Various Economic Area Pretesting Activities

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Guam

FORM

IA-98163

OMB No. : Approval Expires

(DRAFT)

IA-98163

Need help or have questions about filling out this
form?
Visit www.census.gov/econhelp
Call 1-800-233-6136, between 8:00 a.m. and 6:00 p.m.,
Eastern time, Monday through Friday.
- OR Write to the address below. Include your 11-digit Census
File Number (CFN) printed in the mailing address.
Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001

(Please correct any errors in this mailing address.)
YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, requires businesses and other organizations
that receive this questionnaire to answer the questions and return the report to the U.S. Census Bureau. By the same
law, YOUR CENSUS REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality
of Census Bureau information and may be used only for statistical purposes. Further, copies retained in respondents'
files are immune from legal process.

• Use blue or black ballpoint pen. • Please center numbers in their respective boxes. Examples:
• Do not use pencil or felt-tip pen. • Do not put slashes through 0 or 7.
0 1 2 3 4 5 6 7 8 9
• Place an "X" inside the box.
The reporting unit for this form is an establishment. An establishment is generally a single physical location where
business is conducted or where services or industrial operations are performed or a permanent office, payroll office, or other
place where business activities related to construction are conducted. For further clarification, see information sheet(s).
1

EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) shown in the mailing address the same as the one used for this
establishment on its latest 2012 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return, or
Form 944-SS, Employer's Annual Federal Tax Return?

98163017

0021

2

Yes - Go to

2

No - Enter current EIN (9 digits)

0022

-

0025

PHYSICAL LOCATION
A. Is this establishment's physical location the same as shown in the mailing address?
(P.O. box and rural route addresses are not physical locations.)
0031

0032

0035

Number and street or location description

0036

City, town, etc.

Yes
No - Enter physical
location

0037

State, other

0038

ZIP Code

-

B. District/village where this establishment is physically located
0049

PENALTY FOR FAILURE TO REPORT

USCENSUSBUREAU

CONTINUE ON PAGE 2

Form IA-98163
3

Page 2

(DRAFT)

OPERATIONAL STATUS
Which ONE of the following best describes this establishment's operational status at the end of 2012?
(Mark "X" only ONE box.)
0011

In operation

0014

Ceased operation - Give date at right

0015

0013

Temporarily or seasonally inactive
Month

Sold or leased to another operator - Give
date at right AND enter name and address
of new owner or operator and Employer
Identification Number (EIN) below
0060

Day

Year

0018

Name of new owner or operator

0061

EIN (9 digits)

0062

0063

Mailing address (Number and street, P.O. Box, etc.)

City, town, village, etc.

0064

State, other

0065

ZIP Code

0016

4

Other status - Specify

0815

Mark "X" 2012
if None Number

MONTHS IN OPERATION
Number of months in operation during 2012 (If none, mark "X" and go to
HOW TO
REPORT
DOLLAR
FIGURES

5

30 .)

. . . . . . . . . . . .
Mark "X"
if None

Dollar figures should be rounded to
thousands of dollars.

$ Mil.

2012
Thou.

If a figure is $2,035,628.79:

Report

2 0 3 6

If a value is "0" (or less than $500.00):

Report

EXAMPLE

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Mark "X"
if None

Sales of merchandise, shipments, operating receipts, and/or revenue (Exclude
grants, sales taxes, or other taxes collected.) . . . . . . . . . . . . . . . . . . .
6

0002

$ Mil.

2012
Thou.

Dol.

Dol.

0100

E-COMMERCE SALES, SHIPMENTS, RECEIPTS, OR REVENUE
A. Were any of the sales, shipments, receipts, and/or revenue reported in 5 a result of e-commerce transactions?
(Transactions are agreements between buyers and sellers to transfer ownership of, or rights to use, goods or
services. Payment for these goods or services may or may not be made online. Please see the information sheet(s)
for further clarification.)

