Various Economic Area Pretesting Activities

Generic Clearence for Questionnaire Pretesting Research

omb1133SBOenc2

Various Economic Area Pretesting Activities

OMB: 0607-0725

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0725 can be found here:

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10022010
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
FORM

SBO-2

2012 SURVEY OF BUSINESS OWNERS AND
SELF-EMPLOYED PERSONS
OMB No. 0607-0943: Approval Expires xx/xx/xxxx

(08-31-2011) Draft 1

DUE DATE
30 days after receipt of form

Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
- OR -

Report online at:
www.census.gov/econhelp/sbo
Need help or have questions
about completing this form?
Visit www.census.gov/econhelp
Call 1-888-824-9954, between
8 a.m. and 6 p.m., Eastern time,
Monday through Friday.
- OR -

Write to the address above.
Include your 11-digit Census
File Number (CFN) printed in
the mailing address.
(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.

➜

Start Here

Please PRINT the first and last name of the person who
is filling out this form.
Name

The Census Bureau is responsible for
collecting information on the U.S. economy.
• The data that you provide will be combined with
the responses from other businesses and
business owners.

Include today’s date and a telephone number so we can
contact you if there is a question.

• Survey results will contain information on the
demographic and economic composition of
businesses in the United States.

YYYY

• Your response is important, and we keep your
answers confidential.
Area code

This form asks for two types of information:
• specific information about the business

Number

–

• information about the principal business owners
Extension

INSTRUCTIONS
Please read the enclosed insert before
answering the questions.
• Use blue or black ink.
• Place an "✘" inside the box.

✘

• Center numbers in boxes.
• Do not put slashes through 0 or 7.

7 0

➜

Please turn to the next page to continue.

§+#5+¤

10022028

Please answer the following questions for the self-employment or business activity of the person(s) or
business named in the mailing label even if the business has since been sold, reorganized, or discontinued.
You may use estimates if this form requests information that is not available in your business records.
An enclosure with answers to the most frequently asked questions regarding this survey has been provided.
1 In 2012, did another company or organization own more
than 50% of this business?
Yes - Go to 26 on Page 5

C. As of December 31, 2012, how many owners were
there in this business?
• Do not combine two or more owners to create
one owner.
• Count spouses and partners as separate owners.

2 In 2012, did employees under an Employee Stock
Ownership Plan (ESOP) own more than 50% of this
business?
Yes - Go to 26 on Page 5

3 In 2012, did members in a cooperative or club own more
than 50% of this business?
Yes - Go to 26 on Page 5

4 In 2012, did an estate or trust own more than 50% of this
business?
Yes - Go to 26 on Page 5

5 In 2012, did an Alaska Native Regional or Village
Corporation or an American Indian tribal entity own
more than 50% of this business?
Yes - Go to 26 on Page 5

5–9

10 – 49

50 or more

Unknown

D. For the person(s) owning the largest percentage(s)
in this business in 2012, please list the percentage
owned by each person and his or her position title.
• Do not report percentages owned by parent
companies, estates, trusts, etc.
• If more than 4 persons owned this business equally,
select any 4.
• Round percentages to whole numbers. For example,
report 1/3 ownership (33.3%) as:

3 3. 0 %

6 In 2012, was this business a nonprofit organization?
Position Title

Yes - Go to 26 on Page 5

Percentage Owned
(Estimates are
acceptable)

7 In 2012, was this business a publicly held corporation?
Yes

Owner 1:

. 0 %

Owner 2:

. 0 %

Owner 3:

. 0 %

Owner 4:

. 0 %

(Example: sole owner,
co-owner, shareholder,
president,
vice president, etc.)

8 In 2012, did any individual own 10% or more of the
rights, claims, interests, or stock in this business?
Yes

No - Go to 26 on Page 5

9 A. In 2012, was this business jointly owned by a
husband and wife?
Yes, equally operated by husband and wife
Yes, but primarily operated by husband
Yes, but primarily operated by wife
No
B. In 2012, did two or more members of the same family
own the majority of this business? (Family refers to
spouses, parents/guardians, children, siblings, or
close relatives.)
Yes

FORM SBO-2 (08/31/2011)

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10022036

Owner 1

Owner 2

Please answer the following questions about Owner 1
listed in 9 D on Page 2.

Please answer the following questions about Owner 2
listed in 9 D on Page 2.

