HC-62401 Prototype Standard Mixed Form

Attachment D-2
2007 Economic Census

Professional, Scientific, and Technical Services; Management of Companies and
Enterprises; Educational Services; Health Care and Social Assistance; Arts,
Entertainment, and Recreation; and Other Services (Except Public Administration)
Sectors

Prototype Standard Mixed Form

R

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U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

2007 ECONOMIC CENSUS
Services for Children and Youth

FORM

HC-62401

OMB No. : Approval Expires

(DRAFT)

DUE DATE
FEBRUARY 12, 2008
HC-62401

Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47134-0001

MIXED PROTOTYPE

Please read the accompanying
information sheet(s) before
answering the questions.
Need help or have questions
about filling out this form?
Visit our Web site at
www.census.gov/econhelp
Call 1-800-233-6136, between
8:00 a.m. and 8:00 p.m., Eastern
time, Monday through Friday.
- OR Write to the address above.
Include your 11-digit Census File
Number (CFN) printed in the
mailing address.

(Please correct any errors in this mailing address.)

YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, requires businesses and other organizations
that receive this questionnaire to answer the questions and return the report to the U.S. Census Bureau. By the same
law, YOUR CENSUS REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality
of Census Bureau information and may be used only for statistical purposes. Further, copies retained in respondents'
files are immune from legal process.
• Use blue or black ink.
• Do not use pencil.
• Place an "X" inside the box.

• Please center numbers in their respective boxes.
• Do not put slashes through 0 or 7.

Examples:

0 1 2 3 4 5 6 7 8 9

The reporting unit for this form is an establishment. An establishment is generally a single physical location
where business is conducted or where services or industrial operations are performed. For further clarification, see
information sheet(s).
EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) shown in the mailing address the same as the one used for this
establishment on its latest 2007 Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return?
0021

2

Yes - Go to

2

No - Enter current EIN (9 digits)

0022

-

0025

PHYSICAL LOCATION
A. Is this establishment's physical location the same as shown in the mailing address?
(P.O. box and rural route addresses are not physical locations.)
0031

0032

Yes - Go to line B

No - Enter
physical
location

0035

Number and street

0036

City, town, village, etc.

0037

State

0038

ZIP Code

B. Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
(Mark "X" only ONE box.)
0041

Yes

0042

No

0043

No legal boundaries

0044

Do not know

C. In what type of municipality is this establishment physically located? (Mark "X" only ONE box.)
0229

City, village, or borough

PENALTY FOR FAILURE TO REPORT

USCENSUSBUREAU

0230

Town or township

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0231

Other

0232

Do not know

CONTINUE ON PAGE 2

62401013

1

Form HC-62401
3

Page 2

(DRAFT)

OPERATIONAL STATUS
Which ONE of the following best describes this establishment's operational status at the end of 2007?
(Mark "X" only ONE box.)
0011

In operation

0013

Temporarily or seasonally inactive

0014

Ceased operation - Give date at right

Month

Day

Year

0018
0015

Sold or leased to another operator - Give date at right AND enter
name and address of new owner or operator and Employer
Identification Number (EIN) below
0060

Name of new owner or operator

0061

EIN (9 digits)

0062

Mailing address (Number and street, P.O. Box, etc.)

0063

City, town, village, etc.

0064

State

0065

ZIP Code

4

Mark "X" 2007
if None Number

MONTHS IN OPERATION
Number of months in operation during 2007 (If none, mark "X" and go to 30 .) . . . . . . . . . . . .

HOW TO
REPORT
DOLLAR
FIGURES

5

Mark "X"
if None $ Bil.

Dollar figures should be rounded to
thousands of dollars.
If a figure is $1,025,628.79:

Report

If a value is "0" (or less than $500.00):

Report

0002

2007
Mil.

Thou.

Dol.

