2017 Annual Survey of Businesses (ASB)
Contact Info
Please enter the first and last name of the person who is filling out this survey. We request a telephone number so we can contact you if there is a question.
Contact Name: _______________________________________________________________________
Phone: ______________________________________________________________________________
Business Structure
In
2017, how many people owned this business?
• Do not
combine two or more owners to create one
• Count spouses
and partners as separate owners
☐
1 person –
Skip to 10 percent or more ownership
☐
2 people –
Skip to 10 percent or more ownership
☐
3 people -
Skip to 10 percent or more ownership
☐
4 people –
Skip to 10 percent or more ownership
☐
5-10 people
– Skip to 10 percent or more ownership
☐
11 or more
people
☐
Business is
owned by a parent company, estate, trust, or other entity
☐
Don’t
know
In 2017, was this business owned by a government or tribal entity?
☐ Yes
☐ No
In 2017, did at least one person own 10% or more of this business? (Do not count parent companies, estates, trusts or other entities.)
☐ Yes
☐ No
For the person(s) owning the largest percentage(s) in this business in 2017, please list the percentage owned by each person and his or her name.
• Do not report percentages owned by parent companies,
estates, trusts, or other entities
• If more than 4 people
owned this business equally, select any 4 people
• Round
percentages to whole numbers. For example, report 1/3 ownership as
33.0%.
Percentage Owned |
Name of Owner |
|
|
|
|
|
|
|
|
Owner Characteristics
What is the sex of Owner X?
☐ Male
☐ Female
Is Owner X of Hispanic, Latino, or Spanish origin?
☐ No, not of Hispanic, Latino, or Spanish origin
☐ Yes, Mexican, Mexican American, Chicano
☐ Yes, Puerto Rican
☐ Yes, Cuban
☐ Yes, another Hispanic, Latino, or Spanish origin - please enter origin below. For example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.
What is Owner X’s race? NOTE: For this survey, Hispanic origins are not races. Select all that apply.
☐ White
☐ Black or African American
☐ American Indian or Alaska Native – please enter name of enrolled or principal tribe below
__________________________________________
☐ Asian Indian
☐ Chinese
☐ Filipino
☐ Japanese
☐ Korean
☐ Vietnamese
☐ Other Asian – please enter race below. For example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
__________________________________________
☐ Native Hawaiian
☐ Guamanian or Chamorro
☐ Samoan
☐ Other Pacific Islander – please enter race below. For example, Fijian, Tongan, and so on.
___________________________________________________
☐ Some other race – please enter below.
____________________________________________________
Has Owner X ever served in any branch of the U.S. Armed Forces, including the Coast Guard, the National Guard, or Reserve component of any service branch?
☐ Yes
☐ No – SKIP to Initial Acquisition
Does Owner X have a disability or injury incurred or aggravated during military service?
☐ Yes
☐ No
Do any of the following characteristics describe Owner X’s military service? Select all that apply.
☐ Served on active duty military service, not including training for the Reserves or National Guard
☐ Served on active duty military service after September 11, 2001
☐ Served on active duty military service in 2017
☐ Served in the National Guard or as a reservist of any branch of the U.S. Armed Forces in 2017
☐ None of the above
How did Owner X initially acquire ownership of this business? Select all that apply.
☐ Founded or started
☐ Purchased
☐ Inherited
☐ Received transfer of ownership or gift
In what year did Owner X acquire ownership of this business?
YEAR ______
☐ Don’t Know
In 2017, which of the following were Owner X’s function(s) in this business? Select all that apply.
☐ Managing day-to-day operations
☐ Providing services and/or producing goods
☐ Financial control with the authority to sign loans, leases, and contracts
☐ None of these functions
In 2017, what was the average number of hours per week that Owner X spent managing or working in this business?
☐ None
☐ Less than 20 hours
☐ 20-39 hours
☐ 40 hours
☐ 41-59 hours
☐ 60 hours or more
In 2017, did this business provide Owner X’s primary source of personal income?
☐ Yes
☐ No
Prior to establishing, purchasing, or acquiring this business, how many previous businesses has Owner X owned? (Include self-employed businesses.)
☐ 0
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5 or more
What was the highest degree or level of school Owner X completed prior to establishing, purchasing, or acquiring this business?
☐ Less than high school graduate
☐ High school graduate – Diploma or GED
☐ Technical, trade, or vocational school
☐ Some college, but no degree
☐ Associate Degree
☐ Bachelor’s Degree
☐ Master’s, Doctorate, or Professional Degree
Prior to establishing, purchasing, or acquiring this business, what was the field of the highest degree completed for Owner X?
