Various Governments Area Pretesting Activities

Generic Clearence for Questionnaire Pretesting Research

omb1210ASPEPenc1_rev

Various Governments Area Pretesting Activities

OMB: 0607-0725

Document [pdf]
Download: pdf | pdf
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
FORM

E-4

2013 ANNUAL SURVEY OF
PUBLIC EMPLOYMENT & PAYROLL
March 2013 – Municipalities, Counties, Townships
OMB No. 0607-0452: Approval Expires 04/30/2013

(03-12-2012) Draft 1

DUE DATE:

RETURN TO:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001

Need help or have
questions?
• Visit
census.gov/govs/asps
• Call
1-800-832-2839 weekdays,
7am to 5pm EST
• Email
govs.employ@census.gov
In correspondence
pertaining to this report,
please refer to the User ID
below the address box.

REPORT ONLINE: It’s fast and secure. Respond
to this survey via the Internet at the following web
address using the supplied User ID and Password:
respond.census.gov/aspep

1

User ID:
➤

Password:

Is your addressee title/department and mailing address the same as shown in the address label?
Yes – Go to 2

No – Enter correct information below

Addressee Title or Department

ATTN:
Street 1

City

State

Zip Code

–

Please continue on the next page

19043017

§4%?2¤

Street 2

Page 2
PART 1 – FULL-TIME EMPLOYEES STANDARD WEEKLY HOURS

2

On average, how many hours per week do the majority of your full-time employees work?
Include
• Persons paid to work the number of hours that represents regular, full-time employment.
• Temporary or seasonal employees who are working the number of hours that represents regular, full-time
employment.
• Officials paid on salary basis; by fees or commissions; on a per meeting basis; or a flat sum quarterly,
semi-annually, or annually.
Exclude
• Employees on unpaid leave, unpaid officials, pensioners, and contractors and their employees.
Mark "X" only one box.
A

40 hours or more

C

34 to 37.4 hours

E

30 to 31.9 hours

B

37.5 to 39.9 hours

D

32 to 33.9 hours

F

No Full-Time Employees

PART 2 – EMPLOYEES, PAYROLL, AND PART-TIME HOURS

3

For each applicable pay interval, what were the TOTAL number of employees and TOTAL gross payroll
amounts for the pay periods which include MARCH 12, 2013 for both full-time and part-time employees?
Please also report hours paid for each applicable pay interval for part-time employees.
Include
• Salaries, wages, fees, or commissions.
• Amounts withheld for taxes, employee contributions to retirement systems, etc.
• Persons in paid leave status and persons paid from Federal grant funds.
• Part-time employees working less than the regular, full-time workweek.
• Current employees whether paid from the general fund or special funds.
• All elected or appointed officials who receive any amount of pay or stipend (even small amounts of $25 per
meeting or $100 annually).
• Employees of fee offices should be included in “Financial administration”.
• Include any county supervision of public schools in “All other”.
• If more than three payroll intervals need to be reported, please photocopy the necessary pages and return them
with this form.
Exclude
• Lump sum payments and the value of living quarters and subsistence allowances furnished to

employees.

Do not report
• Cumulative salaries since the beginning of the calendar or fiscal year.
• Payroll amounts from last fiscal year.
• Employer costs of non-wage employee benefits such as workers’ compensation, FICA, health insurance, etc.

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

Example
Sea and inland port facilities – Docks, wharves, and related warehouses owned and operated by your government
Exclude
• Facilities for pleasure boats only (report in item 15.)

FORM E-4

Part-time
Number of
Payroll
Code Full-time Employees

M

2 7

W

1

5

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

9 4

5 0 0

8

2 5 0

Please continue on the next page

19043025

§4%?:¤

a. Full-time employees, gross payroll, and hours

Page 3

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

M

2 7

W

1

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

5

Part-time Hours Paid

9 4

5 0 0

6 0 0

8

2 5 0

3 0 0

A. CENTRAL GOVERNMENT ADMINISTRATION
1.

Financial administration
Include
• Treasurer’s office
• Auditor’s or comptroller’s office
• Tax assessment, tax billing and collection
• Budgeting
• Purchasing
• Central accounting offices
• Information technology
• Similar financial administration
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employee, gross payroll, and hours
Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

FORM E-4

19043033

§4%?B¤

Part-time
Number of
Payroll
Code Part-time Employees

Please continue on the next page

Page 4

W = Weekly;

2.

