Prototype Classifi Prototype Classification Form

Attachment E
2012 Economic Census
Retail Trade and Accommodation and Food Services Sectors
Classification Forms
E-1.
E-2.
E-3.

Prototype Classification Form
Variable Content for Item 19—Kind of Business
Variable Content for Item 26—Special Inquiries

Attachment E-1
2012 Economic Census
Retail Trade and Accommodation and Food Services Sectors
Prototype Classification Form

Attachment E-1

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Classification Form

FORM

RT-44190

OMB No. : Approval Expires

(DRAFT)

DUE DATE
30 DAYS AFTER
RECEIPT OF FORM

RT-44190

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

PROTOTYPE
Need help or have questions
about filling out this form?

4/18/2011

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.
• Place an "X" inside the box.

• Please center numbers in their respective boxes.
• Do not put slashes through 0 or 7.

Examples:

0 1 2 3 4 5 6 7 8 9

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

0032

Yes - Go to line B
No - Enter
physical
location

0035

Number and street

0036

City, town, village, etc.

0037

State

0038

ZIP Code

44190015

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

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

USCENSUSBUREAU

0047

Town or township

0048

Other

0024

Do not know

CONTINUE ON PAGE 2

Form RT-44190
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

0014

Ceased operation - Give date at right

0015

Temporarily or seasonally inactive

0013

Month

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

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
Which ONE of the following best describes this establishment's principal kind of business in 2012?
(Mark "X" only ONE box.)
GASOLINE STATIONS:

44190023

0700

447 190 10 1

Gasoline station

447 110 00 1

Gasoline station with convenience store

447 190 10 2

Gasoline station with automotive repair

447 110 00 2

Convenience store selling gasoline

445 120 00 4

Convenience store not selling gasoline

447 110 00 4

Gasoline station with convenience store and car wash

447 110 00 3

Gasoline station with convenience store and automotive repair

447 190 10 4

Gasoline station/car wash

447 190 20 1

Truck stop

454 311 00 1

Heating/fuel oil dealer

454 312 00 1

Liquefied petroleum (LP) gas dealer

AUTOMOTIVE PARTS, ACCESSORIES, AND TIRE STORES:
441 320 00 8

Tire dealer, new and/or used

441 310 40 3

Auto parts/supply store

441 310 40 4

Auto/truck accessories store

441 310 50 1

Used automobile parts dealer

CONTINUE WITH

19

ON PAGE 3

CONTINUE ON PAGE 3

Form RT-44190

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 KIND OF BUSINESS - Continued
AUTOMOTIVE PARTS, ACCESSORIES, AND TIRE STORES: - Continued
0700

441 310 40 2

Automotive stereo store

452 990 40 3

Home and auto supply store

AUTOMOBILE, RV, BOAT, AND OTHER MOTOR VEHICLE DEALERS:
441 110 00 1

Motor vehicle sales, new

441 120 00 2

Motor vehicle sales, used only

441 221 00 1

Motorcycle and/or all-terrain vehicle (ATV) dealer, including motor bikes, motor scooters, and
mopeds

441 221 00 2

Motorcycle parts and accessories dealer

441 210 00 7

Recreational vehicle (RV) and RV parts dealer, including travel trailers, 5th wheels, camping
trailers, motor homes, truck campers, van campers, etc.

441 222 00 1

Boat/marine dealer

441 222 00 2

Boating equipment and supply store

441 229 00 7

Utility trailer dealer

441 229 00 3

Motorized golf cart dealer

423 110 50 2

Heavy duty truck and trailer dealer

423 120 20 3

Heavy duty truck and trailer parts dealer

44190031

OTHER KINDS OF BUSINESS:
811 121 10 1

Paint or body repair shop

713 930 00 4

Marina

423 820 10 2

Farm machinery and equipment dealer

326 212 00 2

Tire retread shop

721 211 00 1

Trailer park, recreational vehicle (RV) park, or campground, except residential

532 111 00 2

Passenger car rental

532 112 00 2

Passenger car leasing

488 410 00 1

Towing, wrecker service

811 111 00 4

Automotive repair, general

777 440 00 1

Automotive repair, specialized - Specify

772 000 00 1

Other kind of business - Specify

0701

0701

CONTINUE ON PAGE 4

Form RT-44190

Page 4

(DRAFT)

20 CLASS OF CUSTOMER
A. As a general business practice, did this establishment sell to household consumers and individual users in 2012?
0251

Yes

0252

No

B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2012?
0256

Yes

0257

No

C. Did this establishment require proof of business or professional license from new customers in 2012?
0276

Yes

0277

No
2012
Whole percent
of sales and
receipts

D. Estimate the percentage of this establishment's total sales by class of customer.
(Circle all that apply and then report percentages for the items circled.)
1.

Household consumers and individuals

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

0261

2.

Retailers for resale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0263

3.

Wholesalers/distributors for resale

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

0264

4.

Repair shops for use in repair work . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0265

5.

Manufacturing and mining industrial users for use as input goods in production . . . . . . .

0266

6.

Restaurants, hotels, food services, and contract feeding

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

0267

7.

Businesses for end use in their own operation, not for resale or production . . . . . . . . .

0268

8.

Building contractors, heavy construction, and special trade contractors . . . . . . . . . . .

0269

9.

Farmers for use in farm production . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0270

10. Governmental bodies (Federal, state, and local) . . . . . . . . . . . . . . . . . . . . . .

0271

11. Export sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0262

%
%
%
%
%
%
%
%
%
%
%

44190049

12. Other - Specify
0874

13. TOTAL

0272

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

%
1 0 0 %

CONTINUE ON PAGE 5

Form RT-44190

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
21 METHOD OF SELLING
Which ONE of the following best describes this establishment's principal method of selling in 2012?
(Mark "X" only ONE box.)
0751

Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)

0752

Store or display showroom (selling from a fixed or permanent location with physical displays of priced
merchandise and/or from a counter)

0753

Warehouse or office (including telephone/fax orders or outside sales representatives)

0754

Mail order

0755

Home shopping via television

0756

Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party
plan, or temporary kiosk sales)

0757

Vending machines

0758

Other - Specify

0759

22 – 25 Not Applicable.
26 SPECIAL INQUIRIES
AUTO FRANCHISE
Did this establishment have a franchise for the sale of new passenger cars, vans, sport utility vehicles, or light
trucks in 2012?
2561

Yes

2562

No

27 – 29 Not Applicable.
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.

44190056

Is the time period covered by this report a calendar year?
Yes

No - Enter time period covered

Month

FROM

Name of person to contact regarding this report

Area code

Telephone

Number

-

E-mail address

Year

Month

Year

TO
Title

Extension

Area code

Number

Fax
Date
completed

Month

Day

Thank you for completing your 2012 ECONOMIC CENSUS form.
PLEASE PHOTOCOPY THIS FORM FOR YOUR RECORDS AND RETURN THE ORIGINAL.

Year