☐ Agriculture, Environmental and Related
☐ Architecture and Building
☐ Business or Finance
☐ Education
☐ Engineering and Related Technologies
☐ Food or Hospitality
☐ Health, Medicine or Pharmacy
☐ Humanities or Arts
☐ Information Technology or Computer Science
☐ Law or Legal Studies
☐ Mathematics, Economics, or Statistics
☐ Natural and Physical Sciences
☐ Social Sciences
☐ Other (Specify)
_________________________________________
☐ No Bachelor’s, Master’s, Doctorate, or Professional Degree
☐ Don’t know
What was the age of Owner X as of December 31, 2017?
☐ Under 25
☐ 25-34
☐ 35-44
☐ 45-54
☐ 55-64
☐ 65 or over
Is Owner X a citizen of the United States?
☐ Yes
☐ No
Was Owner X born in the United States?
☐ Yes
☐ No
Does Owner X have any of the following difficulties? Select all that apply.
☐ Deaf or have serious difficulty hearing
☐ Blind or have serious difficulty seeing even when wearing glasses
☐ Because of a physical, mental, or emotional condition have serious difficulty concentrating, remembering, or making decision
☐ Have serious difficulty walking or climbing stairs
How important to Owner X are each of the following reasons for owning this business?
Not Important Somewhat Important Very Important
Wanted to be my own boss ☐ ☐ ☐
Flexible hours ☐ ☐ ☐
Opportunity for greater income ☐ ☐ ☐
Best avenue for my ideas/goods/services ☐ ☐ ☐
Unable to find employment ☐ ☐ ☐
Other (specify) ☐ ☐ ☐
Business Structure
In 2017, did two or more members of one family own the majority of this business? (Family refers to spouses/unmarried partners, parents/guardians, children, siblings, or close relatives.)
☐ Yes
☐ No
Did spouses/unmarried partners jointly own this business?
☐ Yes
☐ No – Skip to Business Aspirations
Was this business operated equally by both spouses/unmarried partners?
☐ Yes, equally operated by spouses/unmarried partners
☐ No, primarily operated by Owner 1
☐ No, primarily operated by Owner 2
Other Business Characteristic
Where would the owner(s) like this business to be in five years?
☐ Larger in terms of sales or profits
☐ About the same amount of sales or profits
☐ Smaller in terms of sales or profits
☐ Other (specify)
Business Financing
For 2017, what was the total amount of money that the owner(s) personally put into the business? Your best estimate is fine.
Include:
Investments from personal savings
Personal retirement accounts
Home equity loans
Personally borrowed funds
☐ No Owners
☐ $0
☐ $1 - $4,999
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 or more
☐ Don’t Know
For the owners reported, what was the source(s) of capital used to start or initially acquire this business? If you did not report any owners, skip to Amount of Capital Needed to Start or Initially Acquire Business.
☐ Personal/family savings of owner(s)
☐ Personal/family assets other than savings of owner(s)
☐ Personal/family home equity loan
☐ Personal credit card(s) carrying balances
☐ Business credit card(s) carrying balances
☐ Government-guaranteed business loan from a bank or financial institutions, including SBA-guaranteed loans
☐ Business loan from a bank or financial institution
☐ Business loan from a federal, state, or local government
☐ Business loan/investment from family/friend(s)
☐ Investment by venture capitalist(s)
☐ Grants
☐ Other source(s) of capital
☐ Don’t know
☐ None needed – Skip to Funding from Family, Friends, and Employees
For the owners you reported, what was the total amount of capital used to start or initially acquire this business?
☐ Less than $5,000
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 - $999,999
☐ $1,000,000 - $2,999,999
☐ $3,000,000 or more
☐ Don’t know
For 2017, what was the total amount of money this business received from family, friends, and employees?
☐ $0
☐ $1 - $4,999
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 or more
☐ Don’t know
For 2017, what was the total amount of money this business borrowed from a bank or other financial institutions, including business loans, a business credit card carrying a balance, or a business line of credit? Include all draws on a business line of credit, even if paid off during the year.
☐ $0
☐ $1 - $4,999
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 or more
☐ Don’t know
For 2017, what was the total amount of money this business received from angel investors, venture capitalists, or other businesses in return for a share of ownership in this business?
☐ $0
☐ $1 - $4,999
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 or more
☐ Don’t know
For 2017, what was the total amount of money this business received from government grants (such as the Small Business Innovation Research (SBIR) and/or Small Business Technology Transfer (STTR) programs)?