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

Central administration 029
Include
• Council board of supervisors or commissioners
• Central administrative officers and agencies, such as manager or mayor
• Clerk
• Recorder
• Zoning
• Central personnel agency
• Central planning agency
Exclude
• Financial activities (reported in item 1.)
• Judicial/legal activities (report in item 3.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employee, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

FORM E-4

Part-time Hours Paid

Judicial and legal 025
Include
• All court and court related activities
• Court activities of sheriff’s office (e.g., bailiffs, process servers)
• Prosecuting attorney’s and public defender’s offices
• Legal department and attorney providing government-wide legal services
Exclude
• Probation activities (report in item 5.)
• Private attorneys on retainer
• Court appointed attorneys
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Please continue on the next page

19043041

§4%?J¤

3.

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Page 5

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employee, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

B. PUBLIC SAFETY
4.

Police protection
Include
• Police department
• Law enforcement
• Activities of sheriff’s and constable’s offices
• Coroner
• School crossing guards (report as Part-time employees)
Exclude
• Sheriff’s correctional employees (report in item 5.)
a. Persons with power of arrest

062

Include
• Police employees only
Exclude
• Other employees with power of arrest (reported in item 3. or report in item 5.)
(1) Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

FORM E-4

Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

19043058

§4%?[¤

(2) Part-time employees, gross payroll, and hours

Please continue on the next page

Page 6

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Other police protection employees 162
Include
• All police protection employees not reported in item 4a.
(1) Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

(2) Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

5.

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

Corrections 005
Include
• Jails, reformatories, detention homes
• Probation and parole activities for both adults and juveniles
Exclude
• Lock-up employees (reported in item 4.)
a. Full-time employees and gross payroll

FORM E-4

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

Please continue on the next page

19043066

§4%?c¤

Full-time
Number of
Payroll
Code Full-time Employees

Page 7

W = Weekly;

6.

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

Fire protection
Include
• Paid volunteer firefighters (report as Part-time employees)
Exclude
• Unpaid volunteer firefighters
• Forest fire protection employees (report in item 17.)
• Recsue squad and emergency medical services not part of fire department ( report in tiem 11.)
a. Firefighters

024

Include
• Persons engaged in fire suppression and prevention
• Employees trained in these activities but performing such other duties as dispatching, emergency
medical care, etc.
(1) Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

(2) Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Other fire protection employees

Part-time Hours Paid

124

Include
• All fire protection employees not reported in item 6a.

FORM E-4

Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

19043074

§4%?k¤

(1) Full-time employees and gross payroll

Please continue on the next page

Page 8

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

(2) Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

C. TRANSPORTATION
7.

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

044

Streets and highways
Include
• Maintenance, repair, construction, and administration of streets, alleys, sidewalks,
roads, highway, and bridges
• Engineering activities
• Traffic signal maintenance
Exclude
• Street cleaning employees (report in item 13.)
• Sewer employees (report in item 14.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

FORM E-4

19043082

§4%?s¤

Part-time
Number of
Payroll
Code Part-time Employees

Please continue on the next page

Page 9

W = Weekly;

8.

Airports

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

001

a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

9.

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

Sea and inland port facilities 087 – Docks, wharves and related warehouses owned and operated
by your government
Exclude
• Facilities for pleasure boats only (report in item 15.)
a. Full-time employees and gross payroll

FORM E-4

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

Please continue on the next page

19043090

§4%?s¤

Full-time
Number of
Payroll
Code Full-time Employees

Page 10

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

D. SOCIAL SERVICES AND INCOME MAINTENANCE
10. Public welfare 001
Include
• Maintenance of homes and other institutions for the needy
• Nursing homes
• Administrtation of public assistance and vereran services
• Senior citizen and handicap transportation
• Social workers
Exclude
• Hospital employees (report in item 12.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours

FORM E-4

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

11. Health 032
Include
• Public health services
• Emergency medical services
• Mental health
• Alcohol and drug abuse
• Outpatient clinics
• Visiting nurses
• Food and sanitary inspections
• Animal control
• Other environmental health activities (e.g., pollution control)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Please continue on the next page

19043108

§4%@)¤

Part-time
Number of
Payroll
Code Part-time Employees

Page 11

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

12. Hospitals

036

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

– Institutions for inpatient medical care

Include
• All paid student help
Exclude
• Nursing home and welfare institution employees (reported in item 10.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

FORM E-4

19043116

§4%@1¤

Part-time
Number of
Payroll
Code Part-time Employees

Please continue on the next page

Page 12

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

E. ENVIRONMENT AND HOUSING
13. Solid waste management 081
Include
• Street cleaning
• Recycling
• Garbage and refuse collection and disposal
• Operation of sanitary landfill
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

14. Sewerage 080
Include
• Provision, maintenance, and operation of sanitary and storm sewer systems
• Sewerage disposal plants
Exclude
• Water supply employees (report in item 18.)
a. Full-time employees and gross payroll
Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

