QSS-1E-PEO Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 10/31/2009
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

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U.S.
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U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

ENT OF C
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AR

US

QSS-1E-PEO

R

S

BU

EA

FORM

EN
U O
F TH E C

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-1E (4-21-2004)

Attachment A

3

REVENUE

06 $ Bil.

Mil.

Thou.

Dol.

A. Gross billings/professional service fees – Report the professional service fee, or
gross billings, for the company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Direct costs of worksite employees – Report salaries, wages, employment-related taxes,
benefit premiums, and worker’s compensation insurance costs, for PEO worksite employees . . . . . .

C. NET REVENUE – Difference between lines A and B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
07 1

D. Are the revenues reported in C above book figures or estimates? . . . . . . . . . . . . . . .

4

2

Book figures
Estimates

REPORT PERIODS
1
2

Yes – Continue with 5
No – Provide beginning and ending dates for
the most recent and prior quarters.

Most recent quarter
Month

Day

Year

08

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

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

5

SOURCE OF REVENUE
What percentage of revenue (reported in 3 )
is received from each of the following types
of customers?
Estimates are acceptable if actual data is not available.
10

%

1. Government (local, State, and Federal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11

%

2. Business firms and not-for-profit organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12

%

3. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

qss-2peo-1q (1-23-2007)

100%

Page 2

6

ORGANIZATIONAL CHANGE
Did your firm experience any organizational
change during Jan, Feb,or March 2007?
13

1

14

Name of company acquired/merged with/sold to

Number and street

Yes
o

acquired

City, State, and ZIP Code

merged with
sold to

15

Date of acquisition,
sale, or merger

Month

Year

16

EIN

–

NO

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.
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-3 (4-21-2004)

Page 3