1 0 2 6

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
A. Tax Status
1. Is this establishment operated on a not-for-profit basis?
0106

Yes - Go to line A2

0107

No - Complete line B

2. Was all or part of the income of this establishment or organization exempt from Federal income taxes under
section 501 of the Internal Revenue Code?
0103

Yes - Complete line C

0104

Mark "X"
if None $ Bil.

No - Complete line B

B. Operating receipts of this (taxable) establishment . . . . . . . . . .

2007
Mil.

Thou.

Dol.

0100

6

1. Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0101

2. Expenses (Include payroll. Exclude contributions, gifts, and grants
paid.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0140

62401021

C. Revenue and expenses of this (tax-exempt) establishment

Not Applicable.

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Form HC-62401

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
7

EMPLOYMENT AND PAYROLL
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) shown in the mailing address or corrected in 1 .
Exclude:
• Temporary staffing obtained from a staffing service.
• Contractors, subcontractors, or independent contractors.
• Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN.
• Purchased or managed services, such as janitorial, guard, or landscape services.
• Professional or technical services purchased from another firm, such as software
consulting, computer programming, engineering, or accounting services.
2007
Number

Mark "X"
if None

For further clarification, see information sheet(s).
A. Number of employees for pay period including March 12 . . . . . . . . . . . . . .

0320

Mark "X"
if None $ Bil.

B. Payroll before deductions (Exclude employer's cost for fringe benefits.)
1. Annual payroll . . . . . . . . . . . . . . . . . . . . . . . . . .

0300

2. First quarter payroll (January-March, 2007). . . . . . . . . . . . . .

0310

2007
Mil.

Thou.

Dol.

8 – 18 Not Applicable.
19 KIND OF BUSINESS OR ACTIVITY
Principal kind of business or activity in 2007
(Mark "X" only ONE box.)

624 410 00 1

Child day care services, including those with preschool

624 410 00 2

Preschool

624 410 00 3

Before and/or after school care program

624 120 00 B

Childcare or preschool for the developmentally or physically disabled

624 410 00 4

Babysitting service

624 410 00 5

Head start programs

611 110 00 1

Elementary or secondary schools

611 691 00 2

Tutoring services or academic skills learning centers

Child or youth counseling, mentoring, intervention, and therapy services
621 330 00 2

Counseling or therapy service provided by mental health practitioners, excluding services
provided by physicians (Include counseling by psychologists, psychiatric social workers, clinical
psychologists, psychotherapists, etc.)

621 410 00 2

Teen pregnancy counseling service or clinic

624 110 00 1

Other nonmedical social assistance counseling service

624 110 00 2

Mentoring program
CONTINUE WITH

19

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62401039

Childcare and selected educational services
0700

Form HC-62401

Page 4

(DRAFT)

19 KIND OF BUSINESS OR ACTIVITY - Continued
Child or youth counseling, mentoring, intervention, and therapy services - Continued
0700

624 120 00 8

Child early intervention center or service (providing services to children with disabilities or
special needs)

621 340 10 1

Speech therapist(s) and/or audiologist(s)

621 340 20 5

Occupational therapist(s)

621 340 20 1

Physical therapist(s)

777 624 01 1

Other child or youth counseling or therapy service - Specify

0701

Child or youth placement and residential care services
624 110 00 3

Adoption and/or foster care placement service

623 990 00 1

Children's home, group foster home, or orphanage

624 221 00 2

Child abuse shelter, including child crisis stabilization centers

624 221 00 3

Center for runaway youth

623 990 00 2

Juvenile correctional center or home

623 210 00 2

Mental retardation facility, including group homes and intermediate care facilities providing
residential care for the mentally retarded

623 220 00 1

Residential alcohol or substance abuse rehabilitation facility, excluding nursing care facilities

623 220 00 2

Residential facility for the mentally ill, excluding facilities for the mentally retarded

777 624 01 2

Other child or youth residential care facility - Specify

0701

713 940 90 3

Youth recreational center

624 110 00 4

Youth center (not primarily providing recreational services)

