MI-21102 Natural Gas Liquid Extraction

Source: CURRENT; layout IN SYNC as of 15-Feb-2007 15:40:32
Item : Q uestionnaire M I-21102 -2007 ECO N O M IC CEN SU S :N aturalG as Liquid Extraction
M edia: PA PER /LETTER (8 1/2 X 11)
S tatus:U N LO CKED (D RA FT)
U ser: W ILSO 056
EM R : EQ CPRD /6.05.16.13.33.55
G ID S : 0.3.62.206
D ate: 15-Feb-2007 15:28:22

N o errors ☺
N o w arnings ☺

U .S.D EPA RTM EN T O F CO M M ERCE
Econom ics and Statistics A dm inistration

U .S.CEN SU S BU REA U

2007 EC O N O M IC C EN S U S
N aturalG as Liquid Extraction

FO RM

M I-21102

O M B N o.:A pprovalExpires

(D R A FT)

D U E D A TE
FEB R U A R Y 12, 2008
M I-21102

M ailyour com pleted form to:
U .S .C EN S U S B U R EA U
1201 East 10th S treet
Jeffersonville,IN 47134-0001
P lease read the accom panying
inform ation sheet(s)before
answ ering the questions.
N eed help or have questions
about filling out this form ?
V isit w w w .census.gov/econhelp
C all1-800-233-6136,betw een
8:00 a.m .and 6:00 p.m .,Eastern
tim e,M onday through Friday.
-O R W rite to the address above.
Include your 11-digitCensus File
N um ber (CFN )printed in the
m ailing address.

(Please correct any errors in this m ailing address.)

Y O U R R ES P O N S E IS R EQ U IR ED B Y LA W . Title 13,U nited States Code,requires businesses and other organizations
thatreceive this questionnaire to answ er the questions and return the reportto the U .S.Census Bureau. By the sam e
law ,Y O U R C EN S U S R EP O R T IS C O N FID EN TIA L. Itm ay be seen only by persons sw orn to uphold the confidentiality
ofCensus Bureau inform ation and m ay be used only for statisticalpurposes. Further,copies retained in respondents'
files are im m une from legalprocess.
•U se blue or black ballpointpen. •Please center num bers in their respective boxes. Exam ples:
•D o notuse pencilor felt-tip pen. •D o notputslashes through 0 or 7.
0 1
•Place an "X " inside the box.

2 3 4 5 6 7 8 9

The reporting unitfor this form is an establishm ent. A n establishm ent is generally a single physicallocation
w here business is conducted or w here services or industrialoperations are perform ed. For further clarification,see
inform ation sheet(s).
1

EM PLO YER ID EN TIFICA TIO N N U M BER
Is the Em ployer Identification N um ber (EIN )show n in the m ailing address the sam e as the one used for this
establishm enton its latest2007 InternalRevenue Service Form 941,Em ployer's Q uarterly FederalTax Return?
0021

Yes -G o to

2

-

N o -Enter currentEIN (9 digits)

0022

0025

2

PH YSICA L LO CA TIO N
A . Is this establishm ent's physicallocation the sam e as show n in the m ailing address?
(P.O .Box and ruralroute addresses are notphysicallocations.)

21102017

0031

0032

Yes -G o to line B
N o -Enter
physical
location

0035

N um ber and street

0036

City,tow n,village,etc.

0037

State

0038

ZIP Code

B . Is this establishm entphysically located inside the legalboundaries ofthe city,tow n,village,etc.?
(M ark "X " only O N E box.)
0041

Yes

0042

No

0043

N o legalboundaries

0044

D o notknow

C . In w hattype ofm unicipality is this establishm entphysically located? (M ark "X " only O N E box.)
0046

City,village,or borough

P EN A LTY FO R FA ILU R E TO R EP O R T

USCENSUSBUREAU

0047

Tow n or tow nship

0048

O ther

0024

D o notknow

C O N TIN U E O N P A G E 2

Form M I-21102
3

Page 2

(D R A FT)

O PERA TIO N A L STA TU S
W hich ofthe follow ing bestdescribes this establishm ent's operationalstatus atthe end of2007?
(M ark "X " only O N E box.)
0011

In operation

0016

U nder construction,developm ent,or exploration

0013

Tem porarily or seasonally inactive

0014

Ceased operation -G ive date atright

0018

M onth

D ay

Year

Sold or leased to another operator -G ive date atrightA N D
enter nam e and address ofnew ow ner or operator and
Em ployer Identification N um ber (EIN )below

0015

6030

N am e ofnew ow ner or operator

0061 EIN

(9 digits)

6031

M ailing address (N um ber and street,P.O .Box,etc.)