98163025

E-commerce transactions include:
• Internet
• E-mail
• Extranet
0181

Yes - Go to line B

0182

No - Go to

• Electronic Data Interchange (EDI)
• Other online systems

2012
Whole percent
of sales and
receipts

7

B. Percent of total sales, shipments, receipts, and/or revenue reported in 5 that are a result of ecommerce transactions. (Exclude sales taxes. Report whole percents. Estimates are acceptable.) . .

0109

%

CONTINUE ON PAGE 3

Form IA-98163

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
7

EMPLOYMENT AND PAYROLL
Include:
• Full- and part-time employees working at this establishment whose payroll was reported on Internal
Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's
Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) shown in the
mailing address or corrected in 1 .
• Non-residential employees working at this establishment, whether or not FICA taxes were withheld.
For further clarification, see information sheet(s).
Mark "X"
if None

A. Number of paid employees for pay period including March 12, 2012
1. For whom FICA taxes were withheld . . . . . . . . . . . . . . . . . . . . . .

0254

2. For whom FICA taxes were NOT withheld . . . . . . . . . . . . . . . . . . .

0274

3. TOTAL (Add lines A1 and A2) . . . . . . . . . . . . . . . . . . . . . . . . .

0320

Mark "X"
if None

B. Payroll before deductions (Exclude employer's cost for fringe benefits.)
1. Annual payroll for 2012

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

0300

2. First quarter payroll (January-March, 2012) . . . . . . . . . . . . . . . .

0310

$ Mil.

2012
Number

2012
Thou.

Dol.

C. Employer's cost for fringe benefits

0221

2. Voluntarily provided fringe benefits (Include such items as payments for
life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.) . . . . . . . . . . . . . . . . . . . . . . . . . . .

0222

3. TOTAL (Add lines C1 and C2) . . . . . . . . . . . . . . . . . . . . . . .

0220

Not Applicable.

98163033

8

1. Legally required fringe benefits (Include employer payments for
Social Security, Medicare, unemployment compensation, workmen's
compensation, and local disability programs, if required.) . . . . . . . . .

CONTINUE ON PAGE 4

Form IA-98163
9

Page 4

(DRAFT)

INVENTORIES
Report inventories using current cost (if using LIFO method of valuation, adjust to obtain FIFO or current cost).
A. Did this establishment own inventory, regardless of where held, at the end of 2012 and/or 2011?
0486

Yes - Go to line B

0487

No - Go to

12

B. Total Inventories
(Report the total value of inventories the
establishment owned.) . . . . . . . . .

Mark "X"
if None

End of 2012
$ Mil.
Thou.

Mark "X"
if None

Dol.

0460

End of 2011
$ Mil.
Thou.

Dol.

0470

C. Did this establishment have inventories by stage of fabrication (finished goods; work-in-process; and/or
materials, supplies, fuels, etc.) at the end of 2012 and/or 2011?
0388

Yes - Complete lines 1 through 3. Total should equal the amounts reported in line B.

0389

No - Go to

12

Mark "X"
if None

End of 2012
$ Mil.
Thou.

Mark "X"
if None

Dol.

1. Finished goods . . . . . . . . . . .

0461

0471

2. Work-in-process

. . . . . . . . . .

0463

0473

3. Materials, supplies, fuels, etc. . . . .

0462

0472

End of 2011
$ Mil.
Thou.

Dol.

10 and 11 Not Applicable.
12 LEGAL FORM OF ORGANIZATION
Legal form of organization that best describes this establishment at the end of 2012 (Mark "X" only ONE box.)
0691

Individual proprietorship

0692

Partnership

0694

Corporation

0696

Other - Specify

0806

13 CAPITAL EXPENDITURES AND DEPRECIATION EXPENSES
Mark "X"
if None

98163041

Report the dollar value of capital expenditures and depreciation expenses.
A. Capital expenditures (Include purchases of equipment, spending on buildings
and structures that were capitalized, and capital lease agreements in 2012.) . .

