BLS-Green Form 325 Green Form 325311

Green Goods and Services Survey

O.M.B. No. 1220−xxxx

Expires Month Day Year

Please return this form within 14 days. If you need help completing this form, contact information is listed on the last page. Thank you!

West Dakota

012345678

Please report for location(s) in Using Unemployment Insurance account number

1

What is the address where your business is physically located?

Report data for the location below. If this address is no longer correct, please provide us with an updated address in the space provided.

Enter Physical Location Address Corrections Here

XYZ ADVISORS

4TH FLOOR

1310 SILVER STREET

SOMECITY WD 12345-6789

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2

ave we identified your main business activity correctly?

We have listed below a description of your main business activity at this location. If this description is incorrect, please call XXX-XXX-XXXX or email GGS@bls.gov.

NAICS code: 325311 Nitrogenous fertilizer manufacturing
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in: Manufacturing nitrogenous fertilizer materials and mixing ingredients into fertilizers Manufacturing fertilizers from sewage or animal waste Manufacturing nitrogenous materials and mixing them into fertilizers		Mixing ingredients made elsewhere into nitrogenous fertilizers

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3

hat is your business’s fiscal year?

Please provide us with your fiscal year that includes the month of June 2010.

Start of Fiscal Year				End of Fiscal Year
MM	DD	YYYY		MM	DD	YYYY

4

What is your percent revenue from specific product lines?

In Columns 1 and 3, please estimate the percent of total revenue at your location listed in Item 1that comes from products approved for use in USDA certified organic production. Please base your estimate on total revenue for your fiscal year from Item 3. The sum of Columns 1 and 3 may not equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.

Percent of Revenue for Fiscal Year listed in Item 3
1 Percent of total revenue for approved products	2 Product line		3 Percent of total revenue for approved products	4 Product line
	Ammonia, anhydrous and aqueous, manufacturing			Fertilizers, of animal waste origin, manufacturing
	Ammonium nitrate manufacturing			Fertilizers, of sewage origin, manufacturing
	Ammonium sulfate manufacturing			Nitric acid manufacturing
	Anhydrous ammonia manufacturing			Nitrogenous fertilizer materials manufacturing
	Fertilizers, mixed, made in plants producing nitrogenous fertilizer materials			Plant foods, mixed, made in plants producing nitrogenous fertilizer materials
	Fertilizers, natural organic (except compost), manufacturing			Urea manufacturing
	Other			Other
	Other			Other

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5

hat is your contact information? For the person or persons who helped complete this form.

1. Contact 1’s name: __________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:__________________________________

Business website:______________________________________________

2. Contact 2’s name: ____________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:________________________________

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6

o you have any questions about completing this form?

Please send an email to GGS@bls.gov, or call (202)-691-XXXX.

Confidentiality Statement. 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. This report is authorized by law 29 U.S.C.2. Paperwork Reduction Act Statement. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate, and timely. We estimate that completing this form will take an average of 20 minutes. This estimate takes into account time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding this survey, including suggestions for reducing the burden, send them to the Bureau of Labor Statistics, Office of Industry Employment Statistics, Paperwork Reduction Project, 2 Massachusetts Avenue, N.E., Room 4840, Washington, DC 20212. The OMB control number for this voluntary survey is 1220-NEW and expires on month day, year. Without a currently valid number BLS would not be able to conduct this survey.

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