Online Group Size Questionnaire

	Column A. Total number of full-time employees (as of the end of the month)	Column B. Total number of part-time employees (as of the end of the month)	Column C. Others not reported in Column A or B	Combined total (add total from Columns A+B+C)
January 2024
February 2024
March 2024
April 2024
May 2024
June 2024
July 2024
August 2024
September 2024
October 2024
November 2024
December 2024

Employers

Are you part of a group of affiliated employers? Yes No

In the last year, has your total employee count increased to 20 or more employees or decreased to 19 or fewer employees?

Increased to 20 or more employees Decreased to 19 or fewer employees None

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Thank you for your cooperation in this important federal compliance matter.
Questions? Please contact Customer Service at 888-672-0062.