QSS-1p(E) Quarterly Services Survey

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1p(E)

(DRAFT)

Due Date

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(Please correct any errors in name, address, and ZIP Code.)

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GENERAL INSTRUCTIONS
Throughout this survey, any reference to "this firm" is referring to the EIN that is printed in the mailing
address area or the new EIN that was provided as a response in 2 . Any responses related to "this firm" should
only include data for the EIN referenced.

21904016

• Any significant change in this firm's operations should be noted in 8
• For establishments sold or acquired during the quarter(s), report data only for the period the establishments
were operated by this firm
• Estimates are acceptable if book figures are not available
• Enter "0" where applicable
• Report data on an accrual basis
Bil.
Mil.
Thou.
Dol.
• Dollars should be rounded to the nearest dollar
• If a figure is $1,030,280,456 it should be reported as
Include:
• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and
Construction operations) operated by this firm
• Data for auxiliary facilities primarily engaged in supporting services to this firm's establishment(s) such as
warehouses, garages, central administrative offices, and repair services

CONTINUE ON PAGE 2

Form QSS-1p(E)
1

Page 2

(DRAFT)

SURVEY COVERAGE
Did this firm provide the business activities described below?

Yes
No - Specify this firm's business activity

2

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes
EIN (9 digits)
No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

3

Day

Year

ORGANIZATIONAL CHANGE
A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in third or second quarter
of 2012?
Yes
No - Go to

4

B. Which of the following organizational changes occurred in third or second quarter of 2012?
Check all that apply. If more than one organizational change occurred during the reporting period, explain in
Month

Acquisition

Day

8

.

Year

Date of organizational change . . . . . . . . . . . . . . . .
Sale

21904024

AND
Merger
Enter detailed information below
Divestiture
Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-1p(E)
4

Page 3

(DRAFT)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Third Quarter
Beginning Date
Month Day
Year

Calendar quarter

Second Quarter
Beginning Date
Month Day
Year

Other - Report beginning and ending dates . . . . . .
Month

5

End Date
Day
Year

Month

End Date
Day
Year

SALES, RECEIPTS, OR REVENUE

A. What were this firm's gross billing/
professional service fees in third and
second quarters of 2012? . . . . . . .
Report the professional service fee, or
gross billing for the company.

$ Bil.

Third Quarter
Mil.
Thou.

Dol.

$ Bil.

Second Quarter
Mil.
Thou.

Dol.

B. What were this firm's direct costs
of worksite employees in third and
second quarters of 2012? . . . . . . .
Report salaries, wages, employmentrelated taxes, benefit premiums, worker's
compensation insurance costs, for PEO
worksite employees.
C. What was this firm's net revenue in
third and second quarters of 2012? . .
5 A minus 5 B.
6

CLASS OF CUSTOMER
What percentage of gross billing/professional service fees reported in 5 A was
received from the following classes of customer in third and second quarters
of 2012?
1. Household consumers and individual users . . . . . . . . . . . . . . . . . . . .
2. Business firms and not-for-profit organizations . . . . . . . . . . . . . . . . . .
3. Government (Federal, state, and local) . . . . . . . . . . . . . . . . . . . . . . . +

Third
Quarter

Second
Quarter

Percent

Percent

%

%

%

%

%

%

1 00 % 1 00 %
Not Applicable.

21904032

7

CONTINUE ON PAGE 4

Form QSS-1p(E)

Page 4

(DRAFT)

8

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

9

CONTACT INFORMATION
Name of person to contact regarding this report (Please print)

21904040

Area code
Telephone

Number

-

Title

Extension

Area code
Fax

Number

-

Website

THANK YOU
for completing your QUARTERLY SERVICES SURVEY.
We suggest you keep a copy for your records.
Public reporting burden for this collection of voluntary information is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 06070907, U.S. Census Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments to [email protected]; use "Paperwork
Project 0607-0907" as the subject. PLEASE INCLUDE FORM NAME AND NUMBER IN ALL CORRESPONDENCE.
Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget.
This 8-digit number appears in the top right corner on the front of this form.