10 What is the sex of Owner 1?

14 What is the sex of Owner 1?

Male

Female

Male

Female

Please answer BOTH Question 11 about
Please answer BOTH Question 15 about
☞ NOTE:
☞ NOTE:
Hispanic origin and Question 12 about race. For
Hispanic origin and Question 16 about race. For
this survey, Hispanic origins are not races.
11 Is Owner 1 Spanish/Hispanic/Latino?

this survey, Hispanic origins are not races.
15 Is Owner 2 Spanish/Hispanic/Latino?

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin - Print
origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

12 What is Owner 1’s race? Mark ✘ one or more races.
White

Black, African Am., or Negro

16 What is Owner 2’s race? Mark ✘ one or more races.
White

Black, African Am., or Negro

American Indian or Alaska Native - Print name of
enrolled or principal tribe. C

Asian Indian

Japanese

Asian Indian

Japanese

Chinese

Korean

Chinese

Korean

Filipino

Vietnamese

Filipino

Vietnamese

Other Asian - Print race, for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander - Print race, for example, Fijian,
Tongan, and so on. C

Some other race - Print race C

13 A. Is Owner 1 a veteran of any branch of the U.S. military
service including the Coast Guard?
Yes

No - Go to 14

B. (If Yes) Was Owner 1 disabled as the result of injury
incurred or aggravated during active military service?
Yes
FORM SBO-2 (08/31/2011)

17 A. Is Owner 2 a veteran of any branch of the U.S. military
service including the Coast Guard?
Yes

No - Go to 18

B. (If Yes) Was Owner 2 disabled as the result of injury
incurred or aggravated during active military service?
Yes

§+#5E¤

10022044

Owner 3

Owner 4

Please answer the following questions about Owner 3
listed in 9 D on Page 2.

Please answer the following questions about Owner 4
listed in 9 D on Page 2.

18 What is the sex of Owner 3?

22 What is the sex of Owner 4?

Male

Female

Male

Female

Please answer BOTH Question 19 about
Please answer BOTH Question 23 about
☞ NOTE:
☞ NOTE:
Hispanic origin and Question 20 about race. For
Hispanic origin and Question 24 about race. For
this survey, Hispanic origins are not races.
19 Is Owner 3 Spanish/Hispanic/Latino?

this survey, Hispanic origins are not races.
23 Is Owner 4 Spanish/Hispanic/Latino?

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin - Print
origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

20 What is Owner 3’s race? Mark ✘ one or more races.
White

Black, African Am., or Negro

24 What is Owner 4’s race? Mark ✘ one or more races.
White

Black, African Am., or Negro

American Indian or Alaska Native - Print name of
enrolled or principal tribe. C

Asian Indian

Japanese

Asian Indian

Japanese

Chinese

Korean

Chinese

Korean

Filipino

Vietnamese

Filipino

Vietnamese

Other Asian - Print race, for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander - Print race, for example, Fijian,
Tongan, and so on. C

Some other race - Print race C

21 A. Is Owner 3 a veteran of any branch of the U.S. military
service including the Coast Guard?
Yes

No - Go to 22

B. (If Yes) Was Owner 3 disabled as the result of injury
incurred or aggravated during active military service?
Yes
FORM SBO-2 (08/31/2011)

25 A. Is Owner 4 a veteran of any branch of the U.S. military
service including the Coast Guard?
Yes

No - Go to 26

B. (If Yes) Was Owner 4 disabled as the result of injury
incurred or aggravated during active military service?
Yes

§+#5M¤

10022051

26 A. Is this business currently operating?
Yes

B. (If No) Did the operations cease for any of the reasons
listed below? Mark ✘ all that apply.
Owner(s) retired

Lack of personal
loans/credit

Owner(s) deceased

Started another business

Operated for
a specific or
one-time event
Inadequate cash
flow or low sales

Sold this business
Other

Thank you for participating in the Survey of Business
Owners and Self-Employed Persons.
Please return the completed original questionnaire in the
postage-paid envelope. Make sure the barcode above your
address shows in the window of the envelope. Please make
a photocopy of this form for your records.
If the envelope has been misplaced, please mail the form to:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001

Lack of business
loans/credit
Remarks

FORM SBO-2 (08/31/2011)

§+#5T¤

File Type	application/pdf
File Title	sbo2_p01_12.g
File Modified	2011-10-06
File Created	2011-08-31