FORM E-4

19043124

§4%@9¤

Full-time
Number of
Payroll
Code Full-time Employees

Please continue on the next page

Page 13

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

15. Parks and recreation
Include
• Parks
• Playgrounds
• Swimming pools
• Auditoriums
• Museums
• Marinas
• Zoos
a.

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

061

Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours

FORM E-4

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

16. Housing and community development 061 – Construction, operation, and support of housing and
redevelopment programs and any housing projects of your government
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Please continue on the next page

19043132

§4%@A¤

Part-time
Number of
Payroll
Code Part-time Employees

Page 14

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

17. Natural resources 059
Include
• Forest fire protection
• Irrigation and drainage
• Flood control
• Forestry
• Agriculture
• Extension service
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

F. UTILITIES

FORM E-4

18. Water supply system

091

– Public water supply or distribution system operated by your government

a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Please continue on the next page

19043140

§4%@I¤

Part-time
Number of
Payroll
Code Part-time Employees

Page 15

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

19. Electric power system 091 – Public electric power supply or distribution system operated by your
government
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

20. Gas supply system

091

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

– Public gas supply or distribution system operated by your government

FORM E-4

Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

19043157

§4%@Z¤

a. Full-time employees and gross payroll

Please continue on the next page

Page 16

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

21. Transit system 094 – Public transportation system (bus, rail, etc.) operated by your government
Exclude
• Transit system exclusively for handicapped or senior citizens (reported in item 10.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

G. OTHER ACTIVITIES
22. Libraries 052 – Public libraries operated by your government
Exclude
• Law libraries (reported in item 3.)

FORM E-4

a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

Please continue on the next page

19043165

§4%@b¤

Part-time
Number of
Payroll
Code Part-time Employees

Page 17

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

23. All other 094 – All employees of your government and it’s agencies not reported elsewhere
Include
• Employees concerned with elections and voter registration
• Protective inspection (building, electrical, etc.)
• Motor pools
• Maintenance of general public building
• Parking facilities
• Other activities not reported elsewhere
Exclude
• School system employees and payrolls
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

FORM E-4

19043173

§4%@j¤

Part-time
Number of
Payroll
Code Part-time Employees

Please continue on the next page

Page 18

W = Weekly;

B = Bi-Weekly;

Payroll Interval Codes
T = Twice a Month;
M = Monthly;
Q = Quarterly;

S = Semi-Annually;

A = Annually

24. TOTAL – (Sum of items1. through 23.)
a. Full-time employees and gross payroll
Full-time
Number of
Payroll
Code Full-time Employees

Gross Payroll for Full-time Employees
$Bil.
Mil.
Thou.
Dol.

b. Part-time employees, gross payroll, and hours
Part-time
Number of
Payroll
Code Part-time Employees

Gross Payroll for Part-time Employees
$Bil.
Mil.
Thou.
Dol.

Part-time Hours Paid

PART 3 – REMARKS

4 Use this space to:

FORM E-4

19043181

§4%@r¤

a) Explain any significant changes to employment or payroll occurring within the last year that would
aid in understanding this report;
b) Describe any difficulties you encountered in completing this form;
c) List the groups of employees for which you were unable to supply information;
d) Provide contact information for other people who assisted you in completing this report.

Please continue on the next page

Page 19
PART 4 – CONTACT INFORMATION
5

Who should be contacted to answer questions about data reported on this form?

Name of contact person - Please print

Area code and phone number

–

–

E-mail address - Please print

Title of contact person - Please print

Extension

Area code and fax number

–

–

Date form was completed
(MM)
(DD)
(YYYY)

Thank you for completing this form.
Retain a copy of the completed questionnaire for your records.
NOTE: The U.S. Census Bureau receives its authorization to conduct this survey from Title 13, United States Code, Section 182. This form has been approved by the Office of
Management and Budget (OMB) and given the number 0607-0143. Please note the number displayed in the upper right-hand corner of this form. Display of this number confirms
that we have approval from OMB to conduct this survey. If this number was not displayed, under the Paperwork Reduction Act, we could not request your participation in this
voluntary survey. Information provided on this questionnaire compiled from or customarily provided in public records are exempt from confidential treatment as cited in Title 13,
United States Code, Section 9.

FORM E-4

19043199

§4%@ƒ¤

Please note that this is a national form that applies to governments with wide differences in the size of their service areas, the amount of population served, and the extent and
complexity of their activities. Public reporting burden for this collection of information is estimated to vary from 30 minutes to 2 hours per response, with an average of 45 minutes
per response, including 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 0607-0143, 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
0607-0143 as the subject.


File Typeapplication/pdf
File Titlee4_p01_13.g
File Modified2012-03-14
File Created2012-03-12

© 2024 OMB.report | Privacy Policy