QSS-6(E) Quarterly Services Survey

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-6(E)

(DRAFT)

Due Date

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

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GENERAL INSTRUCTIONS
Throughout this survey, any reference to "this firm" is referring to the EIN that is printed in the mailing
address area or the new EIN that was provided as a response in 2 . Any responses related to "this firm" should
only include data for the EIN referenced.

21920012

• Any significant change in this firm's operations should be noted in 8
• For establishments sold or acquired during the quarter(s), report data only for the period the establishments
were operated by this firm
• Estimates are acceptable if book figures are not available
• Enter "0" where applicable
• Report data on an accrual basis
Bil.
Mil.
Thou.
Dol.
• Dollars should be rounded to the nearest dollar
• If a figure is $1,030,280,456 it should be reported as
Include:
• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and
Construction operations) operated by this firm
• Data for auxiliary facilities primarily engaged in supporting services to this firm's establishment(s) such as
warehouses, garages, central administrative offices, and repair services

CONTINUE ON PAGE 2

Form QSS-6(E)
1

Page 2

(DRAFT)

SURVEY COVERAGE
Did this firm provide the business activities described below?

Yes
No - Specify this firm's business activity

2

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes
EIN (9 digits)
No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

3

Day

Year

ORGANIZATIONAL CHANGE
A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in third or second quarter
of 2012?
Yes
No - Go to

4

B. Which of the following organizational changes occurred in third or second quarter of 2012?
Check all that apply. If more than one organizational change occurred during the reporting period, explain in
Month

Acquisition

Day

8

.

Year

Date of organizational change . . . . . . . . . . . . . . . .
Sale

21920020

AND
Merger
Enter detailed information below
Divestiture
Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-6(E)
4

Page 3

(DRAFT)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Third Quarter
Beginning Date
Month Day
Year

Calendar quarter

Second Quarter
Beginning Date
Month Day
Year

Other - Report beginning and ending dates . . . . . .
Month

5

End Date
Day
Year

Month

End Date
Day
Year

SALES, RECEIPTS, OR REVENUE
Firms operating on a commission basis should report commissions, fees, and other operating revenue income,
not gross billings or sales.
INCLUDE
• Net realized gains as well as losses within
specified area(s) of activity
• Earned interest
• Commissions and fees received from all sources,
including fees earned for exchanging currencies,
selling money orders, and cashing checks
• Net gains (losses) from the sale of real property
owned by this establishment for investment, rent, or
lease (NOT gross sales)
• Gross sales (NOTE net gains (losses)) of real
property developed or buildings built by this
establishment for sale
• Gross rents from real property leased by this
establishment to others
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Rents from departments or concessions operated by
other companies at this establishment
• Franchise sales, fees, and royalties
• Sale or licensing of rights to intellectual property
protected by copyright or as industrial property
(e.g., patents, trademarks)

$ Bil.

EXCLUDE
• Taxes (sales, amusement, occupancy, use, or other)
collected directly form 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
• Revenue of departments or concessions operated
by other companies at this establishment
• 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)
• Intracompany transfers

Third Quarter
Mil.
Thou.

Dol.

$ Bil.

Second Quarter
Mil.
Thou.

Dol.

A. What was this firm's revenue in third
and second quarters of 2012? . . . . .
B. Does the revenue reported in

5

A represent book figure(s) or estimate(s)?

21920038

Book figures
Estimates

CONTINUE ON PAGE 4

Form QSS-6(E)
6

Page 4

(DRAFT)

SOURCE OF REVENUE
Loan fees - Defined to include origination fees, participation fees, and other fees associated with loans to
consumers, secured and unsecured, such as vehicle loans, boat loans, student loans, unsecured lines of credit,
personal loans, and overdraft protection (except residential mortgage loans or home equity). Excluding interest
income.
Other fees - Defined to include fees associate with services that provide a revolving line of credit to holders
of credit cards, such as annual fess and penalty fees (i.e., late charges and other over-limit fees); also include
service charges on general purpose deposit account related products, such as ATM charges and other electronic
transaction fees, per-check fees, NSF or overdraft fees, and other deposit account service fees; inquiry and
research fees; stop payment fees; early withdrawal penalties and fees; money order fees; travelers' check fees;
remittance fees; and cashier's and certified check fees. Excluding interest income.
Individual - Refers to a person or household spending, investing, or saving their own money on their own behalf.
All money managers in any form (such as fund managers or investment advisors) or investment funds should be
treated as businesses.
How much of the revenue reported in 5 A
was received from the following sources
of revenue in third and second quarters
of 2012?

Third Quarter
Mil.
Thou.

$ Bil.

INTEREST INCOME

Dol.

$ Bil.

Second Quarter
Mil.
Thou.

Dol.

A. Gross interest income . . . . . . . . .
NON-INTEREST INCOME
B. Loan fees and other fees income from
individuals . . . . . . . . . . . . . . .
C. Loan fees and other fees income from
business and government . . . . . . .
D. All other non-interest income . . . . .
TOTAL
E. Verify Total
Sum of 6 A- 6 D. Total must equal

5

A.

7

Not Applicable.

8

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

9

CONTACT INFORMATION
Name of person to contact regarding this report (Please print)

21920046

Area code
Telephone

Number

-

Title

Extension

Area code
Fax

Number

-

Website

THANK YOU
for completing your QUARTERLY SERVICES SURVEY.
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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 06070907, U.S. Census Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments to Paperwork@census.gov; use "Paperwork
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