Form BLS 3021 BLS 3021 Report of Federal Employment and Wages 3021

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Report of Federal Employment and Wages − BLS 3021

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, 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.

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FEDERAL AVIATION ADMINISTRATION
DIVISION OF INVESTIGATIONS
1234 CONSTITUTION AVE
SAN FRANCISCO UA 12345−6789

QUARTERLY REPORT INFORMATION
UCFE NUMBER : 1234567890
QUARTER ENDING : JUNE 30, 2012
: JULY 31, 2012
DUE DATE
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

WORKSITE NAME
STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE
WORKSITE DESCRIPTION (site name, base number, etc)

00001
000005
926120
001

FAA−DIVISION OF INVESTIGATIONS
3324 PALISADES PKWY
PALISADES UA 12345−9876
FIELD OFFICE SITE 12345

00002
000025
926120
003

FAA−DIVISION OF INVESTIGATIONS
2234 PACIFIC ROAD, BUILDING 2
LOS ANGELES UA 12349
FIELD OFFICE SITE 54322

00003
000125
926120
005

FAA−DIVISION OF INVESTIGATIONS
*** Address Unknown −− Please Provide ***

00004
000003
926120
007

FAA−DIVISION
123 MARIPOSA
MARIPOSA UA
FIELD OFFICE

NUMBER OF EMPLOYEES

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

APR

MAY

JUN

QUARTERLY
WAGES
OF WORKSITE

(on all payrolls)

Round to the nearest dollar

.00
COMMENTS:

.00
COMMENTS:

.00
COMMENTS:

OF INVESTIGATIONS
PKWY
12347−2347
SITE 71A

.00
COMMENTS:

.00
COMMENTS:

.00
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

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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 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
12th 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

.
.

. 12th.
WAGES: Enter wages paid during the quarter (on all payrolls) for each worksite. Round wages to the nearest dollar.
. seasonal
COMMENTS: Explain any large changes in employment or wages. Changes might result from layoffs, bonuses,
or decreases, or similar events.
. CLOSED: increases
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 DEPARTMENT OF LABOR AND INDUSTRY
DIVISION OF RESEARCH AND STATISTICS − QCEW/UCFE 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 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.

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.