713 990 80 3

Day camps, excluding instructional camps

777 624 01 3

Instructional day camp, providing instruction in academics, the arts, sports, and other
disciplines - Specify type of instructional program

813 410 30 1

Scouting and related youth development membership organizations developing life, leadership,
or business skills

713 990 80 5

Youth sports club or program, including after-school programs

777 624 01 4

All other youth membership, sports, and recreation programs - Specify

0701

0701

CONTINUE WITH

19

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62401047

Youth centers, day camps, and selected membership, sports, and recreation programs

Form HC-62401

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS OR ACTIVITY - Continued
Case management and other social assistance services for children and youth
0700

624 120 00 A

Social work case management services primarily to the disabled, mentally retarded, or mentally
ill

624 110 00 5

Social work case management services for children without disability or mental illness

624 110 00 6

Multi-service organization providing a range of social assistance services to children and youth

624 110 00 7

Court-appointed advocate service, providing services to abused and neglected children in the
juvenile court system

624 110 00 8

Teen outreach program

624 110 00 9

Youth drug and/or alcohol abuse prevention program

624 110 00 A

Youth smoking prevention program

624 110 00 B

Youth HIV/AIDS prevention program

624 210 00 2

Child care food program

624 310 00 2

Job placement, training, or counseling program, including sheltered workshops

777 620 00 4

Other social assistance services primarily for children or youth - Specify

0701

Services for the elderly, mentally retarded, and disabled
624 120 00 1

Adult activity or day care center

624 120 00 2

Agency for the aging

777 620 00 5

Other social assistance services primarily for the elderly, mentally retarded, or disabled Specify

0701

Other individual and family services
Community action agency

624 190 00 2

Family service agency

624 190 00 3

Other multi-service organization providing a range of social assistance services to families and
individuals, excluding services primarily to children, the elderly, the disabled, the mentally
retarded, or the mentally ill

777 620 00 6

Other individual and family social assistance services - Specify

62401054

624 190 00 1

0701

CONTINUE WITH

19

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Form HC-62401

Page 6

(DRAFT)

19 KIND OF BUSINESS OR ACTIVITY - Continued
Grantmaking, giving, advocacy, and all other activities
0700

777 620 00 7

Grantmaking or giving organization not directly providing social services - Specify

777 620 00 8

Advocacy group - Specify cause or belief promoted

777 620 00 9

Other social assistance service - Specify

773 000 00 3

Other kind of activity or facility - Specify

0701

0701

0701

0701

20 – 21 Not Applicable.
22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
(Report receipts or revenue by source (reported in 5 ) in dollar figures. See HOW TO REPORT DOLLAR FIGURES on
page 2. Do not combine data for two or more receipts or revenue lines. Both taxable and tax-exempt establishments
should complete all applicable lines.)
Line 1 - Report payments from providing social assistance (e.g., child care, counseling, community food, temporary
shelter, relief, vocational rehabilitation) and related services to individuals and families. Report receipts from health
and residential care on the appropriate lines.
Line 2a - Report payments for care to the mentally retarded provided in a facility (or portion of a facility) certified to
receive Medicaid reimbursement as an Intermediate Care Facility for the Mentally Retarded (ICF/MR).
Line 2c - Report payments for residential care to youth, the elderly, or the disabled, excluding care provided in an
Intermediate Care Facility for the Mentally Retarded, hospice, or nursing home.
Line 2e - Continuing care retirement communities should report receipts from entrance fees here.
Line 11 - Report investment income, including interest and dividends. Report proceeds from the sale of investments
and other assets on line 12.
Line 12 - Report the net gain (or loss) from the sale or trade of real property and financial assets such as stocks and
bonds.
Line 13 - Report revenues from sources not separately identified on other lines.
2007
Description of sales, shipments, receipts, or revenue

Census
use

Estimates are acceptable
$ Bil.

