.12.1#0; in South Carolina, under Section 41-29-120 of the Code of Laws of South Carolina (for firms employing more than twenty individuals); and in Puerto Rico, under State Law 15, Sections 5, 6 and 15, amended and approved on April 14, 1931.

We estimate that it will take an average of 10 minutes to complete this form each month including time to review instructions, search existing data sources, gather and maintain the necessary data, and complete and review this information. If you have any comments regarding these estimates or any other aspects of this survey, send them to the Bureau of Labor Statistics, Division of Current Employment Statistics (1220-0011), 2 Massachusetts Avenue, NE, Washington, DC 20212. You are not required to respond to the collection of information unless it displays a currently valid OMB control number. Form Approved OMB No. 1220-0011.

If You Need the Instructions to fill out this Form Please Call: dccphone2.