0520

B. Depreciation expenses (Include depreciation charges taken against tangible
assets owned and used by your firm, tangible assets and improvements owned
by your firm within leaseholds, tangible assets obtained through capital lease
agreements, and amortization charges against intangible assets (e.g., patents,
copyrights) in 2012.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0540

$ Mil.

2012
Thou.

Dol.

14 and 15 Not Applicable.

CONTINUE ON PAGE 5

Form IA-98163

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
16 SELECTED EXPENSES
Mark "X"
if None

A. Operating expenses (Include payroll, fringe benefits, depreciation, etc. Exclude
cost of goods sold, interest, capital expenditures, and bad debt.) . . . . . . . .

0136

B. Net purchases of merchandise for resale. (Include amounts allowed for tradeins. Exclude returns, allowances, trade/cash discounts, and merchandise for
further processing.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0137

C. Interest (Include both short-term and long-term interest paid in 2012.) . . . . .

5050

$ Mil.

2012
Thou.

Dol.

17 and 18 Not Applicable.
19 KIND OF BUSINESS
Which ONE of the following best describes this establishment's principal kind of business in 2012?
(Mark "X" only ONE box.)
Health care and social assistance

98163058

0700

621 110 00 1

Office of physician (M.D. or D.O.)

621 210 00 2

Office of dentist

621 310 00 2

Office of chiropractor

621 320 00 3

Office of optometrist

621 390 00 1

Office of other health practitioners

621 410 00 6

Family planning center

621 420 00 6

Outpatient mental health and substance abuse center

621 610 00 6

Home health care services

621 910 00 3

Ambulance services

623 310 00 1

Residential care facilities for the elderly

624 110 00 C

Social assistance service for children and youth

624 120 00 C

Social assistance service for the elderly and disabled

624 410 00 7

Child day care services

772 000 00 B

Other health care and social assistance - Specify

0701

Repair and maintenance services
811 110 00 1

General automotive repair shop

811 120 00 1

Automotive body, paint, interior, glass repair, and maintenance

811 190 00 1

Carwash, oil change, lubrication, or other automotive services and maintenance

811 210 00 1

Electronic repair and maintenance

811 310 00 1

Commercial or industrial equipment repair and maintenance
CONTINUE WITH

19

ON PAGE 6
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Form IA-98163

Page 6

(DRAFT)

19 KIND OF BUSINESS - Continued
Repair and maintenance services - Continued
0700

811 420 00 3

Reupholstery and furniture repair

772 000 00 8

Other maintenance and repair services - Specify

0701

Accommodations
721 110 00 6

Hotel or motel

772 000 00 4

Other traveler accommodation - Specify

0701

Food services
722 110 00 4

Full-service restaurant

722 210 00 1

Refreshment place, limited service restaurant, or fast food restaurant

722 320 00 3

Caterer for banquets, weddings, conferences, seminars, etc.

722 410 00 9

Bar, tavern, pub, or other drinking place (alcoholic beverages)

772 000 00 2

Other food services - Specify

0701

Information, professional, business, educational and personal services
511 110 00 1

Newspaper publisher except Internet publisher

511 120 00 2

Periodical publisher and shopping news publisher except Internet publisher

519 130 00 1

Internet publishing and broadcasting

772 200 00 Z

Other publisher except Internet publisher - Specify

512 130 00 1

Motion picture theaters

541 110 00 3

Office of lawyers

541 190 00 1

All other legal services

541 211 00 6

Accounting, tax preparation, bookkeeping, and payroll services

541 310 00 1

Architectural services, excluding landscape

541 330 00 E

Engineering services

541 430 00 1

Graphic design services

541 610 00 1

Management consulting service

541 810 00 3

Advertising agency

98163066

0701

CONTINUE WITH

19

ON PAGE 7
CONTINUE ON PAGE 7

Form IA-98163

Page 7

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS - Continued
Information, professional, business, educational and personal services - Continued
0700

