BLS-Green Form 445 BLS-Green Form 445110

226501521

Green Goods and Services Survey

O.M.B. No. 1220−0181
Expires September 30, 2010

Please return this form within 14 days. If you need help completing this form, contact information is listed
on the last page. Thank you!
Please report for location(s) in

1

xxxx

xxxxxxxxxx
using Unemployment Insurance account number                                                  

What is the address where your business establishment 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

2

Have 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 202-691-5185 or email [email protected].

NAICS code: 445110
Supermarkets and other grocery (except convenience) stores
We have identified your main business
Does NOT include:
activity as the following:
Establishments primarily engaged in:
• Retailing automotive fuels in combination with a
• Retailing a general line of food (canned and
convenience store or food mart
frozen foods, fresh fruits and vegetables,
• Retailing a limited line of goods, known as convenience
fresh and prepared meats, fish, poultry)
stores or food marts
• Includes delicatessen type establishments
• Retailing frozen food and freezer plans via direct sales to
that primarily retail a general line of food
residential customers
• Providing food services in delicatessen-type establishments
• Retailing fresh meat in delicatessen-type establishments

3

What is your business establishment’s fiscal year?   

Please provide us with your fiscal year that includes April 15, 2009 for the location listed in Item 1.

Start of Fiscal Year
MM
DD YYYY

4

End of Fiscal Year
MM
DD YYYY

What is your business establishment’s employment?   
Please provide us with the employment figure you reported on your State’s Quarterly Contributions Report for
September 2009 for the location listed in Item 1. 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 September 12th, 2009.

Employment for pay period that
includes September 12, 2009

Please continue on the next page

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What is your percent revenue from specific product lines?

In Column 1, please estimate the percent of total revenue at the location listed in Item 1 from the sale of USDA
certified organic food products. Please base your estimate on total revenue for your fiscal year from Item 3. The sum

of Column 1 may not equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.
1
Percent of total
revenue

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2

Product line
USDA certified organic products
Other (please specify):
Other (please specify):

What is your contact information? For the 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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Do you have any questions about completing this form?
Please send an email to [email protected], or call (202)-691-5185.

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 1220-0181 and expires on September 30, 2010. Without a currently valid
number BLS would not be able to conduct this survey.

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