Form GUS-1 (04-29-2015) GUS-1 (04-29-2015) 2017 Census Of Governments Units Survey

U.S. DEPARTMENT OF COMMERCE

2017 CENSUS OF GOVERNMENTS
Government Units Survey

Economics and Statistics Administration

U.S. CENSUS BUREAU
FORM

GUS-1 (04-29-2015) Draft 3

OMB No. 0607-0930: Approval Expires xx/xx/xxxx

DUE DATE:

RETURN TO:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001

Need help or have
questions?
• Visit
census.gov/govs/cog2017
• Call
1-800-832-2839 weekdays,
7am to 5pm ET
• Email
[email protected]
In correspondence
pertaining to this report,
please refer to the User ID
below the address box.

REPORT ONLINE: It’s fast and secure. Respond to
this survey via the Internet at the following web
address using the supplied User ID and Password:
https://respond.census.gov/gus

User ID:

➤
Password:

GENERAL INSTRUCTIONS
Please use a black or blue ballpoint pen. Do not use pencil or felt tip pen.

1

Is the addressee title/department and mailing address the same as shown in the address label?
Mark "X" only one box.
Yes – Go to 2

No – Enter correct information below

Addressee Title or Department

Street 1

17017013

§2"g.¤

ATTN:

Street 2

City

State

Zip Code

Please continue on the next page

Page 2

PART 1 – BACKGROUND INFORMATION
2

Was this entity in existence on February 29, 2016?
Mark "X" only one box.
Yes – Go to 3
No – Enter information below and go to 6
(MM)

(DD)

(YYYY)

A. On what date did this entity cease operations?
......................
B. What is the name and address of entity that took over operations?
Name of new entity

Addressee Title or Department

ATTN:
Street 1

Street 2

City

3

State

Zip Code

Does this entity have a website that contains information about it and its activities?
Mark "X" only one box.
Yes – Specify:
No

PART 2 – EMPLOYEES
Did this entity have paid employees and/or paid officials?
Mark "X" only one box.
Yes – Go to 5

17017021

§2"g6¤

4

No – Go to 6

Form GUS-1

Please continue on the next page

Page 3

PART 2 – EMPLOYEES - continued

HOW TO
REPORT
NUMBERS

5

CORRECT marking example – Please
print all information clearly in ordinary
characters. (Use care to keep characters
in their respective boxes.)

INCORRECT marking example –
Do not put slashes through "0" or "7".

7 8 9 0

7

8 9 0

How many total paid employees did this entity have on February 29, 2016? Estimates are acceptable.
Include
• Current employees in paid leave status whether paid from the general, special,
or Federal grant funds
• All elected or appointed officials paid any amount of pay or stipend (even
small amounts of $25 per meeting or $100 annually) or paid on salary basis;
by fees or commissions; on a per meeting basis; or a flat sum quarterly,
semi-annually, or annually
• Seasonal or temporary employees
Exclude
• Employees on unpaid leave, unpaid officials, pensioners, and contractors
and their employees
• School system employees and payrolls

Number of Employees

PART 3 – REMARKS
6

Use this space for any explanations that may be essential in understanding the reported data.
Include
• Any significant changes
• Any difficulties encountered in completing this form

PART 4 – CONTACT INFORMATION
Who should be contacted to answer questions about data reported on this form?

Name of contact person – Please print

§2"gH¤

Area code and phone number

Email Address – Please print

Title of contact person – Please print

Extension

Area code and fax number

Date form was completed
(MM)
(DD)
(YYYY)

Thank you for completing this form.
Retain a copy of the completed questionnaire for your records.
NOTE: The U.S. Census Bureau receives its authorization to conduct this survey from Title 13, United States Code, Sections 161 and 193. This form has been approved by the Office
of Management and Budget (OMB) and given the number 0607-0930. Please note the number displayed in the upper right-hand corner of this form. Display of this number confirms
that we have approval from OMB to conduct this survey. If this number was not displayed, under the Paperwork Reduction Act, we could not request your participation in this voluntary
survey. Information provided on this questionnaire compiled from or customarily provided in public records are exempt from confidential treatment as cited in Title 13, United States
Code, Section 9(b).
Please note that this is a national form that applies to governments with wide differences in the size of their service areas, the amount of population served, and the extent and complexity
of their activities. Public reporting burden for this collection of information is estimated to vary from 15 minutes to 30 minutes per response, with an average of 15 minutes per response,
including 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 0607-0930,
U.S. Census Bureau, 4600 Silver Hill Road, EMD-8K122, Washington, DC 20233. You may e-mail comments to [email protected]; use ECON Survey Comments
0607-0930 as the subject.

Form GUS-1

17017039

7