Prototype Standard Prototype Standard Mixed Form

Attachment C-2
2012 Economic Census

Information; Professional, Scientific, and Technical Services; Management of
Companies and Enterprises; Administrative and Support and Waste Management
and Remediation Services; Educational Services; Health Care and Social
Assistance; Arts, Entertainment, and Recreation; and Other Services (Except Public
Administration) Sectors

Prototype Standard Mixed Form

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Services for Children and Youth

FORM

HC-62405

OMB No. 0607-0934: Approval Expires

(DRAFT)

(Please correct any errors in this mailing address.)

DUE DATE
FEBRUARY 12, 2013
Need help or have questions?
• Read the accompanying information sheet(s) before
answering the questions.
• Visit

HC-62405

census.gov/econhelp

• Call 1-800-233-6136, between 8:00 a.m. and 6:00 p.m.,
Eastern time, Monday through Friday.

Report Online - It's fast and secure!
Go to:
census.gov/econhelp

U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47134-0001

Mail your
completed
form to:

- OR -

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.
• Do not put slashes through 0 or 7.

• Please center numbers in
their respective boxes.
• Place an "X" inside the box.

Examples:

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?

62405014

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

Yes - Go to line B
No - Enter
physical
location

0035

Number and street

0036

City, town, village, etc.

0037

State

0038

ZIP Code

CONTINUE WITH
PENALTY FOR FAILURE TO REPORT

2

ON PAGE 2
CONTINUE ON PAGE 2

Form HC-62405
2

Page 2

(DRAFT)

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

Yes

No

0042

0043

No legal boundaries

0044

Do not know

0024

Do not know

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

3

City, village,
or borough

Town or township

0047

0048

Other

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

0013

Temporarily or seasonally inactive

0014

Ceased operation - Give date at right

0015

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

Month

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"
if None

MONTHS IN OPERATION

62405022

Number of months in operation during 2012 (If none, mark "X" and go to

HOW TO
REPORT
DOLLAR
FIGURES

30 .)

. . . . . . . . . .

Mark "X"
if None

Dollar figures should be rounded to
thousands of dollars.
If a figure is $2,035,628.79:

Report

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

Report

$ Bil.

2012
Number

0002

2012
Mil.

2

Thou.

0

3

6

EXAMPLE

CONTINUE ON PAGE 3

Form HC-62405

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
5

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
A. Tax Status
1. Is this establishment operated on a not-for-profit basis?
0106

Yes - Go to line A2

0107

No - Complete line B

2. Was all or part of the income of this establishment or organization exempt from Federal income taxes under
section 501 of the Internal Revenue Code?
0103

Yes - Complete line C

0104

Mark "X"
if None $ Bil.

No - Complete line B

B. Operating receipts of this (taxable) establishment . . . . . . . . . . . .

2012
Mil.

Thou.

Dol.

0100

C. Revenue and expenses of this (tax-exempt) establishment
1. Revenue

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

0101

2. Expenses (Include payroll. Exclude contributions, gifts, and grants
paid.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0140

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.

A. Number of employees for pay period including March 12 . . . . . . . . . . .
B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)

62405030

2012
Number

Mark "X"
if None

For further clarification, see information sheet(s).
0320

Mark "X"
if None

1. Annual payroll . . . . . . . . . . . . . . . . . . . . . . . .

0300

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

0310

. . . . . . . . . .

$ Bil.

2012
Mil.

Thou.

8 – 18 Not Applicable.

CONTINUE ON PAGE 4

Form HC-62405

Page 4

(DRAFT)

19 KIND OF BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's principal kind of business or activity in 2012?
If none of the provided selections seem appropriate, provide a specific description of the primary business activity.
Mark "X" only ONE box.
Child or youth counseling, mentoring, intervention, and therapy services
0700

621 330 00 2

Counseling or therapy services provided by mental health practitioners, excluding services
provided by physicians (Include counseling by psychologists, psychiatric social workers, clinical
psychologists, psychotherapists, etc.)