☐ $0
☐ $1 - $4,999
☐ $5,000 - $9,999
☐ $10,000 - $24,999
☐ $25,000 - $49,999
☐ $50,000 - $99,999
☐ $100,000 - $249,999
☐ $250,000 or more
☐ Don’t know
In 2017, did this business attempt to establish any new funding relationships (for example, loans, investments, or gifts) with any of the following sources?
|
No |
Yes, received total amount of the funding requested |
Yes, but did not receive the total amount requested |
Family, friends, or employees |
|
|
|
Banks, credit unions, or other financial institutions |
|
|
|
Credit cards |
|
|
|
Angel Investors |
|
|
|
Venture capitalists |
|
|
|
Other investor businesses |
|
|
|
Crowdfunding platform (for example, Prosper, Kickstarter, etc.) |
|
|
|
Grants (for example, Federal government’s Small Business Technology Transfer Program (STTR) or Small Business Innovation Research Program(SBIR) |
|
|
|
Other (Specify) |
|
|
|
At any time during 2017, did this business need additional financing?
☐ Yes, business needed additional financing and the owner(s) chose not to apply
☐ Yes, business needed additional financing and the owner(s) did apply - Skip to Profitability
☐ No, business did not need additional financing – Skip to Profitability
Why did this business choose not to apply for additional financing?
☐ Did not think business would be approved by lender
☐ Did not want to accrue debt
☐ Decided the financing costs would be too high
☐ Preferred to reinvest the business profits instead
☐ Felt the loan search/application process would be too time consuming
☐ Decided to wait until funding conditions improved
☐ Decided to wait until company hit milestones to be in stronger position to raise funds
Business Performance
For 2017, did this business have profits, losses, or break even?
☐ Profits
☐ Losses
☐ Break even
For 2017, which of the following negatively impacted the profitability of this business? Select all that apply.
☐ Access to financial capital
☐ Cost of financial capital
☐ Finding qualified labor
☐ Government regulations (for example, federal, state and/or local)
☐ Slow business or lost sales
☐ Customers or clients not making payments or paying late
☐ The unpredictability of business conditions
☐ Changes or updates in technology
☐ Other (Specify)
Other Business Characteristic
In 2017, which of the following types of customers accounted for 10% or more of this business’s total sales of goods and/or services? Select all that apply.
☐ Federal government
☐ State and local government, including school districts, transportation authorities, etc.
☐ Other businesses
☐ Other organizations (foreign governments, nonprofits, etc.)
☐ Individuals
In 2017, which language(s) did this business conduct transactions with its customers? Select all that apply.
☐ English
☐ African language(s)
☐ Arabic
☐ Chinese
☐ French
☐ French Creole
☐ German
☐ Hindi/Urdu
☐ Italian
☐ Japanese
☐ Korean
☐ Polish
☐ Portuguese
☐ Russian
☐ Spanish
☐ Tagalog
☐ Vietnamese
☐ Other
In 2017, which of the following types of workers were used by this business? Select all that apply.
☐ Full-time paid employees (workers who received a W-2)
☐ Part-time paid employees (workers who received a W-2)
☐ Paid day laborers
☐ Temporary staffing obtained from a temporary help service
☐ Leased employees from a leasing service or a professional employer organization
☐ Contractors, subcontractors, independent contractors, or outside consultants (workers who received a 1099 or payment from another company)
☐ None of the above
In 2017, which of the following employee benefits were paid totally or partly by this business?
☐ Health insurance
☐ Contributions to retirement plans, including 401(k), Keogh, etc. Profit sharing and/or stock options
☐ Paid holidays, vacation, and/or sick leave
☐ Tuition assistance and/or reimbursement
☐ None of the above
In 2017, did this business use any of the following to promote or conduct business? Select all that apply.
☐ Company website
☐ Social media platform (for example, Facebook, Instagram, Twitter, etc.)
☐ Business networking platform (for example, LinkedIn, google +)
☐ Other (Specify) _____________
☐ None of the above
In 2017, did this business operate primarily from somebody’s home?
☐ Yes
☐ No
In 2017, did this business own one or more of the following?
☐ Copyright
☐ Patent (granted)
☐ Trademark
☐ Patent (pending)
☐ None
In 2017, did any of the following characteristics describe the activity of this business?
☐ Operated less than 40 hours per week on average
☐ Operated less than 12 months
☐ Seasonal business (for example, fireworks sales or tax preparer)
☐ Operated occasionally (for example, event organizer or guest speaker)
☐ None of the above
Did operations cease for this business after December 31, 2017 for any of the following reasons? Select all that apply
☐ Business is still operating
☐ Owner’s military deployment
☐ Owner’s illness or injury
☐ Owner(s) retired
☐ Owner(s) deceased
☐ Operated for a specific or one-time event
☐ Inadequate cash flow or low sales
☐ Lack of business loans/credit
☐ Lack of personal loans/credit
☐ Started another business
☐ Sold this business
☐ Other
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Krysten Mesner (CENSUS/ESMD FED) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |