SA-623TA Service Annual Survey

OMB No. 0607-0422: Approval Expires 12/31/2006

2005 Annual Services Report
Service Annual Survey

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Nursing and Residential Care Facilities

FORM

SA-623TA

136
623312

SAS_H
T

REPORT DUE

Any questions call 1–800–772–7851
M–F, 8:30 a.m. to 5:00 p.m. EST.
Please correct any error in the name, address, or ZIP Code.

YOUR RESPONSE IS REQUIRED BY LAW
Title 13, U.S. Code, requires businesses and other organizations that receive this questionnaire to answer the
questions and return the report to the Census Bureau.

YOUR RESPONSE IS CONFIDENTIAL BY LAW
Title 13, U.S. Code, requires that your response may be seen only by persons sworn to uphold the confidentiality of Census
Bureau information and may be used only for statistical purposes. The law also provides that copies retained in your files are
immune from legal process.

YOUR RESPONSE IS IMPORTANT
The services industries account for nearly 70 percent of all economic activity. We conduct this survey to obtain timely,
comprehensive and consistent measures needed by policy-makers, businesses, and the public to accurately assess domestic
economic performance.

FORM asr_a_05 (1-13-2006)

USCENSUSBUREAU

Page 2

Annual Services Report
•
•

This report should be completed and returned on or before the due date in the preaddressed envelope provided.
If filing within the required time frame will cause an undue burden and you would like an extension, or if you have any questions, please write to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
or call a Census Bureau Representative at 1–800–772–7851, weekdays from 8:30 a.m. to 5:00 p.m., eastern standard time.

1

Report Coverage
This report covers all domestic locations operated by your company and its subsidiaries primarily engaged in
providing residential and personal care services (i.e., without on-site nursing care facilities) for the
elderly or other persons who are unable to fully care for themselves and/or the elderly or other persons who
do not wish to live independently. The care typically includes room, board, supervision, and assistance in
daily living, such as housekeeping services.

Does the above coverage describe this firm’s business activity?

0001

1
2

Yes – Go to 3
No – Specify the firm’s business activity and complete the report where applicable beginning with 3 .
0002

2 Not Applicable
3 Report Periods
11
What periods of time will this data represent?
• Report data for the 2005 and 2004 calendar years if possible.
• For locations that were sold or acquired during a year, only report for the periods that this firm operated the locations.
2005
Month

Day

2004
Year

Month

0007
1

2005 and 2004 calendar years – Go to 4

2

Other than calendar years – Enter the periods this report will cover. . .
0008
(e.g., fiscal years, periods with less than a full calendar
year).
To

0006

FORM asr_b1_05 (11-23-2005)

From

From

To

Day

Year

Page 3

4 Operating Revenue
Report the total operating revenue for this firm’s locations defined in 1 for the following categories.
• Enter "0" where applicable.
• Estimates are acceptable.
Exclude:
• Transfers made within the company.
2005 Operating Revenue
Bil.
Mil.
Thou.
Dol.

2004 Operating Revenue
Bil.
Mil.
Thou.
Dol.

1800

1. TOTAL OPERATING REVENUE

FORM asr_62_c_05 (8-29-2005)

..................... $

$

Page 4

5 Sources of Funding
Report the percentage of total revenue reported in 4 from the sources listed.
• Enter "0" where applicable.
• Estimates are acceptable.
• Report whole percents.
Exclude:
• Transfers made within the company.
Note – The sum of lines 1 through 8 should equal 100%.
Sources of Funding

Patient Care Revenue

2004

2005
4001

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

%

%

4002
2. Medicaid – Include funding from the State Children’s Health Insurance
Program (SCHIP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

%

%

%

4. Worker’s compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

%

5. Private insurance
a. Private health insurance – Medical service plans (Blue Cross/Blue
Shield, group hospital plans, etc.) Include third party direct contract
4005
insurers, employer self-insured, and Medicare/Medicaid HMO
payments. Report worker’s compensation sources in line 4. . . . . . . . . . . . . . . . . . . . . . .

