BLS-Green Form 441 Green Form 441310

Green Goods and Services Survey

O.M.B. No. 1220−0181

Expires September 30, 2010

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

Statename

UI (10 digits)

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

1

What is the address where your business establishment 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

T_name

Phy_addr2

PHY_addr1

Phy_city, Phy_state phy_zip-phy_zip_ext

H

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 202-691-5185 or email GGS@bls.gov.

NAICS code: 441310 Automotive parts and accessories stores
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily known as automotive supply stores engaged in: Retailing new, used, and/or rebuilt automotive parts and accessories Retailing automotive parts and accessories and repairing automobiles Retailing and installing automotive accessories		Retailing automotive parts and accessories via electronic home shopping, mail-order, or direct sale Retailing new or used tires Repairing and replacing automotive parts, such as transmissions, mufflers, and brake linings (except establishments known as automotive supply stores)

W

3

hat is your business establishment’s fiscal year?

Please provide us with your fiscal year that includes April 15, 2009 for the location listed in Item 1.

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

W

4

hat is your business establishment’s employment?

Please provide us with the employment figure you reported on your State’s Quarterly Contributions Report for September 2009 for the location listed in Item 1. This figure is the count of all employees subject to State Unemployment Insurance taxes that worked or received pay for the pay period that included September 12^th, 2009.

Employment for pay period that includes September 12, 2009

5

What is your percent revenue from specific product lines?

In Columns 1 and 3, please estimate the percent of total revenue at the location listed in Item 1 that comes from parts or supplies for hybrid or electric vehicles and vehicles that run solely on ethanol or biodiesel. 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 total revenue for fiscal year listed in Item 3
1 Percent of total revenue from hybrid, electric, or ethanol/biodiesel parts	2 Product line		3 Percent of total revenue from hybrid, electric, or ethanol/biodiesel parts	4 Product line
	Auto supply stores			Speed shops
	Automobile parts dealers			Stereo stores, automotive
	Automotive audio equipment stores			Truck cap stores
	Automotive parts and supply stores			Used automotive parts stores
	Automotive parts dealers, used			Other (please specify):
	Parts and accessories dealers, automotive			Other (please specify):

W

6

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:________________________________

D

7

o you have any questions about completing this form?

Please send an email to GGS@bls.gov, or call (202)-691-5185.

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 1220-0181 and expires on September 30, 2010. Without a currently valid number BLS would not be able to conduct this survey.

Please continue on the next page 1