541 900 00 3

Other professional, scientific, and technical services including photographic studios, marketing
research, translation services, and veterinary services

561 310 00 4

Employment placement agency

561 320 00 6

Temporary help services

561 700 00 3

Services to buildings including extermination, janitorial, and landscaping services

611 620 00 1

Sports and recreation instruction services

812 100 00 1

Personal care services including hair, nail, and skin care services or diet center

812 200 00 1

Death care services including funeral homes and cemeteries

812 300 00 1

Drycleaning and laundry services

772 300 00 3

Other personal services - Specify

0701

Transportation and warehousinig
484 110 00 1

General freight trucking

484 120 00 1

Used household and office goods moving

485 310 00 5

Taxi service

485 990 00 2

Other transit and ground passenger transportation

561 510 00 1

Travel agency

561 520 00 2

Tour operator

772 300 00 4

Other travel arrangement and reservation services - Specify

488 110 00 5

Support activities for air transportation

488 410 00 2

Towing services

488 510 00 2

Air, ocean, or other freight forwarder

492 110 00 2

Courier services

492 210 00 4

Local messenger and delivery services

493 110 00 5

Warehousing and storage for general merchandise

562 110 00 3

Waste collection

772 200 00 5

Other transportation and storage services - Specify

98163074

0701

0701

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19

ON PAGE 8
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Form IA-98163

Page 8

(DRAFT)

19 KIND OF BUSINESS - Continued
Retail

98163082

0700

441 110 00 D

Motor vehicle dealer new and used

441 120 00 6

Motor vehicle dealer, used

441 310 00 1

Automotive parts and accessories store

441 320 00 2

Tire dealer

442 110 00 1

Furniture store

442 210 00 1

Floor coverings store

442 290 00 1

Homefurnishing store

443 110 00 1

Household appliance/electronics store

443 120 00 1

Computer and/or software store

444 130 00 1

Hardware store

444 210 00 4

Outdoor power equipment store or dealer

444 220 00 2

Nursery, garden center, or farm supplies store or dealer

445 110 00 6

Supermarket or grocery store

445 120 00 1

Convenience food store

445 200 00 3

Specialty food stores including meat, fish, or fruit and vegetable markets and other specialty
stores

445 210 00 2

Meat market

445 310 00 1

Liquor store

446 110 00 1

Pharmacy or drug store

446 130 00 7

Optical goods store including sunglasses stores

447 110 00 1

Gasoline station with convenience store

447 190 00 1

Gasoline station with no convenience store

448 110 00 1

Men's clothing store

448 120 00 1

Women's clothing store

448 130 00 1

Children's and infants' clothing store

448 140 00 1

Family clothing store

448 210 00 1

Shoe store

448 310 00 1

Jewelry store

448 320 00 1

Luggage and leather goods store

451 110 00 1

Sporting goods store

451 210 00 1

Book/newsstand/comic book store
CONTINUE WITH

19

ON PAGE 9
CONTINUE ON PAGE 9

Form IA-98163

Page 9

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS - Continued
Retail - Continued
0700

452 110 00 1

Department store including discount or mass merchandising

452 990 00 1

General merchandise store, including variety, dollar, and home and auto supply

453 110 00 1

Florist

453 220 00 8

Gift, novelty, craft, and souvenir store

453 210 00 6

Office supply, stationery, and school supplies store

453 310 00 1

Used merchandise store

453 910 00 6

Pet and pet supplies store

772 000 00 9

Other retail business - Specify

0701

Wholesale
772 200 00 7

Merchant wholesaler, durable goods such as automobiles, furniture, construction materials,
equipment and supplies, computer and computer equipment, hardware, appliances, machinery,
etc. - Specify

772 200 00 8

Merchant wholesaler, nondurable goods such as paper, groceries, plastic materials, petroleum
and petroleum products, alcoholic beverages, etc. - Specify

0701

0701

Manufacturing
311 000 00 4

Food manufacturing including fruit and vegetable canning, pickling, and drying of fruits;
seafood preparation and packaging or canning; bread and bakery products; etc.

