BLS-Green Form 335 Green Form 335224

Green Goods and Services Survey

O.M.B. No. 1220−xxxx

Expires Month Day Year

Please return this form within 14 days. If you need help completing this form, contact information is listed on the last page. Thank you!

West Dakota

012345678

Please report for location(s) in Using Unemployment Insurance account number

1

What is the address where your business is physically located?

Report data for the location below. If this address is no longer correct, please provide us with an updated address in the space provided.

Enter Physical Location Address Corrections Here

XYZ ADVISORS

4TH FLOOR

1310 SILVER STREET

SOMECITY WD 12345-6789

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2

ave we identified your main business activity correctly?

We have listed below a description of your main business activity at this location. If this description is incorrect, please call XXX-XXX-XXXX or email [email protected].

NAICS code: 335224 Household laundry equipment manufacturing
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in: Manufacturing household-type laundry equipment		Commercial-type laundry, dry cleaning, and pressing equipment Portable electric irons

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3

hat is your business’s fiscal year?

Please provide us with your fiscal year that includes the month of June 2010.

Start of Fiscal Year				End of Fiscal Year
MM	DD	YYYY		MM	DD	YYYY

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4

hat is your business’s employment?

Please provide us with the employment figure you reported on your State’s Quarterly Contributions Report for March 2010. This figure is the count of all employees subject to State Unemployment Insurance taxes that worked or received pay for the pay period that included March 12^th.

Employment for pay period that includes March 12, 2010

5

What is your percent revenue from specific product lines?

In Columns 1 and 3, please estimate the percent of total revenue that comes from for your location listed in Item 1 for Energy Star rated products. Please base your estimate on total revenues for the fiscal year listed in Item 3. The sum of Columns 1 and 3 may not equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.

Percent of Revenue for Fiscal Year listed in Item 3
1 Percent of total revenue from Energy Star rated products	2 Product line		3 Percent of total revenue from Energy Star rated products	4 Product line
	Dry cleaning and laundry machines, household-type			Laundry equipment (e.g., dryers, washers), household-type
	Dryers, clothes, household-type, gas and electric			Washing machines, household-type
	Dryers, household-type			Other
	Ironers and mangles, household-type (except portable irons)			Other
	Dryers, clothes, household-type, gas and electric			Other environmental standard:

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6

hat is your contact information? for person or persons who helped complete this form.

1. Contact 1’s name: __________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:__________________________________

Business website:______________________________________________

2. Contact 2’s name: ____________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:________________________________

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7

o you have any questions about completing this form?

Please send an email to [email protected], or call (202)-691-XXXX.

Confidentiality Statement. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. This report is authorized by law 29 U.S.C.2. Paperwork Reduction Act Statement. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate, and timely. We estimate that completing this form will take an average of 20 minutes. This estimate takes into account time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding this survey, including suggestions for reducing the burden, send them to the Bureau of Labor Statistics, Office of Industry Employment Statistics, Paperwork Reduction Project, 2 Massachusetts Avenue, N.E., Room 4840, Washington, DC 20212. The OMB control number for this voluntary survey is 1220-NEW and expires on month day, year. Without a currently valid number BLS would not be able to conduct this survey.

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