6032

City,tow n,village,etc.

6033

State

6034 ZIP

Code

4

M ark "X " 2007
if N one N um ber

M O N TH S IN O PERA TIO N
N um ber ofm onths in operation during 2007 (Ifnone,m ark "X " and go to 30 .) . . . . . . . . . . . . 0002

H O W TO
REPO RT
D O LLA R
FIG U RES

D ollar figures should be rounded to
thousands ofdollars.
Ifa figure is $1,025,628.79:
Ifa value is "0" (or less than $500.00):

5

M ark "X "
if N one $ Bil.

2007
M il.

Thou.

1 0 2 6

R eport
R eport

SA LES,SH IPM EN TS,RECEIPTS,O R REVEN U E
(Exclude nonoperating incom e such as royalties,interest,dividends,or the sale
offixed assets.)
A . Totalvalue ofproducts shipped and other receipts (Reportdetailin

22 .)

M ark "X "
if N one $ Bil.

. . .

0100

Reportthe value ofproducts shipped for export.Include shipm ents to
custom ers in the Panam a CanalZone,the Com m onw ealth ofPuerto Rico,
and U .S.possessions,as w ellas the value ofproducts shipped to exporters
or other w holesalers for export.A lso,include the value ofproducts sold to
the U .S.G overnm entto be shipped to foreign governm ents.. . . . . . . . .

0130

2007
M il.

Thou.

B . Value ofproducts exported (This is a breakoutofthe value reported on
line A .)

N otA pplicable.

21102025

6

C O N TIN U E O N P A G E 3

Form M I-21102

Page 3

(D R A FT)

If not show n,please enter your 11-digit C ensus File
N um ber (C FN )from the m ailing address.
7

EM PLO YM EN T A N D PA YRO LL
Include:
•Full-and part-tim e em ployees w orking atthis establishm entw hose payrollw as reported on Internal
Revenue Service Form 941,Em ployer's Q uarterly FederalTax Return,and filed under the Em ployer
Identification N um ber (EIN )show n in the m ailing address or corrected in 1 .
Exclude:
•Full-or part-tim e leased em ployees w hose payrollw as filed under an em ployee leasing com pany's EIN .
•Tem porary staffing obtained from a staffing service.
•Subcontractors and their em ployees.
For further clarification,see inform ation sheet(s).
M ark "X "
if N one

A . N um ber ofem ployees
1. N um ber ofproduction,developm ent,and exploration w orkers for pay period
including M arch 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0325

2. N um ber ofother em ployees for pay period including M arch 12 . . . . . . . .

0336

3. TO TA L (A dd lines A 1 and A 2) . . . . . . . . . . . . . . . . . . . . . . . .

0320

M ark "X "
if N one $ Bil.

B . Payrollbefore deductions (Exclude em ployer's costfor fringe benefits.)

2007
N um ber

2007
M il.

Thou.

1. A nnualpayroll
a. Production,developm ent,and exploration w orkers . . . . . . . . . .

0304

b. A llother em ployees . . . . . . . . . . . . . . . . . . . . . . . . .

0305

c. TO TA L (A dd lines B1a and B1b) . . . . . . . . . . . . . . . . . . .

0300

2. Firstquarter payroll (January-M arch,2007) . . . . . . . . . . . . . . .

0310

M ark "X "
if N one

21102033

C . N um ber ofhours w orked by production,developm ent,and exploration
w orkers (A nnualhours w orked by production,developm ent,and exploration
w orkers reported on line A 1.) . . . . . . . . . . . . . . . . . . . . . . .

CO N TIN U E W ITH

7

2007
H ours
Thou.

0200

O N PA G E 4

C O N TIN U E O N P A G E 4

Form M I-21102
7

Page 4

(D R A FT)

EM PLO YM EN T A N D PA YRO LL -Continued
M ark "X "
if N one $ Bil.

D . Em ployer's costfor fringe benefits -Em ployer's costfor legally required
program s and program s notrequired by law .
1. H ealth insurance -Insurance prem ium s on hospitals,m edicalplans,and
single service plans such as dental,vision,and prescription drug plans.
Include prem ium equivalents for self-insured plans and fees paid to third
party adm inistrators (TPA s).D o notinclude em ployee contributions. . . .