0723

Mil.

Thou.

Dol.

0721

Payments for child care, counseling, community food, temporary shelter,
vocational rehabilitation, and related social assistance services provided to
individuals and families
a. Government payers
b. Private payers

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30391

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30392

c. Sum lines 1a and 1b

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CONTINUE WITH

22

62401062

1.

0720

30390

ON PAGE 7

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Form HC-62401

Page 7

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE - Continued
2007
Census
use

Description of sales, shipments, receipts, or revenue

Estimates are acceptable
$ Bil.

0723

2.

0720

Mil.

Thou.

Dol.

0721

Inpatient and residential services
a. Intermediate care for the mentally retarded . . . . . . . . . . . . . . . . . . . . . .

30320

b. Inpatient hospice care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30280

c. Residential care - no health care services provided

. . . . . . . . . . . . . . . . .

30380

d. Nursing home service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30310

e. Continuing care retirement community entrance fee payments

30370

. . . . . . . . . .

3.

Home health care services, excluding services performed by physicians

4.

Home hospice care

5.

Membership dues

. . . . . .

30260

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30270

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30400

6.

Sales of food and beverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39200

7.

Sales of other merchandise

39012

8.

All other operating receipts - Specify if more than 10 percent of total receipts or
revenue

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39506

9.

OPERATING RECEIPTS - For taxable establishments, sum of preceding
lines should equal 5 , line B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39690

a. Government

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39700

b. Private, including individuals, community efforts, and commissioned
fundraisers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39710

11. Investment income, including interest and dividends

. . . . . . . . . . . . . . . . . .

39720

12. Gains (losses) from assets sold (Report losses by including a dash prior to the
dollar amount.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39730

62401070

10. Contributions, gifts, and grants

13. All other revenue - Specify if more than 10 percent of total receipts or revenue

39906

14. TOTAL REVENUE - For tax-exempt establishments, sum of lines should
equal 5 , line C1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39990

23 – 25 Not Applicable.

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Form HC-62401

Page 8

(DRAFT)

26 SPECIAL INQUIRIES
A. GRANTS, SIMILAR PAYMENTS, AND TRANSFERRED CONTRIBUTIONS OF TAX-EXEMPT ESTABLISHMENTS
(To be completed only by those indicating "Yes" in 5 , line A2)
1. During 2007, did this establishment do any of the following:
• award grants
• make gifts or contributions
• make payments to, or on behalf of, specific individuals
• provide benefits for its members or dependents (except employment-related benefits)
• pay assessments (dues) to the parent or other chapters of the same organization
• transfer funds raised by this establishment to charities or other organizations for charitable purposes?
3511

Yes - Go to line 2

3512

No - Go to

2007

?

$ Bil.

2. Amount of grants, similar payments, and transferred funds . . . . . . . . .

Mil.

Thou.

Dol.

3515

B. SOCIAL ASSISTANCE
Estimate the percent of receipts for social assistance services reported in
the following payers:

22 ,

2007
Percent

lines 1 through 8, from

1. Government payers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0000

%

2. Private payers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0000

%

3. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0000

1 0 0 %

27 – 29 Not Applicable.
REMARKS (Please use this space for any explanations that may be essential in understanding your reported data.)

30 CERTIFICATION - This report is substantially accurate and was prepared in accordance with the instructions.

Yes

No - Enter time period covered

Month

Name of person to contact regarding this report

Area code
Telephone

Year

Month

FROM

Year

TO

62401088

Is the time period covered by this report a calendar year?

Title

Number

Extension

Area code

Number

Fax

-

Internet e-mail address

Date
completed

Month

Day

Thank you for completing your 2007 ECONOMIC CENSUS form.
PLEASE PHOTOCOPY THIS FORM FOR YOUR RECORDS AND RETURN THE ORIGINAL.
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on 22-May-2006 at 01:28 PM

Year