QSS-3(E) Quarterly Services Survey

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-3(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.

21908017

• 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-3(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

21908025

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-3(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
Taxable Firms
Include:
• Operating revenue
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Market value of compensation in lieu of cash

21908033

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly form customers or clients and paid
directly to a local, State, or Federal tax agency
Revenue from a domestic parent organization, or
from franchise locations owned by others
• Rents from and revenue of separately operated
departments, concessions, etc., which are leased to
others
• Revenue from customers for carrying or other credit
charges
• Commissions from vending machine operators
• Revenue of foreign subsidiaries (those located
outside the U.S. , i.e., outside the 50 states, District
of Columbia, U.S. Commonwealth Territories, or
U.S. Possessions)
• Nonoperating revenue such as income from
investments, sales of company-owned real estate
(land and building), or other assets (except
inventory held for resale), securities, gifts, loans,
contributions, or grants
• Revenue from the sale of used equipment
• Installment payments from leasing under capital,
finance, or full-payout leases
• Intracompany transfers
• Interest income

$ Bil.

Tax-exempt Firms
Include:
• Operating and non operating revenue
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income form interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities
Exclude:
• Sales and other taxes collected directly from
customers or clients and paid directly to a local,
State, or Federal tax agency
• Gross receipts of departments or concessions
operated by other companies
• Amounts transferred to operating funds from capital
or reserve funds

Third Quarter
Mil.
Thou.

Dol.

$ Bil.

Second Quarter
Mil.
Thou.

Dol.

A. What was this firm's revenue in third
and second quarters of 2012? . . . . .
6

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-3(E)
7

Page 4

(DRAFT)

OPERATING EXPENSES
Include:
• Payroll and employee benefits
• Interest and rent expenses
• Supplies used for operating your business, cost of
merchandise sold, and other expenses allocated to
operations during the year
• Contracted or purchased services
• Fees paid to other organizations for fundraising
• Depreciation expenses
• Expenses of locations providing support services
(e.g., repair services, administrative services, etc.)
for your service establishments

Exclude:
• Sales and other taxes collected directly from
customers or clients and paid directly to a local,
State, or Federal tax agency
• Outlays for the purchase of real estate (land and
buildings); for construction; for additions, major
alterations, and improvements to existing facilities;
and all other capital expenditures
• Funds invested
• Income taxes
• Assessments (dues) paid to the parent or other
chapters of the same organization
• For establishments engaged in raising funds - funds
transferred to charities or other organizations
Third Quarter
Mil.
Thou.

$ Bil.

Dol.

$ Bil.

Second Quarter
Mil.
Thou.

Dol.

What were this firm's expenses in third
and second quarters of 2012? . . . . . .
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)

21908041

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.
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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.
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