Form QSS-1(A) Quarterly Services Survey

Attachment 2

OMB No. 0607-0907: Approval Expires: 10/31/2009

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

QUARTERLY SERVICES SURVEY

FORM

CE

U.S.
D

ER
M

EP

U.S. CENSUS BUREAU
E NT OF C
TM
OM
AR

US

R

S

BU

QSS-1(A)

EA
EN
UO
F TH E C

DUE
DATE
NOTICE — Your report to the
Census Bureau is confidential by
law (Title 13, U.S. Code). It may
be seen only by persons sworn to
uphold the confidentiality of Census
Bureau information and may be
used only for statistical purposes.
The law also provides that copies
retained in your files are immune
from legal process.
RETURN COMPLETED FORM TO:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
OR
Fax: 1–800–447–4613
NEED HELP?
Visit our web site:
http://www.census.gov/econhelp/qss
or
Call 1–800–772–7851 between 8:30 a.m.
and 5:00 p.m. EST, Monday through Friday.

INTERNET REPORTING
You may complete this survey online at:
Username:

Password:

(Please correct any errors in name, address, or ZIP Code)

http://www.census.gov/econhelp/qss
using your firm’s unique username and original password. If you
change your password, please keep a record for reference.

1 SURVEY COVERAGE

Does this firm have domestic locations providing the business activities described in the
above survey coverage statement?
1
2

Yes – Continue with 2
No – Specify your business activity and continue with 2

2 NOT APPLICABLE TO THIS FORM

USCENSUSBUREAU

qss-a (9-5-2007)

3

REVENUE

$ Bil.

Mil.

Thou.

Dol.

A. What was this firm’s quarterly revenue for the domestic locations
(See 1 ) covered by this report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Is the revenue reported in A above a book figure or estimate?

4

Book figure
Estimate

1

.............

2

REPORT PERIOD
1
2

Yes – Continue with 5
No – Provide beginning and ending dates for
the most recent quarter.

Most Recent Quarter
Month

Day

Year

Beginning date . . . . . . . . . . . . . . . . . . . . . . . .
Ending date . . . . . . . . . . . . . . . . . . . . . . . . . .

5

SOURCE OF REVENUE
What percentage of revenue (reported in 3 )
is received from each of the following types
of customers?
Estimates are acceptable if actual data is not available.

1. Government (local, State, and Federal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

2. Business firms and not-for-profit organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

3. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

qss-2tc-1q (9-4-2007)

100%

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6

ORGANIZATIONAL CHANGE

Name of company acquired/merged with/sold to

Number and street
1

YES
2

acquired
merged with

3

sold to

1

2

City, State, and ZIP Code

NO
Date of acquisition
merger or sale.

Month

Year
EIN

–

7

REMARKS – Please use this space for comments or to explain any significant difference between your
current and prior quarter revenue.

8

CONTACT INFORMATION

Name of person to contact regarding this report

Telephone
Area code Number

Extension

E-mail address
Fax
Area code Number

Company website

THANK YOU
for completing your Quarterly Services Survey.

qss3 (9-4-2007)

Page 3

INSTRUCTIONS FOR 3
Taxable Firms

Tax-Exempt Firms

Firms operating on a commission basis should report
commissions, fees, and other operating income, not
gross billings or sales.

Firms operating on a commission basis should report
commissions, fees, and other operating income, not
gross billings or sales.

Include –

Include –

• Total value of service contracts.

• Program service revenue for services provided in the
quarter, whether or not payment was received in that
quarter.

• Amounts received for work subcontracted to others.
• Market value of compensation in lieu of cash.
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Dues and assessments from members and affiliates.
Exclude –
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, State, or Federal tax agency.
• Revenue from a domestic parent organization, or
from franchise locations owned by others and any
franchise or license fees.
• Rents from and revenue of separately operated
departments, concessions, etc., which are leased to
others.
• Revenue from customers for carrying or other credit
charges.
• Commissions from vending machine operators.
• Revenue of foreign subsidiaries (those located outside
the U.S., i.e., outside the 50 states, District of
Columbia, U.S. Commonwealth Territories, or U.S.
Possessions).
• Nonoperating revenue such as income from
investments, sales of company-owned real estate
(land and building), or other assets, (except inventory
held for resale), securities, gifts, loans, contributions,
royalties, or grants.
• Revenue from the sale of used equipment.
• Installment payments from leasing under capital,
finance, or full-payout leases.

• Gross sales of merchandise, minus returns and
allowances.
• Income from interest, dividends, gross rents
(including display space rentals and share of receipts
from departments operated by other companies),
royalties, and other investments.
• Net gains (or losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale).
• Gross contributions, gifts, and grants (whether or not
restricted for use in operations).
• Dues and assessments from members and affiliates.
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators).
• Gross receipts from fundraising activities.
Exclude –
• Sales and other taxes collected directly from
customers or clients and paid directly to a local, State,
or Federal tax agency.
• Gross receipts of departments or concessions
operated by other companies.
• Amounts transferred to operating funds from capital
or reserve funds.

• Intracompany transfers.
• Interest income.

Public reporting burden for this collection of voluntary information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: Paperwork Project 0607-0907, U.S. Census Bureau, 4600 Silver Hill Road, AMSD - 3K138,
Washington, DC 20233. You may e-mail comments to Paperwork@census.gov; use "Paperwork Project 0607-0907" as the subject.
PLEASE INCLUDE FORM NAME AND NUMBER IN ALL CORRESPONDENCE.
Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of
Management and Budget. This 8-digit number appears in the top right corner on the front of this form.
QSS-4 (4-5-2007)

Page 4