QSS -6A 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-6A

(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.

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GENERAL INSTRUCTIONS

21971015

• 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) as defined by the survey coverage in 1
• 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-6A
1

Page 2

(DRAFT)

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

Yes
No - Specify this firm's business activity

2

Not Applicable.

3

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

Divestiture
Name of company

EIN (9 digits)

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

City, town, village, etc.

State

ZIP Code

21971023

4

REPORTING PERIOD
What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

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

Day

Year

CONTINUE ON PAGE 3

Form QSS-6A
5

Page 3

(DRAFT)

SALES, RECEIPTS, OR REVENUE
Firms operating on a commission basis should report commissions, fees, and other operating revenue income,
not gross billings or sales.
INCLUDE
• Net realized gains as well as losses within
specified area(s) of activity
• Earned interest
• Commissions and fees received from all sources,
including fees earned for exchanging currencies,
selling money orders, and cashing checks
• Net gains (losses) from the sale of real property
owned by this establishment for investment, rent, or
lease (NOT gross sales)
• Gross sales (NOT net gains (losses)) of real property
developed or buildings built by this establishment
for sale
• Gross rents from real property leased by this
establishment to others
• 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.
• Rents from departments or concessions operated by
other companies at this establishment
• Franchise sales, fees, and royalties
• Sale or licensing of rights to intellectual property
protected by copyright or as industrial property
(e.g., patents, trademarks)

EXCLUDE
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from 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
• Revenue of departments or concessions operated
by other companies at this establishment
• 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)
• Intracompany transfers

$ Bil.

A. What was this firm's revenue in the
B. Does the revenue reported in

5

Mil.

Thou.

Dol.

. . . . . . .

A represent book figure(s) or estimate(s)?

Book figures

21971031

Estimates

CONTINUE ON PAGE 4

Form QSS-6A
6

Page 4

(DRAFT)

SOURCE OF REVENUE
Loan fees - Defined to include origination fees, participation fees, and other fees associated with loans to
consumers, secured and unsecured, such as vehicle loans, boat loans, student loans, unsecured lines of credit,
personal loans, and overdraft protection (except residential mortgage loans or home equity). Excluding interest
income.
Other fees - Defined to include fees associated with services that provide a revolving line of credit to holders
of credit cards, such as annual fees and penalty fees (i.e., late charges and other over-limit fees); also include
service charges on general purpose deposit account related products, such as ATM charges and other electronic
transaction fees, per-check fees, NSF or overdraft fees, and other deposit account service fees; inquiry and
research fees; stop payment fees; early withdrawal penalties and fees; money order fees; travelers' check fees;
remittance fees; and cashier's and certified check fees. Excluding interest income.
Individual - Refers to a person or household spending, investing, or saving their own money on their own behalf.
All money managers in any form (such as fund managers or investment advisors) or investment funds should be
treated as businesses.
How much of the revenue reported in
sources of revenue in the

5

A was received from the following
$ Bil.

INTEREST INCOME

Mil.

Thou.

Dol.

A. Gross interest income . . . . . . . . . . . . . . . . . . . . . . . . . . .
NON-INTEREST INCOME
B. Loan fees and other fees income from individuals . . . . . . . . . . . .
C. Loan fees and other fees income from business and government

. . . .

D. All other non-interest income . . . . . . . . . . . . . . . . . . . . . . .
TOTAL
E. Verify Total
Sum of 6 A -

6

D. Total must equal

5

A. . . . . . . . . . . . . . . . . . . .

7

Not Applicable.

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)

21971049

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.