315 000 00 4

Apparel manufacturing including cutting, sewing, and leather manufacturing

323 000 00 1

Printing and related support activities

772 200 00 Y

Other manufacturing - Specify

98163090

0701

Construction
236 000 00 1

Building construction - residential and nonresidential construction or remodeling/additions to
buildings by general contractors or operative builders

237 000 00 1

Heavy and civil engineering construction including streets, bridges, sewers, land subdivision,
etc.

238 000 00 1

Specialty trade contractors including painting, electrical work, plumbing, site preparation
activities, etc.

CONTINUE WITH

19

ON PAGE 10

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Form IA-98163

Page 10

(DRAFT)

19 KIND OF BUSINESS - Continued
Finance, insurance, and real estate
0700

522 110 00 3

Commercial bank

522 120 00 3

Savings institution

522 130 00 1

Credit union

522 290 00 8

Consumer finance or small loan company

522 310 00 3

Mortgage and other loan brokers

524 110 00 1

Life, accident, health, and medical insurance carrier

524 210 00 E

Insurance agent

531 110 00 2

Lessor of residential buildings and dwellings

531 120 00 2

Lessor of nonresidential buildings

531 210 00 3

Real estate agent or broker

772 000 00 6

Other finance, insurance and real estate - Specify

0701

Rental and leasing services, except real estate
532 100 00 3

Passenger car rental and leasing

532 210 00 1

Consumer electronics and appliances

532 220 00 1

Formal wear and costume rental

532 230 00 3

Video tape/DVD rental store

532 290 00 5

Rental of personal items or items for the home including hospital beds, party supplies, etc.

532 310 00 3

General rental center

532 400 00 4

Commercial and Industrial machinery and equipment rental and leasing

772 200 00 F

Other rental and leasing excluding real estate - Specify

0701

98163108

Other kinds of business or activity
813 110 00 2

Church or other religious organization

813 410 00 3

Civic, social, or fraternal organizations

772 200 00 G

Utility - Specify

814 110 00 1

Private household, employing domestic help, e.g., cooks, maids, etc.

0701

CONTINUE WITH

19

ON PAGE 11

CONTINUE ON PAGE 11

Form IA-98163

Page 11

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS - Continued
Other kinds of business or activity - Continued
0700

110 000 00 1

Crop or animal production or agricultural services

772 000 00 C

Other business or activity - Specify

0701

20 CLASS OF CUSTOMER
2012
Whole percent
of sales and
receipts

A.

Estimate the percentage of sales and receipts generated from exports (Include all exports from Guam
to foreign countries, the United States, and U.S. territories.)

%

0262

2012

B.

Whole percent
of sales and
receipts

Excluding the exports reported in line A, estimate the percentage of this establishment's total sales
(reported in 5 ) by class of customer:
1. Household consumers (excluding visiting tourists) . . . . . . . . . . . . . . . . . . . . . . .

0261

2. Visiting tourists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6252

3. Retailers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0263

4. Wholesalers

0264

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

5. Construction contractors

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

0269

6. Local government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3109

7. Federal government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3105

%
%
%
%
%
%
%

8. Other - Specify
0874

0272

9. TOTAL (Add lines B1 through B8 - should add to 100%) . . . . . . . . . . . . . . . . . . . . . . .

%
1 0 0 %

98163116

21 Not Applicable.

CONTINUE ON PAGE 12

Form IA-98163

Page 12

(DRAFT)

HOW TO
REPORT
PERCENTS

2012
Percent

If figure is 38.76% of total sales:

Report whole percents

3 9 %

22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE

2012
Whole percent
of sales and
receipts

A. Percent of this establishment's sales, shipments, revenue, or other operating receipts (reported in
5 ), for products manufactured at this establishment . . . . . . . . . . . . . . . . . . . . . .