%

%

%

%

%

%

%

%

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

%

%

8. All other sources – Include grants, subsidized funds, contributions,
4009
philanthropy, gift shop, cafeteria sales, parking lot receipts, florist
receipts, etc. – Specify
.............................................

%

%

1. Medicare

4003

3. Other government (Veterans, NIH, Indian Affairs, etc.) – Specify

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

1501

4004

4006

b. Property/Casual and auto insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Patient (out-of-pocket)
4071

a. Payment from patients and their families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4072

b. Patients’ assigned Social Security benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4008

7. All other patient care sources not elsewhere classified – Specify
1502

Non-Patient Care Revenue

1503

9. TOTAL – Sum of lines 1–8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FORM asr_623_d_05 (10-18-2005)

100%

100%

Page 5

6 Operating Expenses
Report operating expenses for this firm’s locations as defined in 1 for the following categories.
• Enter "0" where applicable.
• Estimates are acceptable.
Exclude:
• Transfers made within the company
• Capitalized expenses
• Interest
• Bad debt
• Impairment
• Income tax

Personnel Costs

2005 Operating Expenses
Mil.
Thou.
Dol.

2004 Operating Expenses
Bil.
Mil.
Thou.
Dol.

Bil.
1. Gross annual payroll – Total annual Medicare salaries and
1821
wages for all employees as reported on your firm’s IRS
Form 941, Employer’s Quarterly Federal Tax Return, line 5(c)
for the four quarters that correspond to the survey period. . . . . . $

$

2. Employer’s cost for fringe benefits – Employer’s
cost for legally required programs and programs not required
by law. Include insurance premiums for hospital plans, medical
plans, and single service plans (e.g., dental, vision, prescription
drugs); premium equivalents for self-insured plans and fees paid
to third-party administrators (TPAs); defined benefit pension
plans; and defined contribution plans (e.g., profit sharing, 401K
and stock option plans); and other fringe benefits (e.g., Social
Security, workers’ compensation insurance, unemployment tax, 1822
state disability insurance programs, life insurance benefits,
Medicare). Do not include employee contributions. . . . . . . . . . . $

$

3. Temporary staff and leased employee expense – Total costs
1823
paid to Professional Employer Organizations (PEOs) and
staffing agencies for personnel. Include all charges for payroll,
benefits and services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

Expensed Materials, Parts and Supplies (not for resale)
4011

4. Medical supplies – Materials and supplies used in providing
medical services to others. Report medical equipment in line 5 . . . . . $

$

5. Expensed equipment – Expensed computer hardware and
other equipment (e.g., copiers, fax machines, telephones, shop
1824
and lab equipment, CPUs, and monitors). Report packaged
software in line 7. Report leased and rented equipment in
line 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

6. Expensed purchases of other materials, parts, and
supplies – Materials and supplies used in providing services
1825
to others; materials and parts used in repairs; office and
janitorial supplies; small tools; containers and other packaging
materials; and motor fuels. . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

Expensed Purchased Services
7. Expensed purchases of software – Purchases of prepackaged,
custom coded, or vendor customized software. Include software
developed or customized by others, web-design services and 1826
purchases, licensing agreements, upgrades of software; and
maintenance fees related to software upgrades and alterations. . . $

$

8. Purchased electricity and fuels (except motor fuels) – If
1827
the cost of electricity and heating fuels (e.g., natural gas,
propane, oil, coal) are included in lease or rental payments,
report in line 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

9. Lease and rental payments – For land, buildings, offices,
structures, machinery, equipment, and other tangible items.
Include lease and rental of transportation equipment without
operators; and penalties incurred for broken leases. Exclude 1828
capital and financing lease agreements and licensing/leasing
of software. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

FORM asr_62_g1_05 (10-11-2005)

Page 6

6 Operating Expenses – (Continued)
Report operating expenses for this firm’s locations as defined in 1 for the following categories.
• Enter "0" where applicable.
• Estimates are acceptable.
Exclude:
• Transfers made within the company
• Capitalized expenses
• Interest
• Bad debt
• Impairment
• Income tax

Expensed Purchased Services – (Continued)
10. Purchased repair and maintenance – Include expensed
repair and maintenance to buildings and integral building
components (e.g., elevators, heating and cooling systems),
2005 Operating Expenses
structures, offices, machinery, vehicles, equipment, and
Bil.
Mil.
Thou.
Dol.
computer hardware. Exclude materials, parts, and supplies
1829
used for repair and maintenance performed by this firm’s
employees. Report janitorial and grounds maintenance
services in line 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

2004 Operating Expenses
Bil.
Mil.
Thou.
Dol.

$

1830

11. Purchased advertising and promotional services – Include
marketing and public relations services. . . . . . . . . . . . . . . . . . . $

$

4010
12. Professional liability insurance – The cost of professional
liability insurance. Include professional liability insurance
premiums and amounts set aside for self-insurance. . . . . . . . . . . $

$

Other Operating Expenses
13. Depreciation and amortization charges – Include depreciation
charges taken against tangible assets owned and used by your
firm, tangible assets and improvements owned by your firm
1831
within leaseholds, tangible assets obtained through capital
lease agreements, and amortization charges against intangible
assets (e.g., patents, copyrights). Exclude impairment. . . . . . . . . $

$

14. Governmental taxes and license fees – Payments to
government agencies for taxes and licenses. Include business 1832
and property taxes. Exclude income taxes, and sales and
excise taxes collected from customers. . . . . . . . . . . . . . . . . . . . $

$

15. All other operating expenses – Report all other operating
expenses not reported above, unless specifically excluded in
1899
the general instructions at the top of the page. Exclude
purchases of merchandise for resale and non-operating
expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

1900

16. TOTAL OPERATING EXPENSES – Sum of lines 1–15 . . . . . . . $

7 Not Applicable

FORM asr_62_g2_05 (1-11-2006)

$

Page 7

8 E-Commerce Revenue
E-commerce includes sales and receipts from any transaction completed over an Internet, extranet, EDI network,
electronic mail or other online system. Transactions are agreements between buyers and sellers to transfer ownership
of, or rights to use, goods or services. Payment for these goods and services may or may not be made online.
Include:
• Revenue from online orders for goods or services placed by a buyer.
• Commissions or fees from trading of securities or the sale of other financial products online (insurance, loans, etc.).
• Commissions or fees from selling or facilitating the sale of third party products through your company’s website.
• Commissions or fees from use of computerized reservation systems, financial transaction processing systems, etc.
• Revenue from orders or contracts negotiated online with a buyer and seller on the price and terms for transferring
ownership or the rights to use goods or services.
• Revenue from telephone transactions using interactive voice response systems.
Exclude:
• Online billings where the order or contract was not negotiated online.
• Delivery of services online where the order or contract was not negotiated online.
• Provision of telecommunications systems and related infrastructure systems where the order or contract
for such services was not negotiated online.
• Orders for goods or services placed by fax or over switched telephone network.
• Online advertising.

Did the revenue reported in 4 include any e-commerce
revenue?
1
0011
2

2005 E-Commerce Revenue
Bil.
Mil.
Thou.
Dol.
2000

Yes – What was this firm’s e-commerce revenue? . . . . . $
No – Go to 11

$
Month
0010

When did this firm begin e-commerce sales?. . . . . . . . . . . . . . . .

