Prototype Standard Prototype Standard Form

Attachment C
2012 Economic Census
Retail Trade and Accommodation and Food Services Sectors
Standard Forms
C-1.
C-2.
C-3.
C-4.
C-5.
C-6.

Prototype Standard Form
Variable Content for Item 19—Kind of Business
Variable Content for Item 22—Detail of Sales, Shipments, Receipts,
or Revenue
Variable Content for Item 26—Special Inquiries
Content for Item 27—Leased Departments
Ownership or Control Fliers

Attachment C
Page 1 of 2
2012 Economic Census
Retail Trade and Accommodation and Food Services Sectors
Standard Forms
For 2012, we will use 33 standard report forms. All standard report forms will contain
inquiries similar to those illustrated on the prototype form in Attachment C-1, except
where noted. The report forms have the following general inquiries:
1.
2.
3.
4.
5.
6.
7.
8.-18.
19.
20.

Employer Identification Number
Physical Location
Operational Status
Months in Operation
Sales, Shipments, Receipts, or Revenue
Not applicable
Employment and Payroll
Not applicable
Kind of Business (varies by form; see Attachment C-2)
Class of Customer (variation below for Accommodation and Food Services
forms)

CLASS OF CUSTOMER
Estimate the percentage of this establishment’s total sales (reported in 5) by class of
customer.
2012
Whole percent of
sales and receipts
1.
2.
3.
4.

21.
22.
23.
24.
25.
26.

Household consumers and individuals………………………………XXX %
Businesses (billed to expense accounts)……………………………..XXX %
Governmental bodies (Federal, state, and local)……………………..XXX%
TOTAL………………………………………………………………..100 %

Method of Selling (not applicable for Accommodation and Food Services
forms)
Detail of Sales, Shipments, Receipts, or Revenue (varies by form; see
Attachment C-3)
Not applicable
Shipping and Handling (not applicable for forms RT-44701, RT-45402, and
Accommodation and Food Services forms)
Not applicable
Special Inquiries (varies by form; see Attachment C-4)

Attachment C
Page 2 of 2
27.
28.
29.
30.

Leased Departments (appears on forms RT-45201 and RT-45202; see
Attachment C-5)
Not applicable
Not applicable
Certification

Attachment C-1
2012 Economic Census
Retail Trade and Accommodation and Food Services Sectors
Prototype Standard Form

Attachment C-1

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Automobile Dealers

FORM

RT-44101

OMB No. : Approval Expires

(DRAFT)

DUE DATE
FEBRUARY 12, 2013
RT-44101

Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47134-0001
Please read the accompanying
information sheet(s) before
answering the questions.

PROTOTYPE

Need help or have questions
about filling out this form?
Visit www.census.gov/
econhelp

4/18/2011

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 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.
• Use blue or black ballpoint pen.
• Do not use pencil or felt-tip pen.
• Place an "X" inside the box.

• Please center numbers in their respective boxes.
• Do not put slashes through 0 or 7.

Examples:

0 1 2 3 4 5 6 7 8 9

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. 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, Employer's Quarterly Federal Tax Return?
0021

2

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

44101012

Yes - Go to

0032

Yes - Go to line B
No - Enter
physical
location

0035

Number and street

0036

City, town, village, etc.

0037

State

0038

ZIP Code

B. Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
(Mark "X" only ONE box.)
0041

Yes

0042

No

0043

No legal boundaries

0044

Do not know

C. In what type of municipality is this establishment physically located? (Mark "X" only ONE box.)
0046

City, village, or borough

PENALTY FOR FAILURE TO REPORT

USCENSUSBUREAU

0047

Town or township

0048

Other

0024

Do not know

CONTINUE ON PAGE 2

Form RT-44101
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

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

0063

City, town, village, etc.

0064

State

0065

ZIP Code

0016

4

Other - 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 $ Bil.

Dollar figures should be rounded to
thousands of dollars.

0002

2012
Mil.

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 $ Bil.

Sales of merchandise and other operating receipts (Exclude sales taxes or
other taxes collected.) . . . . . . . . . . . . . . . . . . . . . . . . . .

44101020

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

2012
Mil.

Thou.

Dol.

0100

6

Not Applicable.

7

EMPLOYMENT AND PAYROLL
Include:
• Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue
Service Form 941, Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number
(EIN) shown in the mailing address or corrected in 1 .
Exclude:
• Temporary staffing obtained from a staffing service.
• Contractors, subcontractors, or independent contractors.
• Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN.
• Purchased or managed services, such as janitorial, guard, or landscape services.
• Professional or technical services purchased from another firm, such as software
consulting, computer programming, engineering, or accounting services.
2012
Number

Mark "X"
if None

For further clarification, see information sheet(s).
A. Number of employees for pay period including March 12 . . . . . . . . . . . . . .

