QSS-1pE Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 08/31/2015
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1pE

(DRAFT)

Due Date

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YOUR CENSUS REPORT
IS CONFIDENTIAL. This
report is authorized by law
(Title 13, United States Code,
Sections 131 and 182). Under
Section 9 of the same law, your
report to the Census Bureau 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. The law also provides
that information that you report
cannot be used for taxation,
regulation, or investigation and
are exempt from release under
the Freedom of Information Act.
Further, copies of your response
retained in your files are immune
from legal process.

Return via Internet:
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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.

21954011

• 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
1 030280456
• 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-1pE
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 the
Yes
No - Go to

4

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

Acquisition
Merger
Sale

Day

8

.

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND
Enter detailed information below

21954029

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-1pE
4

Page 3

(DRAFT)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Beginning Date

Calendar quarter

Month

Day

Year

Month

End Date
Day
Year

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

5

SALES, RECEIPTS, OR REVENUE

$ Bil.

Mil.

Thou.

Dol.

A. What were this firm's gross billings/professional service fees in the
. . . . . . . . . . . . . . . . . . . . . . . . . .
B. What were this firm's direct costs of worksite employees in the
Report salaries, wages, employment-related taxes, benefit premiums, worker's
compensation insurance costs for PEO worksite employees. . . . . . . . . . .
C. What was this firm's net revenue in
5 A minus 5 B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6

CLASS OF CUSTOMER
What percentage of gross billings/professional service fees reported in
the following classes of customer in the

5

A was received from

A. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Business firms and not-for-profit organizations

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

C. Government (Federal, state, and local) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

Percent

%
%
%

1 00 %
Not Applicable.

21954037

7

CONTINUE ON PAGE 4

Form QSS-1pE

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)

21954045

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:
ECON Survey Comments 0607-0907, U.S. Census Bureau, 4600 Silver Hill Road, Room EMD-8K122, Washington, DC 20233. You may e-mail comments to
[email protected]; use "ECON Survey Comments 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.