9 Not Applicable
10 Not Applicable

FORM asr_e_05 (10-12-2005)

2004 E-Commerce Revenue
Bil.
Mil.
Thou.
Dol.

Year

Page 8

11 Ownership or Control
Does another firm own more than 50 percent of the voting stock or have the power to control the management and
policies of this company?
0014

0013

1
2

Name of owning or controlling company

Yes – Provide this firm’s information. . . . .
0015
No – Go to 12

–

EIN
Street address

City, State, ZIP Code

12 Acquisitions or Mergers
Did this company acquire or merge with another firm in 2005 or 2004?

Month

Year

0018
1

Yes – Provide the date of the merger or acquisition and the firm’s information. . . . . . . . . . .
(for multiple mergers, provide each firm’s information as an attachment to this report)

2

No – Go to 13

0016

0017 Name of company acquired or merged with

0019

–

EIN
Street address

City, State, ZIP Code

13 Remarks –

Please provide an explanation for any inconsistent or incomplete data that would aid in understanding this report.
For any separate correspondence pertaining to this report, please include the identification number shown in the
address label area at the top of the first page.

0027

14 Certification – This report is substantially accurate and has been prepared in accordance with the instructions.
0020 Name of person completing this report – Please print

0024 Title

0025 Date

0021 Address (Street address, City, State, ZIP Code)

0022 Telephone number
Area code
Number

Return Completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
or fax to: 1–800–447–4613

Extension

0023 Fax number
Area code
Number

0026 E-mail address
Extension

Public reporting burden for this collection of information is estimated to average 3.5 hours per response, 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: Paperwork Project 0607-0422, U.S. Census Bureau, 4700
Silver Hill Road, Stop 1500, Washington, DC 20233-1500. You may e-mail comments to [email protected]; use
"Paperwork Project 0607-0422" as the subject. Please include form name and number in all correspondence. Respondents
are not required to respond to any information collection unless it displays a valid approval number from the Office of
Management and Budget. This 8-digit number appears in the top right corner on the front of this form.

To see aggregate industry results of previous Service Annual Surveys, go to the following website: www.census.gov/econ/www/servmenu.html
FORM asr_z_05 (1-11-2006)

2005 Annual Services Report
Instructions for Taxable Firms

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

General Instructions
•

Report data on an accrual basis, except for payroll.

•

Dollars should be rounded to the nearest dollar.

Bil.

•

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

1

Mil.

Thou.

Dol.

030 280 456

Include in operating revenue:

•

Report gross billings, except where noted elsewhere on the form.

•

Amounts received for work subcontracted to others.

•

For locations that were sold or acquired during a year, only report for the periods that this firm operated the locations.

•

Revenue from services performed by domestic locations of foreign parent firms, subsidiaries, branches, etc.

•

Dues and assessments from members and affiliates.

Exclude from operating revenue:

•

Taxes collected directly from customers or clients and paid directly to a local, state, or federal tax agency.

•

Rents from and revenue of separately operated departments, concessions, etc., which are leased to others.

•

Commissions from vending machine operators.

•

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).

•

Non-operating revenue such as income from investments, sales of company-owned real estate (land and building), or other
assets, (except inventory held for resale, securities, gifts, loans, contributions, or grants).

•

Revenue from the sale of used equipment.

Item Specific Instructions
Item 6 – Operating Expenses
Line 1 – Gross annual payroll
Include salaries and wages, commissions, dismissal pay, bonuses, employee contributions to Social Security, income tax
withholding, union dues, group insurance premiums, savings bonds, cash equivalent in-kind, allowances, holiday pay,
vacation pay, sick leave, stock purchase plans, and employee contributions to pension plans. Exclude the cost of leased
employees, employer’s cost for fringe benefits, temporary staff obtained from temporary help services. For unincorporated
businesses, exclude profit or other compensation of proprietors or partners.

All other operating expenses
Include travel and entertainment; postage, shipping or delivery services, warehousing, and storage services; royalties;
security services; janitorial and grounds maintenance services; purchased transportation with operators; and other expenses
not reported elsewhere.

FORM asr_w_05 (1-11-2006)

USCENSUSBUREAU