624 120 00 8

Child early intervention center or services - providing services to children with disabilities or
special needs

624 110 00 2

Mentoring program

624 110 00 1

Other non-medical social assistance counseling services

621 410 00 2

Teen pregnancy counseling services or clinic

621 340 10 1

Speech therapist(s) and/or audiologist(s)

621 340 20 5

Occupational therapist(s)

621 340 20 1

Physical therapist(s)

777 624 01 5

Child care services - Describe

777 624 01 1

Other child or youth counseling or therapy services - Describe

0701

0701

62405048

Child or youth placement and residential care services
624 110 00 3

Adoption and/or foster care placement services

623 990 00 1

Children's home, group foster home, or orphanage

624 221 00 2

Shelter for abused children, including child crisis stabilization centers

624 221 00 3

Center for runaway youth

623 990 00 2

Juvenile correctional center or home

623 210 00 2

Intellectual and developmental disability facility, including group homes and intermediate care
facilities for the intellectually or developmentally disabled (ICF/MR)

623 220 00 1

Residential alcohol or substance abuse rehabilitation facility, excluding nursing care facilities

623 220 00 2

Residential facility for the mentally ill, excluding intellectual and developmental disability
facilities

624 221 00 4

Homeless shelter center

624 229 00 2

Transitional housing

777 624 01 2

Other child or youth residential care facility - Describe

0701

CONTINUE WITH

19

ON PAGE 5
CONTINUE ON PAGE 5

Form HC-62405

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS OR ACTIVITY - Continued
Youth centers, day camps, and selected membership, sports, and recreation programs
0700

713 990 80 3

Day camps, excluding instructional camps

777 624 01 3

Instructional day camp - providing instruction in academics, the arts, sports, and other
disciplines - Describe type of instructional program

713 940 90 3

Youth recreational center

624 110 00 4

Youth center - not primarily providing recreational services

813 410 30 1

Scouting and related youth development membership organization developing life, leadership,
or business skills

713 990 80 5

Youth sport club or program, including after school program

777 624 01 4

All other youth membership, sports, and recreation programs - Describe

0701

0701

62405055

Case management and other social assistance services for children and youth
624 120 00 A

Social work case management services primarily to the elderly, disabled, intellectually and
developmentally disabled, or mentally ill

624 110 00 5

Social work case management services for children without disability or mental illness

624 110 00 6

Multi-service organization providing a range of social assistance services to children and youth

624 210 00 2

Child care food program

624 110 00 7

Court-appointed advocate services - providing services to abused and neglected children in the
juvenile court system

624 110 00 8

Teen outreach program

624 110 00 9

Youth drug and/or alcohol abuse prevention program

624 110 00 A

Youth smoking prevention program

624 110 00 B

Youth HIV/AIDS prevention program

624 310 00 2

Job placement, training, or counseling program, including sheltered workshops

777 620 00 4

Other social assistance services primarily for children or youth - Describe

0701

CONTINUE WITH

19

ON PAGE 6

CONTINUE ON PAGE 6

Form HC-62405

Page 6

(DRAFT)

19 KIND OF BUSINESS OR ACTIVITY - Continued
Services for the elderly, disabled, and intellectually and developmentally disabled
0700

624 120 00 1

Adult activity or day care center

624 120 00 2

Agency for the aging

777 620 00 5

Other social assistance services primarily for the elderly, disabled, or intellectually and
developmentally disabled - Describe

0701

Other individual and family services
624 190 00 1

Community action agency

624 190 00 2

Family service agency

624 190 00 3

Other multi-service organization providing a range of social assistance services to families and
individuals, excluding services primarily to children, the elderly, the disabled, the intellectually
and developmentally disabled, or the mentally ill

777 620 00 6

Other individual and family social assistance services - Describe

0701

Other kind of business or activity
777 620 00 7

Grantmaking or giving organization not directly providing social services - Describe

