MA-10000(L) (Works ASM Long Form (Worksheet)

Attachment A

OMB No. 0607-0449
Approval Expires: 11/30/2017

2016 Annual Survey of Manufactures (ASM)
CFN:
T

In contrast, q

appear

online reporting system

MAILING ADDRESS:
MAILING ADDRESS
The reporting unit for this questionnaire is an establishment which is generally a single physical location where
business is conducted or where services or industrial operations are performed. Please make updates to the
physical location address in the Physical Location Information section.
Attn:
Name 1:

Store/Plant:

Name 2:
Street:
City:

State:

Zip:

CFN:

EMPLOYER IDENTIFICATION NUMBER
EMPLOYER IDENTIFICATION NUMBER VALIDATION
Is
the Employer Identification Number (EIN) used on this establishment's latest 2016 Internal
Revenue Service Form 941, Employer’s Quarterly Tax Return?
Yes
No

EMPLOYER IDENTIFICATION NUMBER
EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on the latest 2016 Internal Revenue
Service Form 941, Employer’s Quarterly Tax Return?
EIN:

1

.

2016 Annual Survey of Manufactures (ASM)
CFN:

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No
OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: MORE THAN ONE LOCATION
Does your company operate at more than one physical location?
Yes
No

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2

2016 Annual Survey of Manufactures (ASM)
CFN:
OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: PERCENT OF VOTING STOCK HELD
What percent of voting stock was held by the owning or controlling company?
(Check only ONE box)
Less than 50%
50%
More than 50%

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the
owning or controlling company?
Name of owning or controlling company:
Home office address (Number and street):
City, town, village:

State:

EIN:

NUMBER OF ESTABLISHMENTS
NUMBER OF ESTABLISHMENTS
How many establishments operated under EIN at the end of 2016?
Number:

3

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:
NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00

**** Additional added establishments (if any) are listed at the end of this printout.

NUMBER OF ESTABLISHMENTS
ADDITIONAL ESTABLISHMENT INSTRUCTIONS
Consolidating Data for Added Establishments:
•

•

The sum value of Sales, Shipments, Receipts or Revenue for all locations of the EIN should also be reported as a
consolidated value in the Sales, Shipments, Rcpts/Revenue section, and also in the Details Sales, Shipments,
Rcpts/Revenue section that follows.
The sum of Employment, First Quarter Payroll, and Annual Payroll for all locations of the EIN, should also be reported
as consolidated values in the respective areas of the Employment and Payroll section that follows.

4

2016 Annual Survey of Manufactures (ASM)
CFN:

PHYSICAL LOCATION
PHYSICAL LOCATION VALIDATION

Is this establishment's physical location the same as the address shown above?
(P.O. Box and rural route addresses are not physical locations)
Yes
No
PHYSICAL LOCATION
PHYSICAL LOCATION INFORMATION
What is this establishment's physical location?
(P.O. Box and rural route addresses are not physical locations)
Number and Street:
City, town, village:

State:

PHYSICAL LOCATION
LEGAL BOUNDARY AND MUNICIPALITY
Is this establishment physically located inside the legal boundaries of the city, town, village, etc?
Yes
No
No legal boundaries
Do not know

In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

5

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:

OPERATIONAL STATUS
OPERATIONAL STATUS
Which of the following best describes this establishment’s operational status at the end of 2016?
(Check only ONE box)
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
OPERATIONAL STATUS
CEASED OPERATION DATE
When did this establishment cease operation?
MMDDYYYY:
OPERATIONAL STATUS
SOLD OPERATION DATE AND INFORMATION
When was this establishment sold or leased to another operator?
MMDDYYYY:

What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator:
Mailing address (Number and street, P.O. Box, etc.):
City, town, village:

State:

EIN:
MONTHS IN OPERATION
MONTHS IN OPERATION
How many months was this establishment in operation during 2016?
Check
if None

Number:

6

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:

ADDITIONAL REPORTING GUIDELINES
ADDITIONAL REPORTING GUIDELINES
How to Report Dollar Figures:

Check

Dollar figures should be rounded to thousands of dollars
EXAMPLE:

2016

if None

If a dollar figure is $2036.355.25

Report 

If a dollar figure is “0” (or less than $500.00):

Report 

$ 2036,000.00
X

$

,000.00

Where available, your establishment’s Prior Year data is prelisted in the 2015 column. Check these
figures and make any necessary corrections as needed. If 2015 Inventories figures are not prelisted, report these figures in
the appropriate sections as instructed.
SALES, SHIPMENTS, RECEIPTS, OR REVENUE
SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What was the total value of products shipped and other receipts?
(Report details in the DETAIL SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)
Exclude:
•

Freight charges

Check
if None

•

Excise Taxes
2015

2016
,000.00

$

$

,000.00

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
EXPORTS
What was the value of products exported?
(This is a breakout of the $
,000.00 reported in total value of products shipped and other receipts
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Include:
• Shipments to customers in the Commonwealth of Puerto Rico and U.S. possessions
• Products shipped to exporters or other wholesalers for export
• Products sold to the U.S. Government to be shipped to foreign governments
Exclude:
Check
if None

• Products shipped for further manufacture, assembly or fabrication in the U.S.
2016
$

2015
,000.00

,000.00

$

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
PRODUCTS SHIPPED FOR FURTHER MANUFACTURE
What was the market value of products shipped to other domestic plants of your company for further assembly, fabrication, or
manufacture?
(This is a breakout of the $
,000.00 reported in total value of products shipped and other receipts in
SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Check
if None

2016
$

2015
,000.00

$

,000.00

7

the

2016 Annual Survey of Manufactures (ASM)
CFN:

E-SHIPMENTS
E-SHIPMENTS

What percent of the $
,000.00 reported in total value of products shipped and other receipts, in the
SALES, SHIPMENTS, RECEIPTS, OR REVENUE area, were for goods that were ordered or whose movement was
controlled or coordinated over electronic networks? (Report whole percents. Estimates are acceptable.).
Electronic networks include:
•
• Electronic Data Interchange (EDI)
E-mail
• Internet
•
Extranet
Other online systems

•
2016

2015

.00%

.00%

EMPLOYMENT AND PAYROLL
EMPLOYMENT
Include:
• Full- and part-time employees working at this establishment whose payroll was reported on Internal
Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed under the
Employer Identification Number (EIN)
• Spread on stock options that are taxable to employees as wages.
Exclude:
• Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN.
(Report values on line A in the OTHER OPERATING EXPENSES area of the SELECTED EXPENSES section)
• Temporary staffing obtained from a staffing service.
(Report values on line A in the OTHER OPERATING EXPENSES area of the SELECTED EXPENSES section)
• Purchased professional and technical services.
(Report values on line I in the OTHER OPERATING EXPENSES area of the SELECTED EXPENSES section)
What was the number of:
A.

Production workers for the pay periods
including:

Check
if None

1. March 12
2. June 12
3. September 12
4. December 12
TOTAL Production Workers (Add lines A1 through A4)
B.

Average annual production workers
(Divide TOTAL Production Workers by 4
and round to nearest whole number)

C.

All other employees for pay period including March 12

TOTAL (Add lines B and C)

8

2016
Number

2015
Number

2016 Annual Survey of Manufactures (ASM)
CFN:
EMPLOYMENT AND PAYROLL
HOURS WORKED
What was the annual number of hours worked by the
workers reported in the EMPLOYMENT area?
Check
if None

Average annual production
2016
Hours

2015
Hours
,000

,000

EMPLOYMENT AND PAYROLL
PAYROLL
Exclude: Employer’s costs for fringe benefits
What was the annual payroll before deductions for…
A.

Production workers?

B.

Check
if None

2016

2015

$

,000.00

$

,000.00

All other employees?

$

,000.00

$

,000.00

TOTAL (Add lines A and B)

$

,000.00

$

,000.00

$

,000.00

$

,000.00

What was the first quarter payroll before
deductions (January-March 2016)?

EMPLOYMENT AND PAYROLL
EMPLOYER’S ANNUAL COST FOR FRINGE BENEFITS
(This is the employer's annual cost for legally required programs and programs not required by law).
What were the employer’s annual costs for…
A.

Health Insurance - Insurance premiums on hospitals,
medical plans, and single service plans such as dental, vision,
and prescription drug plans?
Include:
• Premium equivalents for self-insured plans and fees
paid to third-party administrators (TPAs).
Exclude:
 Employee contributions
 Disbursement from trusts or funds to
satisfy health insurance claims
Check

if None
$

9

2015

2016
,000.00 $

,000.00

2016 Annual Survey of Manufactures (ASM)
B.

1.

