MI-21171 Crude Petroleum and Natural Gas Extraction

Attachment B

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Crude Petroleum and Natural Gas Extraction

FORM

MI-21171

OMB No. 0607-0939: 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

MI-21171

econhelp.census.gov

• 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:
econhelp.census.gov

- OR -

Mail your
completed
form to:

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

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 oil and gas field mineral establishment. An oil and gas field mineral
establishment represents oil and gas field activities in one state or offshore area operated by the reporting company.
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 one used for this
establishment on its latest 2012 Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return?

21171012

0021

2

Yes - Go to

2

0022

No - Enter current EIN (9 digits)

0025

-

PHYSICAL LOCATION
State

State where oil and gas field operations of this establishment are physically located (Use 2-letter postal
abbreviation.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PENALTY FOR FAILURE TO REPORT

0050

CONTINUE ON PAGE 2

Form MI-21171
3

Page 2

(DRAFT)

OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2012?
(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

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

4

Mark "X"
if None

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

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

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

Exclude nonoperating income such as royalties, interest, dividends,
or the sale of fixed assets.
A. Total value of products shipped and other receipts (Report detail
in 22 .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ Bil.

2012
Mil.

Thou.

0100

21171020

B. Value of products exported (This is a breakout of the value
reported on line A.)
Report the value of products shipped for export. Include
shipments to customers in the Panama Canal Zone, the
Commonwealth of Puerto Rico, and U.S. possessions, as well as
the value of products shipped to exporters or other wholesalers
for export. Also, include the value of products sold to the U.S.
Government to be shipped to foreign governments. . . . . . . .
6

0130

Not Applicable.

CONTINUE ON PAGE 3

Form MI-21171

Page 3

(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 .
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.
• Subcontractors and their employees.
For further clarification, see information sheet(s).

1. Number of mining, production, development, and exploration workers for
pay period including March 12 . . . . . . . . . . . . . . . . . . . . . .

0325

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

0336

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

0320

$ Bil.

2012
Mil.

Thou.

Mark "X"
if None

$ Bil.

2012
Mil.

Thou.

Mark "X"
if None

$ Bil.

2012
Mil.

Thou.

Mark "X"
if None

$ Bil.

2012
Mil.

Thou.

Mark "X"

B. Payroll before deductions (Exclude employer's cost for fringe benefits.) if None
1. Annual payroll

2012
Number

Mark "X"
if None

A. Number of employees

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

0300

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

0310

8 – 12 Not Applicable.
13 CAPITAL EXPENDITURES

A. Capital expenditures for new and used buildings, structures,
machinery, and equipment (Exclude land.) . . . . . . . . . . . .

0520

B. Capital expenditures for mineral exploration and development . . .

0536

C. TOTAL (Add lines A and B.) . . . . . . . . . . . . . . . . . . .

0535

21171038

14 RENTAL PAYMENTS

Buildings, machinery, and equipment (Include land.) . . . . . . . . .

0550

15 Not Applicable.
16 COST OF SUPPLIES, RESALES, FUELS, ELECTRICITY, AND WORK DONE
FOR YOU BY OTHERS
Cost of supplies used, minerals received for preparation, purchased
machinery installed; cost of products bought and sold as such without
further processing; cost of purchased fuels consumed for heat, power,
or the generation of electricity; and cost of purchased electricity; and
cost of work done for you by others . . . . . . . . . . . . . . . . .

0420

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