777 620 00 8

Advocacy group - Describe cause or belief promoted

777 620 00 9

Other social assistance services - Describe

773 000 00 3

Other kind of activity or facility - Describe

0701

0701

0701

0701

62405063

20 and 21 Not Applicable.
22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
(Report receipts or revenue by source (reported in 5 ) in dollar figures. See HOW TO REPORT DOLLAR FIGURES on
page 2. Do not combine data for two or more receipts or revenue lines. Both taxable and tax-exempt establishments
should complete all applicable lines.)
Line 1 - Report receipts from providing a wide variety of non-medical social assistance services to children, youth, and
families, including disabled children. Report receipts from providing food services, shelter services, or emergency relief
services on lines 4 through 6. Report receipts from providing child day care services on line 9.
Line 1c(1) - Report receipts from providing access to a gathering of children, youth, or families with a common
problem or concern to offer advice, emotional support, guidance, and feedback to each other.
Line 1c(2) - Report receipts from providing information and referrals to children, youth, and families on topics such as
abuse, contraception, sexually transmitted disease, and other community resources.
Line 1c(3) - Report receipts from providing immediate help by telephone in the form of non-judgmental, active
listening, and information and referral, that assist the child or youth callers in dealing with an immediate problem.
CONTINUE WITH

22

ON PAGE 7
CONTINUE ON PAGE 7

Form HC-62405

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
Line 2 - Report receipts from providing non-medical social assistance services for elderly and disabled adults.
Examples include prepared meals, home-aide services, vocational rehabilitation services, adult daycare services, social
interaction services, and counseling and information services.
Line 3 - Report receipts from providing social assistance services to the general population. Include counseling and
information services, home-aid services, and vocational rehabilitation; exclude services for children, youth, families, and
elderly and disabled adults. Report receipts from providing food services, shelter services, or emergency relief services
on lines 4 through 6.
Line 8 - Report receipts from providing children and youth with opportunities for social interaction by offering various
programs that support physical, emotional, and intellectual development. Examples include tutoring, after-school
programs, overnight camping trips, team sports, and other recreational programs.
Line 9 - Report receipts from providing daily/recurring custodial care and supervision for children, including disabled
children, who need assistance in a protective setting during the day. Services may be provided in the day-care center,
child's home, or in other private residence. Report preschool receipts, including preschool combined with child day
care, on line 10.
Line 11 - Report receipts from providing a bundle of services offered by civic and social organizations to members in
exchange for payment of nonrefundable initiation fees and/or annual membership dues. Exclude receipts from services
to members of religious congregations, services to members of performing arts organizations, services to members
of other cultural organizations, or membership or initiation fees that are either refundable upon termination of the
membership or are a transferrable asset.
Line 12 - Report receipts from providing seminars, workshops, and other training to promote social assistance.
Line 18 - Report revenue from investments, including interest and dividends. Exclude unrealized gains or losses.
Report proceeds from the sale of investments and other assets on line 19.
Line 19 - Report the net gain (or loss) from the sale or trade of real property and financial assets, such as stocks and
bonds. Exclude unrealized gains or losses.
2012
Description of sales, shipments, receipts, or revenue

Census
use

Estimates are acceptable
$ Bil.

0723

1.

0720

Mil.

Thou.

Dol.

0721

Social assistance services for children, youth, and families
a. Adoption services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30860

b. Foster care and guardianship arrangement services

30870

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

c. Counseling and information services for children, youth, and families
(1)

Self-help group services

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

30891

(2)

Information and referral services . . . . . . . . . . . . . . . . . . . . . . . . .

30892

(3)

Hotline/Crisis intervention services (Include youth telephone hotline
services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30893

62405071

(4)

Other counseling and information services for children, youth, and families
- Describe

30894

(5)

Sum lines 1c(1) through 1c(4) . . . . . . . . . . . . . . . . . . . . . . . . .