2.

Defined benefit pension plans - Cost for both qualified
and nonqualified defined pension plans. Plans that specify the
benefit to be paid to employees upon retirement, generally either a
specific amount or a percentage of compensation.
Employer contributions are based on actuarial computations
that include employee's compensation and years of service
and are not allocated to specific accounts maintained for
employees.

$

,000.00 $

,000.00

$

,000.00 $

,000.00

$

,000.00 $

,000.00

$

,000.00 $

,000.00

Defined contribution plans - Costs under defined
contribution plans. Pension plans that define the employer
contributions to a separate account provided for each employee.
The employee "benefit" at retirement depends on the amount
contributed and the results of the account's activity.

Examples:
•
•

•
C.

CFN:

Pension Plans:

Profit sharing plans
Money purchase (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs))

Payroll taxes, employer-paid insurance premiums, and
other employer-paid benefits
Include:

Exclude:

• Legally-required fringe benefits
• Disbursements from trusts or funds to
Examples:
satisfy health insurance claims
o Social Security
o Workers’ compensation insurance
o State disability insurance programs
o Unemployment tax
o Medicare
• Benefits for life insurance
• “Quality of life” benefits
Examples:
o
Childcare assistance
o
Subsidized commuting, etc.
• Employer contributions to pre-tax benefit accounts
(e.g. health savings account)
• Education assistance
• Other benefits not specified above

TOTAL (Add lines A, B1, B2 and C)

VALUE OF INVENTORIES
INVENTORIES
Did this establishment own inventories, regardless of where held, at the end of 2016 and/or 2015?
Yes
No

10

2016 Annual Survey of Manufactures (ASM)
CFN:

VALUE OF INVENTORIES
VALUE OF INVENTORIES
What were the value of inventories owned by this
establishment as of December 31 before Last-in,
First-out (LIFO) adjustment (if any) for…

Check
if None

End of
2016

Check
if None

End of
2015

A.

Finished goods?:

$

,000.00

$

,000.00

B.

Work-in-process?:

$

,000.00

$

,000.00

C.

Materials, supplies, fuels, etc?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through C)

INVENTORIES BY NON-LIFO VALUATION METHOD
INVENTORIES BY NON-LIFO VALUATION METHODS
Of the $
,000.00 reported in total value of
inventories owned by this establishment as of December 31,
how much is subject to the following valuation methods…

Check
if None

End of
2016

Check
if None

End of
2015

A.

First-In, First-out (FIFO):

$

,000.00

$

,000.00

B.

Average Cost:

$

,000.00

$

,000.00

C.

Standard Cost.

$

,000.00

$

,000.00

D.

Other non-LIFO valuation method(s)
Specify method: _______________

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through D)

INVENTORIES BY LIFO VALUATION METHOD
LIFO VALUATION METHOD
Did this establishment use the Last-in, First-out (LIFO) valuation method?
Yes
No

11

2016 Annual Survey of Manufactures (ASM)
CFN:

INVENTORIES BY LIFO VALUATION METHOD
INVENTORIES BY LIFO VALUATION METHOD
Of the $
,000.00 reported in total
value of inventories owned by this establishment
as of December 31, what was the…

A.

Check if
None

Amount subject to LIFO gross?
(gross LIFO amount)

End of
2016

Check if
None

End of
2015

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A and B)

$

,000.00

$

,000.00

Amount of LIFO reserve (if any)?

$

,000.00

$

,000.00

B.

Amount not subject to LIFO?
(should equal $
,000.00
TOTAL Inventories by Non-LIFO valuation method)

INVENTORIES OUTSIDE THE UNITED STATES
INVENTORIES OUTSIDE THE UNITED STATES
Of the $
,000.00 reported in total value inventories, what was the value of inventories stored or en route
OUTSIDE the 50 U.S. states and the District of Columbia for 2016?
Exclude:
• Inventory held in Foreign Trade Zones or
in bonded warehouses in the U.S.
For more detailed definitions, please see
http://enforcement.trade.gov/ftzpage/info/ftzstart.html
End of
2016

Check if
None
$

Check if
None
,000.00

End of
2015
,000.00

$

CAPITAL EXPENDITURES
CAPITAL EXPENDITURES
(Refer to the instructions on how to report leasing arrangements)
What were the capital expenditures for new and used depreciable assets spent in 2016
5 for …

A.