0320

Mark "X"
if None $ Bil.

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

0300

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

0310

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

Dol.

2012
Mil.

Thou.

Dol.

CONTINUE ON PAGE 3

Form RT-44101

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
8 – 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.)
0700

441 110 00 1

Motor vehicle sales, new

441 120 00 2

Motor vehicle sales, used only

423 110 50 3

Heavy duty truck dealer, new and used

441 320 00 5

Tire dealer, new

441 310 40 3

Auto parts/supply store

441 310 50 1

Used automobile parts dealer

423 930 11 2

Automotive scrap dealer

447 190 10 1

Gasoline station

441 229 00 5

Snowmobile dealer

441 221 00 4

Motorcycle dealer

441 210 00 7

Recreational vehicle (RV) and RV parts dealer, including travel trailers, 5th wheels, camping
trailers, motor homes, truck campers, van campers, etc.

441 229 00 2

Utility trailer dealer, including horse/livestock trailers

441 222 00 1

Boat/marine dealer

441 221 00 5

All-terrain vehicle (ATV) dealer, including motor bikes, motor scooters, and mopeds

811 121 10 1

Paint or body repair shop

532 111 00 2

Passenger car rental

532 112 00 2

Passenger car leasing

777 440 00 1

Automotive repair, specialized - Specify

811 111 00 4

Automotive repair, general

772 000 00 1

Other kind of business - Specify

44101038

0701

0701

20 CLASS OF CUSTOMER
A. As a general business practice, did this establishment sell to household consumers and individual users in 2012?
0251

Yes

0252

No

CONTINUE WITH

20

ON PAGE 4

CONTINUE ON PAGE 4

Form RT-44101

Page 4

(DRAFT)

20 CLASS OF CUSTOMER - Continued
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2012?
0256

Yes

0257

No

C. Did this establishment require proof of business or professional license from new customers in 2012?
0276

Yes

0277

No
2012

D. Estimate the percentage of this establishment's total sales (reported in
(Circle all that apply and then report percentages for the items circled.)

5

Whole percent
of sales and
receipts

) by class of customer.

1.

Household consumers and individuals

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

0261

2.

Retailers for resale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0263

3.

Wholesalers/distributors for resale

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

0264

4.

Repair shops for use in repair work . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0265

5.

Manufacturing and mining industrial users for use as input goods in production . . . . . . .

0266

6.

Restaurants, hotels, food services, and contract feeding

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

0267

7.

Businesses for end use in their own operation, not for resale or production . . . . . . . . .

0268

8.

Building contractors, heavy construction, and special trade contractors . . . . . . . . . . .

0269

9.

Farmers for use in farm production . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0270

10. Governmental bodies (Federal, state, and local) . . . . . . . . . . . . . . . . . . . . . .

0271

11. Export sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0262

%
%
%
%
%
%
%
%
%
%
%

12. Other - Specify
0874

0272

1 0 0 %

44101046

13. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

CONTINUE ON PAGE 5

Form RT-44101

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
21 METHOD OF SELLING
Which ONE of the following best describes this establishment's principal method of selling in 2012?
(Mark "X" only ONE box.)
0751

Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)

0752

Store or display showroom (selling from a fixed or permanent location with physical displays of priced
merchandise and/or from a counter)

0753

Warehouse or office (including telephone/fax orders or outside sales representatives)

0754

Mail order

0755

Home shopping via television

0756

Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party
plan, or temporary kiosk sales)

0757

Vending machines

0758

Other - Specify

0759

2012

HOW TO
REPORT
PERCENTS

Estimates are acceptable.
Report dollars OR percents.
$ Bil.

If figure is 38.76% of
total sales:

Mil.

Thou.

Dol.

Percent

Report whole percents

3 9

22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
(Report sales for each product line sold by this establishment, either as a dollar figure or as a whole percent of total
sales (reported in 5 ). See HOW TO REPORT DOLLAR FIGURES on page 2 and HOW TO REPORT PERCENTS above.)
2012
Census
use

Description of sales, shipments, receipts, or revenue

Estimates are acceptable.
Report dollars OR percents.
$ Bil.

0723

44101053

1.

0720

0721

Mil.

Thou.

Dol.

Percent
0722

Cars, trucks, motorcycles, and other powered transportation vehicles,
including all outright sales plus the fair sales value of all motor vehicles
marketed under leases negotiated in 2012, transportation and dealer
preparation charges, and dealer installed options (Deduct discounts
granted to the purchaser as an increase in trade-in allowance over
fair market value and manufacturers' rebates and incentives. Report
receipts from the rental of automobiles or trucks on line 10a, labor
charges on line 10, and the value of service contracts on line 10b.)
a. New passenger cars -- retail

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

20701

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

20715

c. New passenger cars -- fleet . . . . . . . . . . . . . . . . . . . . . . . . .

