QSS-4fE Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 09/30/2018
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4fE

(04-14-2017)

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Due Date

Need help or have questions?
Call 1-800-772-7851
(8:30 a.m. - 5:00 p.m. ET, M-F)
or Visit
https://econhelp.census.gov/qss

Title 13 United States Code (U.S.C.),
Sections 131 and 182, authorizes the
Census Bureau to conduct this collection.
The U.S. Census Bureau is required by
Section 9 of the same law to keep your
information confidential and can use
your responses only to produce statistics.
The Census Bureau is not permitted
to publicly release your responses in a
way that could identify your business,
organization, or institution. Per the
Federal Cybersecurity Enhancement Act
of 2015, your data are protected from
cybersecurity risks through screening of
the systems that transmit your data.
This collection has been approved by
the Office of Management and Budget
(OMB). The eight-digit OMB approval
number is 0607-0907 and appears at
the upper right of this page. Without
this approval, we could not conduct this
survey.

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

Return via Internet:
https://econhelp.census.gov/qss

Return via Fax:
1-800-447-4613

To view Survey Results:
https://www.census.gov/services

Username:
Password:

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.

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

IN

21964010

• 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
1 030280456
• If a figure is $1,030,280,456 it should be reported as

We estimate this survey will take an average of 10 minutes to complete. More information about this estimate and an address where you may
write with comments is on the back of this form.

CONTINUE ON PAGE 2

Form QSS-4fE
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(04-14-2017)

SURVEY COVERAGE

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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 the
Yes

No - Go to

4

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

Acquisition
Merger
Sale

Day

8

.

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

IN

21964028

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-4fE
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REPORTING PERIOD
What time period is covered by the data provided in this report?
Beginning Date
Month

Day

Year

Month

End Date
Day
Year

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Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

5

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 (NOT 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)
• Dues and assessments from members and affiliates

EXCLUDE
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from 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
• Revenue from customers for carrying or other credit
charges
• Commissions from vending machine operators
• Revenue from the sale of used equipment

$ Bil.

A. What was this firm's revenue in the
B. Does the revenue reported in

5

Mil.

Thou.

Dol.

. . . . . . .

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

IN

21964036

Book figures

6 and 7

Estimates

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-4fE

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

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CONTACT INFORMATION

IN

21964044

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

Telephone

Area code

Number

-

Title

Extension

Area code

Fax

Number

-

Website

THANK YOU
for completing your QUARTERLY SERVICES SURVEY.
We suggest you keep a copy for your records.
We estimate this survey will take an average of 10 minutes to complete, 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 voluntary collection of information, including suggestions for reducing this burden, to: EID Survey Comments 0607-0907, U.S. Census Bureau, 4600 Silver
Hill Road, Room EID-8K175, Washington, DC 20233. You may email comments to sssd.qss@census.gov. Be sure to use "EID Survey Comments 0607-0907" as the
subject.