B.

New and used building and other structures?
Exclude:
•
Land

Check if
None

New and used machinery and equipment?

TOTAL (Add lines A and B)

12

2015

2016
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
CAPITAL EXPENDITURES
CAPITAL EXPENDITURES: MACHINERY DETAIL
What is the breakdown of expenditures for new and used machinery and equipment by type?
(This is a breakout of the $
,000.00 reported in new and used machinery and
equipment in the CAPITAL EXPENDITURES area)
Check if
None

2016

2015

A.

Automobiles, trucks, etc., for highway use?

$

,000.00

$

,000.00

B.

Computers and peripheral data processing
equipment?

$

,000.00

$

,000.00

C.

All other expenditures for machinery and
equipment?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A, B, and C)

RENTAL PAYMENTS
RENTAL PAYMENTS
Include:
• Operating leases
Exclude:
• Capital leases
(leases with a contract to own at the end of the lease).
What were the payments for
A.

B.

Rental or lease of buildings?
Include:
• Job-site trailers
• Other structures
• Land

Rental or lease of machinery and equipment?
Include:
• Construction equipment
• Tools
• Office equipment
• Furniture
• Vehicles
• Other structures

TOTAL (Add lines A and B)

Check if
None

2016

2015

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

13

2016 Annual Survey of Manufactures (ASM)
CFN:

SELECTED EXPENSES
SELECTED PRODUCTION COSTS AND ELECTRICITY
A.

What were the selected production related
costs in 2016 for
1.

Materials, parts, containers,
packaging, etc. used?

2.

Products bought and sold without
further processing?
(Report sales in code 9998991 in the DETAILS

Check if
None

2015

$

,000.00

$

,000.00

SALES, SHIPMENTS, REVENUE, RECEIPTS section)

$

,000.00

$

,000.00

3.

Purchased fuels consumed for heat,
power, or the generation of electricity?

$

,000.00

$

,000.00

4.

Purchased electricity?
(Report comparable quantity on line B1)

$

,000.00

$

,000.00

5.

Work done for you by others on your materials?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A1 through A5)

B.

2016

What was the quantity of…

Check if
None

2016
Kilowatt Hours

2015
Kilowatt Hours

1.

Purchased electricity?
(Quantity comparable to cost reported in line A4)

,000

,000

2.

Generated electricity?
(gross less generating station use)

,000

,000

3.

Electricity sold and transferred to other
establishments?
(Also include on lines B1 or B2.)

,000

,000

SELECTED EXPENSES
OTHER OPERATING EXPENSES
What were the other operating expenses paid by this
establishment in 2016 for
A.

Check if
None

Temporary staff and leased employees?
(Professional Employer Organizations and
staffing agencies for personnel)
Include all charges for: Payroll, benefits, services

$

14

2015

2016

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
B.

C.

D.

E.

F.

CFN:

Expensed equipment?
(Expensed computer hardware and other equipment)
Include:

Copiers

Fax machines

Telephones

Shop and lab equipment

CPUs

Monitors
(Report packaged software in line C)

$

,000.00

$

,000.00

Expensed purchases of software?
(Purchases of prepackaged, custom coded or vendor
customized software)
Include:
• Software developed or customized by others
• Web-design services and purchases
• Licensing agreements
• Upgrades of software
• Maintenance fees related to software upgrades
and alterations

$

,000.00

$

,000.00

Data processing and other purchased computer
services?
Include:
• Facilities management services
• Computer input preparation
• Data Storage
• Computer time rental
• Optical scanning services
• Other computer related advice and services,
including training.
Exclude:
• Expensed integrated systems
• Repair and maintenance of computer equipment
• Payroll processing and credit card transaction fees
• Expenses for telecommunication services,
(e.g., internet, connectivity, telephone.)