%

0110

B. Briefly describe your principal business activities and report as whole percent of total sales, shipments,
revenue, or other operating receipts reported in 5 (e.g., gasoline 60%, auto repairs 21%, oil 8%).
2012
Census Whole percent
use
of sales and
receipts

Description of principal business activities

0723

0720

1.

19811

2.

19812

3.

19813

0722

%
%
%

Note - Answer 22 C AND 26 only if the principal kind of business activity reported in 19 for this establishment is
HOTEL, MOTEL, or OTHER TRAVELER ACCOMMODATION. Otherwise, go to 27 .
C. Report receipts by source, as a whole percent of total receipts (reported in
data for two or more receipt lines.

5

). Do not combine
2012
Census Whole percent
use
of sales and
receipts

Description of principal business activities

98163124

0723

0720

1. Guestroom or unit rentals, including campground and RV rental fees EXCLUDING
OCCUPANCY TAXES (If meals are included as a room package, estimate the percentage
for meals on line 2.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20010

2. Meals, unpackaged snacks, sandwiches, unpacked ice cream and yogurt, bakery items,
and nonalcoholic beverages generally served for immediate consumption . . . . . . . .

20120

3. Alcoholic drinks served at this establishment . . . . . . . . . . . . . . . . . . . . . .

20130

4. Packaged liquor, wine, and beer . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20140

5. All other merchandise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29810

6. All other nonmerchandise receipts, including receipts from rental of conference/
convention meeting rooms, ballrooms, other public rooms; storage, other services
provided to customers, and receipts OTHER than from customers EXCLUDING SALES
AND OTHER TAXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29980

7. TOTAL (Add lines 1 through 6.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0722

%
%
%
%
%

%
1 0 0 %

23 – 25 Not Applicable.

CONTINUE ON PAGE 13

Form IA-98163

Page 13

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
26 SPECIAL INQUIRIES
NOTE - Answer only if the principal kind of business reported in 19 for this establishment is HOTEL, MOTEL, OR
OTHER TRAVELER ACCOMMODATION. Otherwise, go to 27 .
2012

NUMBER AND TYPE OF ACCOMMODATIONS
1. Number of rooms, units, or quarters primarily rented as transient as of December 31,
2012 (Consists of the number which can be rented as single units. Suites of rooms
which cannot be subdivided should be counted as a single unit.) . . . . . . . . . . .

Number as of
December 31
2402

2. Were more than half of guestroom or unit rental receipts from transient guests?
2921

Yes

2922

No

27 OWNERSHIP
A. Citizenship of majority ownership of this establishment in 2012 (Mark "X" only ONE box.)
6095

U.S. citizen - Guam born

6096

U.S. citizen - Other

6088

Japanese citizen

6089

Filipino citizen

6090

Korean citizen

6085

Dual citizenship/other citizenship - Specify

0885
0699

Not known/not determinable (Such as publicly traded)

98163132

B. Gender of majority ownership of this establishment in 2012 (Mark "X" only ONE box.)
6077

Male-owned

6084

Female-owned

6078

50/50 Male/Female - Equal percent of ownership

6079

Not known/not determinable (Such as publicly traded)

28 and 29 Not Applicable.

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Form IA-98163

Page 14

(DRAFT)

REMARKS (Please use this space for any explanations that may be essential in understanding your reported data.)

$$CENSUS_REMARKS$$

30 CERTIFICATION - This report is substantially accurate and was prepared in accordance with the instructions.

98163140

Is the time period covered by this report a calendar year?
Yes

No - Enter time period covered

Month

Name of person to contact regarding this report

Area code
Telephone

Number

-

Internet e-mail address

Year

Month

FROM

Year

TO

Title

Extension

Area code

Number

Fax

Date
completed

Month

Day

Thank you for completing your 2012 ECONOMIC CENSUS form.
PLEASE PHOTOCOPY THIS FORM FOR YOUR RECORDS AND RETURN THE ORIGINAL.

Year