Multiple Payroll Private Sector Fax Form-Short Version-Revised

Bureau of Labor Statistics: Report on Current Employment Statistics – FAX Report Form				U.S. Department of Labor
Firm Name: Con_Firm1	Contact:  		Title: title1		Form Approved O.M.B. No. 1220-0011
Telephone: phone1	Fax Phone: fax1	Please fax report to: faxphone3				by	duedate3

Enter in columns 4 and 6 one of the following codes for the length of pay:

1 Each week

2 Every two weeks

3 Twice a month

4 Once a month

IMPORTANT: Report columns 1-8 for the pay period that includes the 12^th of the month. Report column 9 for the entire previous month.

			Payroll				Hours
	1	2	3	4	5	6	7	8	9
Reference Month/Year: Refmonyr	Employee Count	Women Employee Count	Payroll, Excluding Commissions (Whole dollars)	Length of Pay: Regular Pay	Commissions (Whole dollars)	Length of Pay: Commissions	Total Hours, including overtime (Whole hours)	Overtime Hours (Manufacturing only) (Whole hours)	Gross Monthly Earnings, previous calendar month (Whole dollars)
Report #: reptnum	State: STC		Location: REGlocation
Pay Group 1									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Pay Group 2									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Report #: reptnum	State: STC		Location: REGlocation
Pay Group 1									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Pay Group 2									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Report #: reptnum	State: STC		Location: REGlocation
Pay Group 1									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Pay Group 2									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Report #: reptnum	State: STC		Location: REGlocation
Pay Group 1									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory Workers								XXXXX
Pay Group 2									You no longer need to report Gross Monthly Earnings
All Workers								XXXXX
Production, Construction, or Nonsupervisory 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(g) (l) 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 50.12.180; and in South Carolina, under Section 41-29-120 of the Code of Laws of South Carolina (for firms employing more than twenty individuals). Form Approved OMB No. 1220-0011. We estimate that it will take an average of 11 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.

If the pre-printed information on this form is incorrect, or you need help filling out this form, please contact us at dccphone3. pc#

BLS 790-PvtFAX_short_Multi Rev. Jan 2009