20702

d. New vans and trucks -- retail, including minivans, cargo vans, sport
utility vehicles (SUVs), and light passenger trucks . . . . . . . . . . .

20703

e. New vans and trucks -- leased, including minivans, cargo vans, sport
utility vehicles (SUVs), and light passenger trucks . . . . . . . . . . .

20716

f. New vans and trucks -- fleet, including minivans, cargo vans, sport
utility vehicles (SUVs), and light passenger trucks . . . . . . . . . . .

20704

b. New passenger cars -- leased

CONTINUE WITH

22

ON PAGE 6
CONTINUE ON PAGE 6

Form RT-44101

Page 6

(DRAFT)

22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE - Continued
2012
Census
use

Description of sales, shipments, receipts, or revenue

Estimates are acceptable.
Report dollars OR percents.
$ Bil.

0723

1.

0720

g. Used passenger cars -- retail, including sales of passenger cars
previously rented or leased . . . . . . . . . . . . . . . . . . . . . . . . .

20705

h. Used passenger cars -- wholesale (for resale), including sales of
passenger cars previously rented or leased . . . . . . . . . . . . . . .

20706

i. Used vans, minivans, trucks, and buses -- retail, including sales of
vans, minivans, and light passenger trucks previously rented or
leased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20707

j. Used vans, minivans, trucks, and buses -- wholesale, including sales
of vans, minivans, and light passenger trucks previously rented or
leased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20708

k. New and used medium- and heavy-duty trucks and buses

. . . . . .

20717

l. Motorcycles, motor scooters, motor bikes, including parts and
accessories (Report parts, paint, and materials installed in repair on
line 10.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20709

m. All other powered transportation vehicles

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

20711

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

20700

Thou.

Dol.

Percent
0722

Automotive tires, tubes, batteries, audio equipment, components, parts
and accessories (Report parts, paint, and materials installed in repair on
line 10.)
a. Automotive tires and tubes

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

20741

b. Automotive batteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20749

c. Automotive parts, new and rebuilt, including wheels

. . . . . . . . .

20755

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

20753

e. Automotive audio equipment, components, parts, and accessories,
including radios, stereos, compact disc players, mp3 players (audio
only), and other sound reinforcement and recording equipment . . .

20754

f. Automotive accessories, including safety and comfort related items
(Report infant and booster car seats on line 2h.) . . . . . . . . . . . .

20756

g. Automotive supplies, including appearance and maintenance
chemicals, automotive paint, antifreeze, functional fluids, etc.
(Report lubricants on line 4.) . . . . . . . . . . . . . . . . . . . . . . . .

20757

h. Infant and booster car seats

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

20758

i. Sum lines 2a through 2h . . . . . . . . . . . . . . . . . . . . . . . . .

20740

3.

Automotive fuels

20720

4.

Automotive lubricants, including oil, greases, etc.

d. Automotive parts, used, including wheels

44101061

Mil.

Cars, trucks, motorcycles, and other powered transportation vehicles,
including all outright sales plus the fair sales value of all motor vehicles
marketed under leases negotiated in 2012, transportation and dealer
preparation charges, and dealer installed options - Continued

n. Sum lines 1a through 1m
2.

0721

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

CONTINUE WITH

22

20730

ON PAGE 7
CONTINUE ON PAGE 7

Form RT-44101

Page 7

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE - Continued
2012
Census
use

Description of sales, shipments, receipts, or revenue

Estimates are acceptable.
Report dollars OR percents.
$ Bil.

0723

5.

0720

44101079

Mil.

Thou.

Dol.

Percent
0722

Boats and other sport vehicles, including personal watercraft,
snowmobiles, all-terrain vehicles (ATVs), golf cars, parts and
accessories (Report motorcycles on line 1l.)
a. New boats, canoes, kayaks, motors, parts and accessories

6.

0721

. . . . . .

20591

b. Used boats, canoes, kayaks, motors, parts and accessories . . . . . .

20592

c. All-terrain vehicles (ATVs) and personal watercraft . . . . . . . . . . .

20593

d. All other sport vehicles, including snowmobiles, golf cars, go-carts,
parts and accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20599

e. Sum lines 5a through 5d . . . . . . . . . . . . . . . . . . . . . . . . .

20590

Recreational vehicles, including camping trailers, travel trailers, truck
campers, motor homes, parts and accessories (Report motorcycles on
line 1l.)
a. New recreational vehicles, parts and accessories, including motor
homes, truck campers (for mounting on pick-up trucks), and
camping and travel trailers . . . . . . . . . . . . . . . . . . . . . . . . .

