Form MA-3000 Manufacturers' Unfilled Orders Survey

Appendix A
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
FORM

MANUFACTURERS’ UNFILLED ORDERS SURVEY

MA-3000
OMB No. 0607-0561: Approval Expires 04/30/2016

(08-28-2015) Draft 4

Please correct errors in name, address, and ZIP code. ENTER street and number if not shown.

DUE DATE:

Report by mail:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
OR

https://
econhelp.census.gov/ufo

Report electronically:

User ID:

Password:

Need help or have questions
about completing this form?
Call: (301) 763-1779
YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, Sections 131 and 182 authorizes this collection. Sections 224 and 225 requires
businesses and other organizations that receive this form to answer the questions and return the report to the U.S. Census Bureau. By Section 9 of the same
law, YOUR U.S. CENSUS BUREAU REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality of U.S. Census Bureau
information and may be used only for statistical purposes. Further, copies retained in respondents’ files are immune from legal process.
Name of person to be contacted regarding this report (Please print or type)

Area Code

Number

Title

Email

Extension

Area Code

Telephone

Number

Fax

IMPORTANT - Please read the instructions included with this form, then complete the survey below.
Provide company name (sold or acquired), address, and EIN (if applicable) below.
For additional entries, go to "Remarks".

CHANGE IN OPERATIONAL STATUS

➤

Ceased operations
Sold to another company

Period covered by data (if other than calendar year)
2015
2014
Year
Month Day
Month Day

– Provide company name (sold or acquired), address, and
EIN (if applicable) at right

Acquired another company

FROM

– Provide company name and address at right

Day

Year

Month

DATE OF OPERATIONAL
STATUS CHANGE:
Selected In-Scope Manufacturing Activities
(See Instructions and Activities List)
U.S. MANUFACTURING ONLY
(a)

Line
No.
Code

Day

Description

Month

Year

TO

Day

Year

TO

Annual Sales
2015
(in thousands
of dollars)
(b)

Unfilled Orders
(Order Backlog) as
of Dec. 31, 2015
(in thousands
of dollars)
(c)

Annual Sales
2014
(in thousands
of dollars)
(d)

1
2
3
4

Please continue on the reverse side for additional manufacturing activities and/or remarks.

Unfilled Orders
(Order Backlog) as
of Dec. 31, 2014
(in thousands
of dollars)
(e)

30006019

§?!]4¤

Month

Year

FROM

2
Selected In-Scope Manufacturing Activities
(See Instructions and Activities List)
U.S. MANUFACTURING ONLY

Line
No.

(a)
Code

Description

Annual Sales
2015
(in thousands
of dollars)
(b)

Unfilled Orders
(Order Backlog) as
of Dec. 31, 2015
(in thousands
of dollars)
(c)

Annual Sales
2014
(in thousands
of dollars)
(d)

Unfilled Orders
(Order Backlog) as
of Dec. 31, 2014
(in thousands
of dollars)
(e)

5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

30006027

§?!]<¤

Remarks

CERTIFICATION - This report is substantially accurate and was prepared in accordance with the instructions.
Signature of authorized person

Date

BURDEN HOUR ESTIMATE: Public reporting burden for this collection of information is estimated to be approximately one hour per response for
multi-divisional companies and fifteen minutes for single divisional companies, 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: ECON Survey Comments 0607-0561,
U.S. Census Bureau, 4600 Silver Hill Road, Room EMD-8K122, Washington, DC 20233. You may e-mail comments to
ECON.Survey.Comments@census.gov. Be sure to use ECON Survey Comments 0607-0561 as the subject.
You are not required to respond to this collection of information if it does not display a valid approval number from the Office of Management and
Budget (OMB). The eight-digit OMB number is 0607-0561 and appears in the upper right corner of the first page of this report form.

Form MA-3000

(08-28-2015)