2007
M il.

Thou.

0333

2. Pension plans
a. D efined benefit pension plans -Costs for both qualified and
unqualified defined pension plans.Pension plans thatspecify the
benefitto be paid to em ployees upon retirem ent,generally either
a specific am ountor a percentage ofcom pensation.Em ployer
contributions are based on actuarialcom putations thatinclude the
em ployee's com pensation and years ofservice and are notallocated
to specific accounts m aintained for em ployees. . . . . . . . . . . .

0335

b. D efined contribution plans -Costs under defined contribution
plans.Pension plans thatdefine the em ployer contributions to a
separate accountprovided for each em ployee.The em ployee "benefit"
atretirem entdepends on the am ountcontributed and the results of
the account's activity.Exam ples include profitsharing plans,m oney
purchase (e.g.,401k,403b)and stock bonus plans (e.g.,ESO Ps) . . . .

0337

3. O ther -O ther fringe benefits (e.g.,SocialSecurity,w orkers'
com pensation insurance,unem ploym enttax,state disability insurance
program s,life insurance benefits,M edicare) . . . . . . . . . . . . . . .

0339

4. TO TA L (A dd lines D 1 through D 3) . . . . . . . . . . . . . . . . . . .

0220

8

N otA pplicable.

9

IN VEN TO RIES
(Reportinventories atcostor m arketusing generally accepted accounting practices.)
A . D id this establishm entow n inventories,regardless ofw here held,atthe end of2007 and/or 2006?
0486

Yes -G o to line B

0487

N o -G o to 13

21102041

B . Reportinventories for m ined
products and supplies ow ned by this
establishm entas ofD ecem ber 31.

M ark "X "
if N one $ Bil.

End of 2007
M il.
Thou.

M ark "X "
if N one $ Bil.

1. Finished products and w ork-inprocess . . . . . . . . . . . . .

0461

0471

2. Supplies,parts,fuels,etc. . . . .

0462

0472

3. Totalinventories before Lastin,First-out (LIFO )adjustm ent
(if any)(A dd lines B1 and B2) . .

0460

0470

4. LIFO reserve (ifany) . . . . . . .

0466

0476

5. Totalinventories after LIFO
adjustm ent value (Line B3
m inus line B4) . . . . . . . . .

0468

0469

End of 2006
M il.
Thou.

C O N TIN U E O N P A G E 5

Form M I-21102

Page 5

(D R A FT)

If not show n,please enter your 11-digit C ensus File
N um ber (C FN )from the m ailing address.
10

IN VEN TO RIES BY VA LU A TIO N M ETH O D
Reporthow m uch ofthe inventory reported in
follow ing valuation m ethods.

9

,line B3 for 2007 is subjectto the
M ark "X "
if N one $ Bil.

2007
M il.

Thou.

M ark "X "
if N one $ Bil.

2007
M il.

Thou.

M ark "X "
if N one $ Bil.

2007
M il.

Thou.

A . LIFO valuation m ethod before adjustm ent . . . . . . . . . . . . . . . . . . 0244
B . A ny valuation m ethod -Specify m ethod

0895

0494

C . TO TA L (A dd lines A and B.Totalshould equal 9 ,line B3.) . . . . . . . . . 0490
11 and 12
13

N otA pplicable.

A SSETS,CA PITA L EX PEN D ITU RES,RETIREM EN TS,A N D D EPRECIA TIO N
(See inform ation sheet(s)on how to reportleasing arrangem ents.)

14

0500

B . Capitalexpenditures for new and used buildings,structures,m achinery,and
equipm entdepreciable assets (Exclude land.) . . . . . . . . . . . . . . . .

0520

C . Totalretirem ents and disposition ofdepreciable assets for the year (G ross
value ofassets sold,retired,scrapped,destroyed,etc.) . . . . . . . . . . .

0510

D . G ross value ofdepreciable assets atthe end ofthe year (A dd lines A and B
m inus C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0505

E. D epreciation charges for the year . . . . . . . . . . . . . . . . . . . . .

0540

REN TA L PA YM EN TS

A . Rentalpaym ents for buildings and other structures (Include land.) . . . . . .

0551

B . Rentalpaym ents for m achinery and equipm ent . . . . . . . . . . . . . . .

