MA-10000(S) 2011 Annual Survey of Manufactures (Short Form)

Attachment C
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

2011 ANNUAL SURVEY OF MANUFACTURES

FORM

MA-10000(S) (DRAFT)

OMB No. 0607-0449: Approval Expires 10/31/2011
MA-10001

Need help or have questions about
filling out this form?
Visit www.census.gov/econhelp/dir1
Call:
- OR Write to the address below. Include
your 11-digit Census File Number (CFN)
printed in the mailing address.
Mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001

(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:

Please read the accompanying instructions before answering the questions. The reporting unit for this form is
an establishment which 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 to the left of the mailing address the same as the EIN used for this
establishment on its latest 2011 Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return?

Yes - Go to

2

0022

No - Enter current EIN (9 digits)

0025

-

10001014

0021

PENALTY FOR FAILURE TO REPORT

CONTINUE ON NEXT PAGE

Form MA-10000(S) (DRAFT)
If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
2

PHYSICAL LOCATION
A. Is this establishment's physical location the same as shown to the left of 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

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

Do not know

0044

C. In what type of municipality is this establishment physically located? (Mark "X" only ONE box.)
City, village, or
Town or
0046
0047
0048
0024
borough
township
Other
Do not know
3

OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of
2011? (Mark "X" only ONE box.)
0011

In operation

0016

Under construction, development, or exploration

0013

Temporarily or seasonally inactive

0014

Ceased operation - Give date at right

0015

0018

Month

Day

Year

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

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

10001022

-

CONTINUE ON NEXT PAGE

Form MA-10000(S) (DRAFT)
If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
4

Mark "X" 2011
if None Number

MONTHS IN OPERATION

Number of months in operation during 2011 (If none, mark "X" and go to

Dollar figures should be rounded
to thousands of dollars.

HOW TO
REPORT
DOLLAR
FIGURES

5

Report

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

Report

0002

2011
Mil.

$ Bil.

2

Thou.

0 3 6

EXAMPLE

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Mark "X"
if None

6

. . . . . . . . . .

Mark "X"
if None

If a figure is $2,035,628.79:

Total value of products shipped and other receipts
(Report detail in 22 .) . . . . . . . . . . . . . .

30 .)

$ Bil.

2011
Mil.

2010
$ Thou.

Thou.

0100

E-SHIPMENTS
A. Did this plant use any electronic network to control or coordinate the flow of any of the shipments of goods reported
in 5 ? Or, were the orders for any of the shipments reported in 5 received over an electronic network?
Electronic networks include:
• Electronic Data Interchange (EDI)
• E-mail
• Internet
0181

Yes - Go to line B

0182

• Extranet
• Other online systems
No - Go to

7

0109

2010
Percent

%

%

10001030

B. Percent of total reported in 5 that were ordered, or whose movement was
controlled or coordinated over electronic networks (Report whole percents.
Estimates are acceptable.) . . . . . . . . . . . . . . . . . . . . . . . . .

2011
Percent

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Form MA-10000(S) (DRAFT)
If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
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 to the left of the mailing address or corrected in 1 .
• Spread on stock options that are taxable to employees as wages.
Exclude:
• Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN.
• Temporary staffing obtained from a staffing service.
For further clarification, see information sheet(s).

1. Number of production workers for pay period including
March 12 . . . . . . . . . . . . . . . . . . . . . . .

0325

2. All other employees for pay period including March 12 . .

0353

3. TOTAL(Add lines A1 and A2) . . . . . . . . . . . . . .

0356

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

Mark "X"
if None

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

0300

2. First quarter payroll (January-March 2011) . . . . .

0310

8

Not Applicable.

9

INVENTORIES
Report total inventories,
regardless of where
held, before Last-in,
First-out adjustments
(if any) owned by this
Mark "X"
establishment as of
if None
December 31. Include
finished goods, workin-process, materials,
supplies, fuels, etc. . . . 0460

2011
Number

Mark "X"
if None

A. Number of employees

$ Bil.

End of 2011
Mil.

Thou.

2010
Number

2011
Mil.

$ Bil.

Mark "X"
if None

2010
$ Thou.

Thou.

End of 2010
Mil.

$ Bil.

Thou.

0470

10 – 12 Not Applicable.

10001048

13 CAPITAL EXPENDITURES
(Refer to the instructions on how to report leasing arrangements.)
Report the dollar value of capital expenditures.
Mark "X"
(Do not include land.)
if None
$ Bil.
Total capital expenditures for new and used
buildings, machinery and equipment . . . . . .

2011
Mil.

Thou.

2010
$ Thou.

2011
Mil.

Thou.

2010
$ Thou.

0520

14 RENTAL PAYMENTS
(Exclude capital leases. Include operating leases.)
Total costs for rental or lease of buildings
and equipment (Including portable structures,
machinery, tools, office equipment, vehicles, and
other tangible items used at this establishment.) .

Mark "X"
if None

$ Bil.

0550

15 Not Applicable.
CONTINUE ON NEXT PAGE

Form MA-10000(S) (DRAFT)
If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
16 SELECTED EXPENSES AND DEPRECIATION
A. Cost of materials, parts, containers, packaging,
etc., used; cost of products bought and sold
without further processing; cost of purchased
fuels consumed for heat, power, or the
generation of electricity; cost of purchased
electricity; and cost of work done for you by
others on your materials . . . . . . . . . . .

0420

B. Normal depreciation charges for all tangible
assets including buildings, machinery, and
equipment . . . . . . . . . . . . . . . . .

0540

Mark "X"
if None

$ Bil.

2011
Mil.

Thou.

2010
$ Thou.

10001055

17 – 21 Not Applicable.

CONTINUE ON NEXT PAGE

Form MA-10000(S) (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
If you cannot locate the description of any products that you produce, please enter a description of your products
in column (a) and enter their value in column (c). If additional lines are needed please use the "REMARKS" section.
Report separately for each major kind of product. Include the value of products exported and interplant transfers in the
appropriate product line(s). They should also be reported separately in 5 . Report separately under Product Class code
9998900 sales of products bought and sold without further manufacture, processing, or assembly.
Enter TOTAL value of shipments under code 7700000.

Products and services

Product Class
code

(a)

(b)

Products shipped and other receipts, including interplant
transfers and exports
2011
$ Bil.

(c)
Mil.

2010
Thou.

(d)
$ Thou.

018

026

034

042

059

067

10001063

075

083

091

109

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Form MA-10000(S) (DRAFT)
If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
23 – 29 Not Applicable.
REMARKS (Please use this space for any explanations that may be essential in understanding your reported data.)

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?

Month

Year

FROM

10001071

Yes

Month

Year

TO

No - Enter time period covered

Name of person to contact regarding this report

Area code
Telephone

Number

Title

Extension

Area code

Number

Fax
Month

Internet e-mail address

Day

Year

Date
completed

Thank you for completing your 2011 ANNUAL SURVEY OF MANUFACTURES form.
PLEASE PHOTOCOPY THIS FORM FOR YOUR RECORDS AND RETURN THE ORIGINAL.