BLS-3023-NVM (Non-CARS)

Annual Refiling Survey

Non-CARS NVM -- mandatory

Annual Refiling Survey (Mandatory)

OMB: 1220-0032

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

UTANA DEPARTMENT OF LABOR AND INDUSTRY

In cooperation with the U.S. Department of Labor

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.

Insurance account number
2 The questions on this form concern the work locations of the business using Unemployment
1234567890 IN UTANA.
ABC ENTERPRISES
SUITE 123
1234 MAIN STREET
SOMECITY UA 12345−6789

3 Please provide a contact for us if we have questions about this report. (Please print)
Name: ______________________________

Phone: (_____)_____________

E−mail Address: __________________________________________________
Business Website Address: ____________________________________________

4 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 − 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

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 Administrative Statistics and Labor Turnover (NVM),
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.

OFFICE USE

FY14

EMPL

OWN

1234567890

121234567890

11/01/13

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.
Use the address, county or other geographic unit, approximate employment, and any other printed information to
identify each work location.
Complete Parts A and B for each work location.

PART A: 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 B.
PART B: If you answered "NO" to Part A, 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 B, 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 B 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).

.
.
.

QUESTIONS? For questions concerning this form, contact the state agency listed on the front of this page.

RETURN THE FORM. Return the completed form within 14 days to the address in Item 4 on the front of this page.

Thank you for your cooperation!

INDUSTRY
DESCRIPTION UI Number 1234567890 in Utana
Our records show that the main activity of the businesses listed below is:

Page 1 of 1
238130

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 UA 12657

COUNTY: REDMOND
Approximate Employment: 10
STORE #201

OFFICE USE
00001 3 001
238130
000

A. Does the industry description block above show the main business activity at this location?
YES
NO...Continue with part B.
B. 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
STORE #202

OFFICE USE
00002 3 003
238130
000

COUNTY: ROCKINGHAM
Approximate Employment: 11
CENTRAL ADMINISTRATIVE OFFICE

OFFICE USE
00003 3 005
238130
000

COUNTY: __________________________
Approximate Employment: 20

OFFICE USE
00004 3 999
238130
000

Continue on the next page. If this is the last page, return the completed form to the address in Item 4 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 − 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

File Type	application/pdf
File Title	NVMP1M
File Modified	2013-06-27
File Created	2013-06-27