0552

C . TO TA L (A dd lines A and B) . . . . . . . . . . . . . . . . . . . . . . . .

0550

N otA pplicable.

21102058

15

A . G ross value ofdepreciable assets (acquistion cost)atthe beginning ofthe
year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C O N TIN U E O N P A G E 6

Form M I-21102
16

Page 6

(D R A FT)

SELECTED EX PEN SES
Include costs incurred in the m ining process such as supplies,resales,contractw ork,fuels,and electricity.
A . Selected production related costs
M ark "X "
if N one $ Bil.

1. Costofsupplies used,m inerals received for preparation,and purchased
m achinery installed (Reportdetailin 17 .) . . . . . . . . . . . . . . . . .

0421

2. Costofproducts boughtand sold as such w ithoutfurther processing
(Reportsales in 22 .) . . . . . . . . . . . . . . . . . . . . . . . . . . .

0426

3. Costofpurchased fuels consum ed for heat,pow er,or the generation of
electricity (Reportdetailin 18 .) . . . . . . . . . . . . . . . . . . . . . .

0430

4. Costofpurchased electricity (Reportquantity on line B1.) . . . . . . . . .

0425

5. Costofw ork done for you by others on your m aterials . . . . . . . . . .

0424

6. TO TA L (A dd lines A 1 through A 5) . . . . . . . . . . . . . . . . . . . .

0420

0436

2. G enerated electricity (G ross less generating station use) . . . . . . . . . . . . .

0437

3. Electricity sold or transferred to other establishm ents (Include on lines B1 or B2.)

0438

Thou.

M ark "X "
if N one

2007
Kilow atthours
M il.
Thou.

M ark "X "
if N one

2007
$ M il.
Thou.

B . Q uantity ofElectricity
1. Purchased electricity (Q uantity com parable to costreported on line A 4.) . . . . .

2007
M il.

C . O ther expenses paid by this establishm ent
Include:
• Expenses norm ally considered as non-production related costs purchased from
other com panies.

21102066

Exclude
• Costofm ining activities subcontracted to others and reported in 16 ,line A 5.
• Salaries paid to em ployees ofthis establishm entfor perform ing these services.

1. Purchased com m unication services (telephone,Internet,connectivity,online
services,FA X ,cellular phones,etc.) . . . . . . . . . . . . . . . . . . . . . .

0402

2. Purchased legalservices . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0403

3. Purchased accounting,auditing,and bookkeeping services

. . . . . . . . . . .

0404

4. Purchased advertising and prom otionalservices (advertising,m arketing,
prom otional,or public relations services) . . . . . . . . . . . . . . . . . . . .

0405

5. A llother expenses paid by this establishm ent(Exclude labor costs,depreciation,
rentalpaym ents,m ineralproperty expenses,and any other expenses reported on
this form . A lso exclude loan interest,incom e taxes,and sales and excise taxes.)

0397

6. TO TA L (A dd lines C1 through C5) . . . . . . . . . . . . . . . . . . . . . . .

0449

C O N TIN U E O N P A G E 7

Form M I-21102

Page 7

(D R A FT)

If not show n,please enter your 11-digit C ensus File
N um ber (C FN )from the m ailing address.
17

D ETA ILED CO ST O F M A TERIA LS,PA RTS,A N D SU PPLIES
R eport:
D elivered costofindividualitem s listed below .D elivered costis the am ountpaid or payable after discounts and
including freightand other directcharges incurred by the establishm entin acquiring the m aterials.The figures reported
should representthe totalpurchase costofsupplies,m inerals received for preparation,m achinery installed,etc.,
actually used or processed during 2007.Include purchases,interplanttransfers,and w ithdraw als from inventories.Ifthe
data are notavailable from your records,reasonable estim ates are acceptable.
Q uantities in the unitofm easure specified.
Estim ated value ofgas produced by your com pany or processed on a contractbasis as though actually purchased.
Residue gas after processing in

22 .See

instruction sheets for description ofitem s to be reported on line 1 below .

Include:
The producer's realization from allproducts contained in the gas delivered.Estim ate,ifnecessary.
Item s listed below w hether charged to currentor capitalaccounts.
Costofitem s for w hich less than $25,000 w orth w as used in "A llother supplies," line 9.
Supplies purchased by this establishm entfor use by com panies perform ing contractw ork atthis establishm ent.
Exclude:
A ssociated labor costs ofthe kind reported in

7

and

16 ,line

A 5.

Line No.

Paym ents m ade for contractservices perform ed,including paym ents for supplies and equipm entfurnished by the
contractor incidentalto this w ork.

M inerals received and processed,m achinery installed,and
supplies used

U nit of
Census m aterial m easure for
code
quantities

Purchased from others,received from other
establishm ents of this com pany,or received
for custom m ineralprocessing

Q uantity

Cost,including delivery cost
(freight-in)
$ Bil.

21102074

0634

0630

0636

1

N aturalgas processed (A djustallvolum es to a
pressure base of14.73 pounds absolute at60
degrees Fahrenheit.)
G as received from allsources (Including fields
or leases operated by your com pany and those
operated by others.) . . . . . . . . . . . . .

211110 11

2

Liquids processed
N aturalgas liquids received for further
processing . . . . . . . . . . . . . . . . . .

211112 01

3

Crude petroleum (including condensate)
recevied for processing . . . . . . . . . . . .

211111 05

4

M achinery,purchased and installed (including
m obile loading,transportation,and other
equipm entinstalled atthe operation)(Including
charges to both currentand capitalaccounts.) . . .

333000 07

5

Parts and attachm ents for m ining,m ineral
preparation,construction,and conveying
m achinery and equipm ent . . . . . . . . . . . .

333000 09

6

Supplies used
Lubricating oils and greases (including
hydraulic oils) . . . . . . . . . . . . . . . .

324191 00

7

Industrialorganic chem icals (including ethylene
glycoland fluorinated hydrocarbon gases) . . .

325100 93

0633

M il.

Thou.

0631

m ilft3

CO N TIN U E W ITH

17

1000 bbl

O N PA G E 8

C O N TIN U E O N P A G E 8

Form M I-21102

Line No.

17

Page 8

(D R A FT)

D ETA ILED CO ST O F M A TERIA LS,PA RTS,A N D SU PPLIES -Continued

M inerals received and processed,m achinery installed,and
supplies used

U nit of
Census m aterial
m easure for
code
quantities

Purchased from others,received from other
establishm ents of this com pany,or received
for custom m ineralprocessing

Q uantity

Cost,including delivery cost
(freight-in)
$ Bil.

0634

0630

Supplies used -Continued
Steelshapes and form s (excluding castings
and forgings)such as plates,sheets,strip,
piling,bars,rails,w heels,track accessories,
pipe,tubing,w ire,w ire products,and structural
shapes . . . . . . . . . . . . . . . . . . . .

8

0636

0633

M il.

Thou.

0631

331000 52

A llother supplies (Specify the three principal
types ofsupplies included here.)
9

009700 98

10
18

TO TA L (Should equaltotalreported in

16 ,line

A 1)

771000 00

FU ELS U SED

Line No.

2007 consum ption
Kind of fuel(Report totaldelivered cost,not cost per unit. Fuels
received from other establishm ents of your com pany should be
included at estim ated m arket value.)

U nit of
Census fuelcode m easure for
quantities

Q uantity

Cost,including
delivery cost
(freight-in)
$ M il.

0643

0640

0645

1

Coal(bitum inous,subbitum inous,lignite,and anthracite) .

212110 03

short tons

2

Fueloil
D istillate (light)grade num bers 1,2,4,and lightdiesel
fuel . . . . . . . . . . . . . . . . . . . . . . . . .

324110 17

barrels

3

Residual(heavy)grade num bers 5 and 6 and heavy
dieselfuel . . . . . . . . . . . . . . . . . . . . .

324110 19

4

G as (natural,m anufactured,and m ixed) . . . . . . . . .

211110 15

m ilft3

5

G asoline . . . . . . . . . . . . . . . . . . . . . . . .

324110 15

1000 gal

0642

Thou.

0641

O ther fuels (liquefied petroleum gas,coke,w ood,and
other)(Specify.)
6

21102082

009600 18

7

TO TA L (Should equaltotalreported in

A 3) . . . .

007720 00

8

RESID U E G A S produced and used atthis establishm ent
for heator pow er . . . . . . . . . . . . . . . . . . . .

211110 29

16 ,line

m ilft3

C O N TIN U E O N P A G E 9

Form M I-21102

Page 9

(D R A FT)

If not show n,please enter your 11-digit C ensus File
N um ber (C FN )from the m ailing address.
19

TYPE O F O PERA TIO N
(Include production,developm ent,and exploration operations.)
(M ark "X " the O N E box for w hich you received the m ostreceipts.)
Type of P lant

0600

434

N aturalgasoline

436

Cycle-condensate

438

Fractionating

20 and 21
22

N otA pplicable.

