QSS-3(E) Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 12/31/2006
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

CE
ER

U.S.
D

M

EP

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

ENT OF C
TM
OM
AR

US

(12-9-2004)

R

S

BU

EA

FORM

QSS-3(E)

EN
U O
F TH E C

DUE
DATE
NOTICE — Your report to the
Census Bureau is confidential by
law (Title 13, U.S. Code). It 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.
RETURN COMPLETED FORM TO:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
OR
Fax: 1–800–447–4613
NEED HELP?
Visit our web site:
http://www.census.gov/econhelp/qss
or
Call 1–800–772–7851 between 8:30 a.m.
and 5:00 p.m. EST, Monday through Friday.

INTERNET REPORTING
You may complete this survey online at:
Password:

Username:

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

http://www.census.gov/econhelp/qss
using your firm’s unique username and original password. If you
change your password, please keep a record for reference.

1 SURVEY COVERAGE

Does this firm have domestic locations providing the business activities described in the
above survey coverage statement?
01

1
2

Yes – Continue with 2
No – Specify your business activity and continue with 2
02

2 FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Is the Federal Employer Identification Number (EIN) printed in the upper left of the address label the same as
that used for this firm on its latest Employer’s Quarterly Federal Tax Return (Treasury Form 941)?
1
Yes – Go to Item 3
03
2
No – Enter current EIN and date you started reporting payroll under this EIN.
Federal Employer Identification Number (EIN)

Month

Year

05

04

–

USCENSUSBUREAU

QSS-3E (12-9-2004)

3

REVENUE and EXPENSES

A. What was this firm’s quarterly REVENUE for the domestic locations (See 1 )
covered by this report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

06

$ Bil.

See page 4 for additional instructions.

Mil.

07 1
2

B. What was this firm’s quarterly EXPENSES (include payroll and employee
benefits) for the domestic locations (See 1 ) covered by this report? . . . . . .

25

$ Bil.

2

4

2

Yes – Continue with 6
No – Provide beginning and ending dates for
the most recent and prior quarters.

Book figures
Estimates

Most recent quarter
Month
08

Beginning date . . . . . . . . . . . . . . . . . . .
09

Ending date . . . . . . . . . . . . . . . . . . . . .

5

Thou.

REPORT PERIODS
1

NOT APPLICABLE TO THIS FORM

QSS-2N-1Q (6-6-2005)

Page 2

Day

Dol.

Book figures
Estimates

Mil.

26 1

See page 5 for additional instructions.

Thou.

Year

Dol.

6

ACQUISITIONS OR MERGERS

14

Name of company acquired or merged with

Number and street
13

1

Yes

2

No

City, State, and ZIP Code

15

Date of acquisition
or merger

Month

Year

16

EIN

–

7

REMARKS – Please use this space for comments or to explain any significant difference between your
current and prior quarter revenue.

8

CONTACT INFORMATION

17

Name of person to contact regarding this report

18

Telephone

Area code Number

20

Extension

E-mail address
19

Fax

Area code Number
21

Company website

THANK YOU
for completing your Quarterly Services Survey.

QSS-3 (4-21-2004)

Page 3

INSTRUCTIONS FOR
Taxable Firms

•
3A

REVENUE

OPERATING REVENUE
Include –
• Total value of service contracts.
• Amounts received for work subcontracted to others.
• Market value of compensation in lieu of cash.
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• 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 and any
franchise or license fees.
• Rents from and revenue of separately operated
departments, concessions, etc., which are leased to
others.
• Revenue from customers for carrying or other credit
charges.
• 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).
• Nonoperating 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,
royalties, or grants.
• Revenue from the sale of used equipment.
• Installment payments from leasing under capital,
finance, or full-payout leases.
• Intracompany transfers.
• Interest income.

Tax-Exempt Firms
OPERATING AND NON-OPERATING REVENUE
Include –
• Program service revenue for services provided in the
quarter, whether or not payment was received in that
quarter.
• Gross sales of merchandise, minus returns and
allowances.
• Income from interest, dividends, gross rents
(including display space rentals and share of receipts
from departments operated by other companies),
royalties, and other investments.
• Net gains (or losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale).
• Gross contributions, gifts, and grants (whether or not
restricted for use in operations).

Exclude –
• Sales and other taxes collected directly from
customers or clients and paid directly to a local, State,
or Federal tax agency.
• Gross receipts of departments or concessions
operated by other companies.
• Amounts transferred to operating funds from capital
or reserve funds.

• Dues and assessments from members and affiliates.
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators).
• Gross receipts from fundraising activities.

QSS-4H (12-22-2004)

Page 4

INSTRUCTIONS FOR

•
3B

EXPENSES

Report costs incurred during the quarter specified even though payments may have been made at a later date.
Include –

Exclude –

• Payroll and employee benefits.

• Sales and other taxes collected directly from
customers or clients and paid directly to a local,
State, or Federal tax agency.

• Interest and rent expenses.
• Supplies used for operating your business, cost of
merchandise sold, and other expenses allocated to
operations during the year.
• Contracted or purchased services.

• Outlays for the purchase of real estate (land and
buildings); for construction; for additions, major
alterations, and improvements to existing facilities;
and all other capital expenditures.

• Fees paid to other organizations for fundraising.

• Funds invested.

• Depreciation expenses.

• Income taxes.

• Expenses of locations providing support services
(e.g., repair services, administrative services, etc.) for
your service establishments.

• Assessments (dues) paid to the parent or other
chapters of the same organization.
• For establishments engaged in raising funds - funds
transferred to charities or other organizations.

INSTRUCTIONS FOR

•
5A

INPATIENT DAYS

A patient who is formally admitted and who is discharged or dies on the same day is counted as one patient day,
regardless of the number of hours the patient occupies a hospital bed. For patients switched from observation to
inpatient status, the patient day count should begin on the day the patient was officially admitted as an inpatient. For
inpatient admissions occurring before the current quarter or extending after the current quarter, record only those
days that occur during the quarter and exclude days occurring before or after the quarter. Do not include nursery
discharges unless they are related to neonatal intermediate or intensive care units.
Include –
• Inpatient acute and sub-acute days.

Exclude –
• Nursery days.

• Swing bed days.

• Newborn days.

• Distinct part units days.
• Skilled nursing facilities days.
• Long term care days.

INSTRUCTIONS FOR

•
5B

DISCHARGES

If a patient is discharged from an acute care unit and transferred to a swing bed or distinct part unit, one discharge
would be recorded when the patient is discharged from the acute care unit and a second discharge recorded when
the patient is discharged from the swing-bed or distinct part unit. Do not include nursery discharges unless they are
related to neonatal intermediate or intensive care units.
Include –
• Inpatient acute and sub acute discharges.
• Swing bed discharges.
• Distinct part unit discharges.
• Skilled nursing facility discharges.
• Long term care discharges.
Public reporting burden for this collection of voluntary information is estimated to average 15 minutes 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 0607-0907, 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 0607-0907" 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.

QSS-5H (12-23-2004)

Page 5