$

,000.00

$

,000.00

Purchased communication services?
Include:
•
Telephone, cellular, and fax services
•
Computer-related communications
(e.g., Internet, connectivity, online)
•
Other wired and wireless communication services

$

,000.00

$

,000.00

Purchased repairs and maintenance to buildings and/or
machinery and equipment?
Exclude:
•
Materials, parts, and supplies used for repairs and
maintenance performed by this firm's employees.

$

,000.00

$

,000.00

15

2016 Annual Survey of Manufactures (ASM)
CFN:
G. Water, sewer, refuse removal, and other non-electric
utility payments?
Include:
•
Cost of hazardous waste removal.
(Report electric utility payments in line A4 of the
SELECTED PRODUCTION COSTS AND ELECTRICITY
area of the SELECTED EXPENSES section)
H.

I.

J.

$

,000.00

$

,000.00

Purchased advertising and promotional services
Include:
•
Marketing and public relations services

$

,000.00

$

,000.00

Purchased professional and technical services?
Include:
•
Management consulting
•
Accounting
•
Auditing
•
Bookkeeping
•
Legal
•
Actuarial
•
Payroll processing
•
Architectural
•
Engineering
•
Other professional services
Exclude:
•
Salaries paid to your own employees
for these services

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

Governmental taxes and license fees?
(Payments to government agencies for taxes and
licenses)
Include:
•
Business and property taxes
Exclude:
•
Income taxes

K.

All other operating expenses not reported elsewhere?
Exclude:
•
Purchases of merchandise for resale
•
Nonoperating expenses
Specify :

TOTAL (Add lines A through K)

16

2016 Annual Survey of Manufactures (ASM)
CFN:
DETAIL OF SALES, SHIPM ENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?
(This is a breakout of the $
,000.00 reported in total value of products shipped and other receipts
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below :
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products below).

•

Should NOT BE COMBINED w ith other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials ow ned
by others
o Should not include the amount of products made by others for you from their ow n materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold w ithout further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in line A2 of the SELECTED PRODUCTION COSTS AND ELECTRICITY
area of the SELECTED EXPENSES section)

Code

Description

2016 Value

17

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
DETAIL OF SALES, SHIPM ENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?
(This is a breakout of the $
,000.00 reported in total value of products shipped and other receipts
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below :
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products below).

•

Should NOT BE COMBINED w ith other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials ow ned
by others
o Should not include the amount of products made by others for you from their ow n materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold w ithout further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in line A2 of the SELECTED PRODUCTION COSTS AND ELECTRICITY
area of the SELECTED EXPENSES section)

Code

Description

2016 Value

18

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
DETAIL OF SALES, SHIPM ENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?
(This is a breakout of the $
,000.00 reported in total value of products shipped and other receipts
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below :
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products below).

•

Should NOT BE COMBINED w ith other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials ow ned
by others
o Should not include the amount of products made by others for you from their ow n materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold w ithout further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in line A2 of the SELECTED PRODUCTION COSTS AND ELECTRICITY
area of the SELECTED EXPENSES section)

Code

7700000

Description

2016 Value

TOTAL

19

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
REMARKS
REMARKS
(Please use this space for any explanations that may be essential in understanding your reported data.)

CERTIFICATION
CALENDAR YEAR TIME PERIOD
Is the time period covered by this report a calendar year?
Yes
No

CERTIFICATION
TIME PERIOD COVERED
What time period does this report cover?
From:

onth

Year

To:

Year

onth

CERTIFICATION
CERTIFICATION
I certify that this report is substantially accurate and was prepared in accordance with the instructions
Name of person to contact regarding this report:

Title:

Phone Number:

Fax Number:

E-mail address:

Date Completed: MMDDYYYY

20

2016 Annual Survey of Manufactures (ASM)
CFN:

SUBMISSION CONFIRMATION
SUBMISSION CONFIRMATION

Thank you for completing the 2016 Annual Survey of Manufactures.
Please print or save this page for your records.
ID:

Company Contact Person:

Company Information:
Phone:

Your filing status will update in 2-3 business days. To check your filing status:
•
Go to econhelp.census.gov
•
Click “Self-Service Log In”
•
Enter your User ID and Password
•
Click “Log in”
•
Click “Filing Status”

21

ADDED LOCATIONS
2016 Annual Survey of Manufactures (ASM)
CFN:

NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00

2015 Annual Survey of Manufactures (ASM)

NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00