D ETA IL O F SA LES,SH IPM EN TS,RECEIPTS,O R REVEN U E
R eport nettotalvalues f.o.b.plantafter discounts and allow ances and exclusive offreightcharges and excise taxes.
Include:
A llproducts produced or physically shipped from this establishm entin 2007.
Products shipped on consignm ent,w hether or notsold atthe end of2007.
Products transferred to other establishm ents ofyour com pany (such as petroleum refineries,other m anufacturing
establishm ents,or separate sales branches).
Estim ate the total(100% )value ofproducts recovered from gas and from liquids processed under contractusing know n
prices w ithin the generalarea.
For residue gas shipped on Line 1 include:
A llresidue gas delivered (sold and/or returned),even though som e gas m ay have been processed w ith the producer
retaining title to and actually selling the gas.
A llgas used atyour other com pany operations,returned to supplying producer,or delivered to other com panies.

Line No.

Exclude gas used for fuelatthis plant,gas vented or burned in flares,or losses.
U nit of
Census product
m easure for
code
quantities

D escription

21102090

0734

0730

1

Residue gas shipped (A djustvolum e
to a pressure base of14.73 pounds
absolute at60 degrees F.)(Read
instructions for residue gas shipped.)

211112 3100

2

N aturalgas liquids
Ethane (C 2)(atleast80 percent
purity) . . . . . . . . . . . . . .

211112 1451

3

Propane (C 3)(atleast80 percent
purity) . . . . . . . . . . . . . .

211112 1221

4

Butane (C 4)(atleast80 percent
purity) . . . . . . . . . . . . . .

211112 1331

5

G as m ixtures (C 2,C 3, and C 4) . . .

211112 1461

6

Isopentane and naturalgasoline

.

211112 1111

7

Plantcondensate

........

211112 1441

0736

Q uantity of
production
0733

Shipm ents and interplant transfers
Value,f.o.b.establishm ent
Q uantity
$ Bil.
M il.
Thou.
0732

0731

m ilft3

1000 bbl

O ther naturalgas liquids
(including raw or unfractionated
naturalgas liquid stream s w ith
less than 80 precentpurity)
(Specify kind.)

8

211112 1491
CO N TIN U E W ITH

22

O N PA G E 10
C O N TIN U E O N P A G E 10

Form M I-21102

D ETA IL O F SA LES,SH IPM EN TS,RECEIPTS,O R REVEN U E -Continued

Line No.

22

Page 10

(D R A FT)

U nit of
Census product
m easure for
code
quantities

D escription
0734

0730

Recovered elem entalsulfur from
naturalgas . . . . . . . . . . . . .

9

0736

Q uantity of
production
0733

Shipm ents and interplant transfers
Value,f.o.b.establishm ent
Q uantity
$ Bil.
M il.
Thou.
0732

0731

211112 4100

A llother products m ade in this
establishm ent-Specify and report
each productw ith sales value
of$50,000 or m ore thatcannot
be assigned to one ofthe "listed
products and services". For all
rem aining products,w rite "O ther" and
reporta single totalvalue.
18

10
26

11
34

12
A m ountreceived or due for w ork
or services perform ed for other
establishm ents,excluding am ount
received for processing gas on
contract(Specify kind ofw ork
below .)

13
14

213112 W YW T

TO TA L (Should equal 5 ,line A ) . . .

23 – 29

770000 0000

N otA pplicable.

REM A RKS (Please use this space for any explanations thatm ay be essentialin understanding your reported data.)

$$CENSUS_REMARKS$$

30

CERTIFICA TIO N -This reportis substantially accurate and w as prepared in accordance w ith the instructions.

21102108

Is the tim e period covered by this reporta calendar year?
Yes

N o -Enter tim e period covered

M onth

N am e ofperson to contactregarding this report

A rea code
Telephone

N um ber

-

Year

FRO M

M onth

Year

TO

Title

Extension

A rea code

N um ber

Fax

-

Internete-m ailaddress

M onth

D ay

D ate
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P LEA S E P H O TO C O P Y TH IS FO R M FO R Y O U R R EC O R D S A N D R ETU R N TH E O R IG IN A L.

Year