Prototype Classifi Prototype Classification Form

Attachment E-1
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 Classification Form

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Classification Form

FORM

OS-81190

OMB No. 0607-0934: Approval Expires

(DRAFT)

DUE DATE
30 DAYS AFTER
RECEIPT OF FORM

OS-81190

Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47134-0001

Need help or have questions
about filling out this form?
Visit www.census.gov/econhelp
- 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.
• 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.
1

Not Applicable.

2

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

81190019

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

0024

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

0047

Town or township

0048

Other

CONTINUE ON PAGE 2

Form OS-81190
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

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

Other - Specify

0815

4 – 18 Not Applicable.
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.
General motor vehicle and repair, including mechanical and electrical repair
0700

811 111 00 1

General motor vehicle and light truck repair shop

811 111 00 2

Truck tractor or trailer repair shop, general

811 111 00 3

Diesel engine repair shop

81190027

Specialized motor vehicle mechanical and electrical repair and maintenance
811 118 20 1

Brake, front end, and/or wheel alignment shop

811 118 90 1

Suspension repair shop (primary for motor vehicles and light trucks)

811 118 30 1

Electrical repair shop (primarily for motor vehicles and light trucks)

811 112 00 1

Exhaust system repair shop

811 198 00 2

Air-conditioning repair shop (primarily for motor vehicles and light trucks)

811 118 10 1

Fuel systems and carburetor repair shop

811 113 00 1

Transmission repair shop

CONTINUE WITH

19

ON PAGE 3

CONTINUE ON PAGE 3

Form OS-81190

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS OR ACTIVITY - Continued
Specialized motor vehicle mechanical and electrical repair and maintenance - Continued
0700

811 118 40 1

Radiator repair shop

777 811 01 1

Other motor vehicle mechanical and electrical repair and maintenance services - Describe type
of vehicles and repair

0701

Motor vehicle body, paint, and interior repair and maintenance
811 121 10 2

Collision or auto body repair shop

811 121 10 1

Paint or body repair shop

811 122 00 1

Glass replacement and repair shop (primarily for motor vehicles)

811 121 10 3

Restoration shop, antique and classic automotive

811 121 30 1

Interior and upholstery repair shop

811 122 00 2

Window tinting services

Other motor vehicle care and maintenance services
811 191 00 1

Oil change and lubrication shop

811 198 00 5

Automotive safety inspection services

811 198 00 3

Automotive emissions testing services

488 410 00 6

Towing or wrecker services

811 192 00 1

Carwash

811 192 00 2

Automotive detailing services

811 198 00 4

Rustproofing, undercoating services

326 212 00 1

Tire retreading and recapping

777 811 01 2

All other motor vehicle care and maintenance services - Describe type of services

0701

81190035

Gasoline service stations and retailers of motor vehicles and parts (retailers may also provide motor
vehicle repair services)
441 320 00 1

New tire dealer

441 120 00 2

Motor vehicle sales, used only

447 190 10 5

Other gasoline service station, excluding truck stops

441 310 40 3

Auto parts/supply store

CONTINUE WITH

19

ON PAGE 4

CONTINUE ON PAGE 4

Form OS-81190

Page 4

(DRAFT)

19 KIND OF BUSINESS OR ACTIVITY - Continued
Gasoline service stations and retailers of motor vehicles and parts (retailers may also provide motor
vehicle repair services) - Continued
0700

447 110 00 1

Gasoline station with convenience store

777 811 01 3

All other automotive activity - Describe type of activity

0701

Other repair and maintenance activity
811 310 90 K

Gasoline engine and/or compressor repair, excluding motor vehicle

811 211 00 2

Stereo, television, VCR, and other consumer electronic equipment repair, excluding computer

811 310 90 3

Electric motor repair or armature rewinding shop

777 811 01 4

All other repair and maintenance services - Describe type of services

0701

Other kind of business or activity
777 811 02 7

Rebuilding or remanufacturing equipment or parts on a factory basis - Describe type of
activity

773 000 00 2

Other kind of business or activity - Describe type of business or activity

0701

0701

20 – 25 Not Applicable.
26 SPECIAL INQUIRIES
MERCHANDISE SALES
1. Did this establishment sell 'new' merchandise, excluding parts installed in repair work, in 2012?
3372

Yes - Go to line 2

3374

No - Go to

30

81190043

2. List below the principal lines of 'new' merchandise sold and indicate the approximate
percentage of each to the total dollar sales and receipts in 2012.
2012
CenPercent of
sus total sales and
use receipts of this
establishment

New merchandise sold

3377

a.

3380

3378

b.

3381

3379

c.

3382

d. TOTAL of 'new' merchandise sold (Add lines a through c) . . . . . . . . . . . . . .

3383

%
%
%
%

27 – 29 Not Applicable.
CONTINUE ON PAGE 5

Form OS-81190

Page 5

(DRAFT)

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

81190050

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