30890

d. Other social assistance services for children, youth, and families - Describe

31540

2.

Social assistance services for elderly and disabled adults
CONTINUE WITH

. . . . . . . . . . . . . . .
22

31560

ON PAGE 8
CONTINUE ON PAGE 8

Form HC-62405

Page 8

(DRAFT)

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

Description of sales, shipments, receipts, or revenue

Estimates are acceptable
$ Bil.

0723

3.

0720

Social assistance services for the general population, excluding children, youth,
families, and elderly and disabled adults . . . . . . . . . . . . . . . . . . . . . . . . .

31570

Food, clothing, and related assistance services (Exclude prepared meals for
elderly and disabled adults) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30630

5.

Shelter and related assistance services (Include homeless shelters)

. . . . . . . . .

30640

6.

Emergency relief services

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

31610

7.

Social assistance services for immigrants and refugees

8.

Children and youth recreational programs

9.

4.

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

30620

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

31550

Child day care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30590

10. Pre-primary grade instructional programs (Include preschool programs combined
with child day care) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30690

11. Civic and social organization membership services (Include initiation fees and
dues)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32510

12. Training services related to social assistance . . . . . . . . . . . . . . . . . . . . . . .

30680

13. Outpatient rehabilitation services for substance abuse

30710

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

Mil.

Thou.

Dol.

0721

14. Resale of merchandise - Describe

39661

15. All other operating receipts - Describe if more than 10 percent of total receipts or
revenue

39793

16. OPERATING RECEIPTS - For taxable establishments, sum of preceding
lines should equal 5 , line B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39850

17. Contributions, gifts, and grants

62405089

a. Government

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

39900

b. Private, including individuals, community efforts, and fundraising (Include
commissioned fundraising) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39910

18. Investment income, including interest and dividends . . . . . . . . . . . . . . . . . .

39920

19. Gains (losses) from assets sold (Report losses by including a dash prior to the
dollar amount.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39930

CONTINUE WITH

22

ON PAGE 9

CONTINUE ON PAGE 9

Form HC-62405

Page 9

(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
$ Bil.

0723

0720

Mil.

Thou.

Dol.

0721

20. All other revenue - Describe if more than 10 percent of total receipts or revenue

39983

21. TOTAL REVENUE - For tax-exempt establishments, sum of lines should
equal 5 , line C1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39990

23 – 25 Not Applicable.
26 SPECIAL INQUIRIES
A. GRANTS, TRANSFERRED CONTRIBUTIONS, AND SIMILAR PAYMENTS OF TAX-EXEMPT ESTABLISHMENTS
(To be completed only by those indicating "Yes" in

5

, line A2.)

1. During 2012, did this establishment do any of the following:
• award grants
• make gifts or contributions
• make payments to, or on behalf of, specific individuals
• pay assessments (dues) to the parent or other chapters of the same organization
• transfer funds raised by this establishment to charities or other organizations for charitable purposes?
3861

Yes - Go to line 2

3862

No - Go to B

2012
$ Bil.

2. Amount of grants, transferred contributions, and similar payments . . . . .
B. SOCIAL ASSISTANCE
Estimate the percent of receipts for social assistance services reported in
the following payers:

22 ,

Mil.

Thou.

Dol.

3865

2012
Percent

lines 1 through 8, from

1. Government payers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3741

2. Private payers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3742

3. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
%
1 0 0 %

C. FRANCHISE

62405097

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

Yes - franchisee owned establishment

0238

Yes - franchisor owned establishment

0239

No

27 – 29 Not Applicable.

CONTINUE ON PAGE 10

Form HC-62405

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

62405105

Yes

Month

No - Enter time period covered

Telephone

-

Year

TO
Title

Number

-

Month

FROM

Name of person to contact regarding this report

Area code

Year

Extension

-

Area code

Fax

E-mail address

Number

Month

Day

Date
completed

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

Year