20588

b. Used recreational vehicles, parts and accessories

. . . . . . . . . . .

20589

c. Sum lines 6a and 6b . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20580

7.

Sporting goods and recreational equipment . . . . . . . . . . . . . . . . .

20530

8.

Utility trailers, including horse/livestock trailers . . . . . . . . . . . . . . .

20864

9.

All other merchandise (Report receipts for services on line 10. Report
receipts from the rental of automobiles or trucks on line 10a, and the
fair sales value of leased motor vehicles on line 1.) Specify principal
lines and estimated sales below . . . . . . . . . . . . . . . . . . . . . . . .

29810

a.

29811

b.

29812

c.

29813

10. All nonmerchandise receipts, including rentals, storage, and other
services provided to customers EXCLUDING SALES AND OTHER
TAXES (Report receipts from the rental of automobiles or trucks on line
10a, and the fair sales value of leased motor vehicles on line 1.)
a. Rental of automobiles or trucks

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

29919

b. Value of service contracts . . . . . . . . . . . . . . . . . . . . . . . . . .

29943

c. Labor charges to customers for work performed by this
establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29916

d. Labor charges to insurance companies for work performed by this
establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29931

CONTINUE WITH

22

ON PAGE 8
CONTINUE ON PAGE 8

Form RT-44101

Page 8

(DRAFT)

22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE - Continued
2012
Description of sales, shipments, receipts, or revenue

Census
use

Estimates are acceptable.
Report dollars OR percents.
$ Bil.

0723

0720

Mil.

Thou.

Dol.

0721

Percent
0722

10. All nonmerchandise receipts, including rentals, storage, and other
services provided to customers EXCLUDING SALES AND OTHER
TAXES - Continued
e. Labor charges for warranty and extended contract work by this
establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29947

f. Labor charges for internal and sublet repair

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

29966

g. Parts, paint, and materials installed in repair and charged directly to
customers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29949

h. Parts, paint, and materials installed in repair and charged to
insurance companies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29958

i. Parts, paint, and materials installed in repair and covered by
warranty or extended service contract . . . . . . . . . . . . . . . . . .

29971

j. Parts, paint, and materials sold internally and installed in repair . . .

29973

k. Commissions received for the sale of credit life insurance and the
arrangement of financing . . . . . . . . . . . . . . . . . . . . . . . . . .

29944

l. All other nonmerchandise receipts

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

29974

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

29900

m. Sum lines 10a through 10l
11. TOTAL (Should equal

5

if reporting in dollars.)

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

1 0 0

29990

23 Not Applicable.
24 SHIPPING AND HANDLING
A. Did this establishment have any receipts from customers for shipping and handling of merchandise in 2012?
0981

Yes - Go to line B

0982

No - Go to

2012
Estimates are acceptable
$ Bil.
Mil.
Thou.
Dol.

26

B. Receipts of this establishment from customers for shipping and handling of
merchandise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0985

44101087

C. Are receipts for shipping and handling included in sales and receipts (reported in
0988

Yes

0989

No

5

)?

25 Not Applicable.

CONTINUE ON PAGE 9

Form RT-44101

Page 9

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
26 SPECIAL INQUIRIES
A. SOLD OR LEASED VEHICLES
1. Leased motor vehicles

Mark "X"
if None $ Bil.

a. Fair sales value of leased motor vehicles for this establishment
(Include the fair sales value of leases marketed in 2012, regardless
of whether this establishment held them.) . . . . . . . . . . . .

2160

b. Motor vehicle lease payments received by this establishment . . .

2161

2012
Mil.

B.

Dol.

2012
Number

2. Number of units sold or leased by this establishment for each of the following types of
vehicles:
a. New passenger cars sold

Thou.

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

2162

b. Used passenger cars sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2163

c. New passenger cars leased

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

2164

d. New vans and trucks sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2165

e. Used vans and trucks sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2166

f. New vans and trucks leased . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2167

g. Used passenger cars, vans, and trucks leased . . . . . . . . . . . . . . . . . . . .

2168

h. TOTAL (Sum lines 2a through 2g) . . . . . . . . . . . . . . . . . . . . . . . . .

2169

FRANCHISE
1. Was this establishment operating under a trademark(s) authorized by a franchisor in 2012?
(Mark "X" only ONE box.)
0237

Yes - franchisee-owned establishment

0238

Yes - franchisor-owned establishment

0239

No

2. If yes, provide the trademark(s) below.

0236

44101095

27 – 29 Not Applicable.

CONTINUE ON PAGE 10

Form RT-44101

Page 10

(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.

44101103

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

No - Enter time period covered

Month

FROM

Name of person to contact regarding this report

Area code

Telephone

Number

-

E-mail address

Year

Month

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