MA-10000(S) (Works ASM Short Form (Worksheet)

Attachment A

OMB No. 0607-0449
Approval Expires: 11/30/2017

2016 Annual Survey of Manufactures (ASM)
CFN:
T

In contrast, q

appear

online reporting sytem

MAILING ADDRESS:
MAILING ADDRESS
The reporting unit for this questionnaire is an establishment which is generally a single physical location where
business is conducted or where services or industrial operations are performed. Please make updates to the
physical location address in the Physical Location Information section.
Attn:
Name 1:

Store/Plant:

Name 2:
Street:
City:

State:

Zip:

CFN:

EMPLOYER IDENTIFICATION NUMBER
EMPLOYER IDENTIFICATION NUMBER VALIDATION
Is

the Employer Identification Number (EIN) used on this establishment's latest 2016 Internal

Revenue Service Form 941, Employer’s Quarterly Tax Return?
Yes
No

EMPLOYER IDENTIFICATION NUMBER
EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on the latest 2016 Internal Revenue
Service Form 941, Employer’s Quarterly Tax Return?
EIN:

1

2016 Annual Survey of Manufactures (ASM)
OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL

CFN:

Is your company owned or controlled by another domestic company?
Yes
No
OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: MORE THAN ONE LOCATION
Does your company operate at more than one physical location?
Yes
No

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2

2016 Annual Survey of Manufactures (ASM)
CFN:
OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: PERCENT OF VOTING STOCK HELD
What percent of voting stock was held by the owning or controlling company?
(Check only ONE box)
Less than 50%
50%
More than 50%

OWNERSHIP OR CONTROL
OWNERSHIP OR CONTROL: COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the
owning or controlling company?
Name of owning or controlling company:
Home office address (Number and street):
City, town, village:

State:

EIN:

NUMBER OF ESTABLISHMENTS
NUMBER OF ESTABLISHMENTS
How many establishments operated under EIN at the end of 2016?
Number:

3

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:

NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00

**** Additional added establishments (if any) are listed at the end of this printout.

NUMBER OF ESTABLISHMENTS
ADDITIONAL ESTABLISHMENT INSTRUCTIONS
Consolidating Data for Added Establishments:
•

•

The sum value of Sales, Shipments, Receipts or Revenue for all locations of the EIN should also be reported as a
consolidated value in the Sales, Shipments, Rcpts/Revenue section, and also in the Details Sales, Shipments,
Rcpts/Revenue section that follows.
The sum of Employment, First Quarter Payroll, and Annual Payroll for all locations of the EIN, should also be reported
as consolidated values in the respective areas of the Employment and Payroll section that follows.

4

2016 Annual Survey of Manufactures (ASM)
CFN:

PHYSICAL LOCATION
PHYSICAL LOCATION VALIDATION

Is this establishment's physical location the same as the address shown above?
(P.O. Box and rural route addresses are not physical locations)
Yes
No
PHYSICAL LOCATION
PHYSICAL LOCATION INFORMATION
What is this establishment's physical location?
(P.O. Box and rural route addresses are not physical locations)
Number and Street:
City, town, village:

State:

PHYSICAL LOCATION
LEGAL BOUNDARY AND MUNICIPALITY
Is this establishment physically located inside the legal boundaries of the city, town, village, etc?
Yes
No
No legal boundaries
Do not know

In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

5

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:

OPERATIONAL STATUS
OPERATIONAL STATUS

Which of the following best describes this establishment’s operational status at the end of 2016?
(Check only ONE box)
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
OPERATIONAL STATUS
CEASED OPERATION DATE
When did this establishment cease operation?
MMDDYYYY:
OPERATIONAL STATUS
SOLD OPERATION DATE AND INFORMATION
When was this establishment sold or leased to another operator?
MMDDYYYY:
What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator:
Mailing address (Number and street, P.O. Box, etc.):
City, town, village:

State:

EIN:
MONTHS IN OPERATION
MONTHS IN OPERATION
How many months was this establishment in operation during 2016?
Check
if None

Number:

6

ZIP:

2016 Annual Survey of Manufactures (ASM)
CFN:
ADDITIONAL REPORTING GUIDELINES
ADDITIONAL REPORTING GUIDELINES
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars
EXAMPLE:

If a dollar figure is $2036.355.25

Report 

If a dollar figure is “0” (or less than $500.00): Report 

$ 2036,000.00
X

$

,000.00

Where available, your establishment’s Prior Year data is prelisted in the 2015 column. Check these figures
and make any necessary corrections as needed. If 2015 Inventories figures are not prelisted, report these figures in the
appropriate sections as instructed.

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What was the total value of products shipped and other receipts?
(Report details in Detail Sales, Shipments, Receipts, or Revenue)
Exclude:
•
•

Freight charges
Excise Taxes

Check
if None

2016
$

2015
,000.00

$

,000.00

E-SHIPMENTS
E-SHIPMENTS
What percent of the $
,000.00 reported in total value of products shipped and other receipts, in the SALES,
SHIPMENTS, RECEIPTS, OR REVENUE area, were for goods that were ordered or whose movement was controlled or
coordinated over electronic networks? (Report whole percents. Estimates are acceptable.)
Electronic networks include:
•
Electronic Data Interchange (EDI)
•
E-mail
•
Internet
•
Extranet
•
Other online systems

2016

2015
.00%

7

.00%

2016 Annual Survey of Manufactures (ASM)
CFN:

EMPLOYMENT AND PAYROLL
EMPLOYMENT

Include:
• Full- and part-time employees working at this establishment whose payroll was reported on Internal
Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed under the
Employer Identification Number (EIN)
• Spread on stock options that are taxable to employees as wages.
Exclude:
• Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN.
• Temporary staffing obtained from a staffing service.
• Purchased professional and technical services.
Check
if None

What were the number of:
A.

Production workers for the pay period including March 12?

B.

All other employees for the pay period including March 12?

2016
Number

2015
Number

TOTAL (Add lines A and B)

EMPLOYMENT AND PAYROLL
PAYROLL
Exclude:
•
Employer costs for fringe benefits

Check
if None

2016

2015

What was the annual payroll before deductions?

$

,000.00 $

,000.00

What was the first quarter payroll before
deductions (January-March 2016)?

$

,000.00 $

,000.00

VALUE OF INVENTORIES
VALUE OF INVENTORIES
What were the total value of inventories,
regardless of where held, before Last-in,
First-out (LIFO) adjustment (if any)
owned by this establishment
as of December 31?
Include:
•
Finished goods
•
Work-in-process
•
Materials, supplies, fuels, etc.

Check
if None

Check
if None

End of 2016
$

,000.00

8

End of 2015
$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:

CAPITAL EXPENDITURES
CAPITAL EXPENDITURES
What were the total capital expenditures for
new and used depreciable assets spent in 2016?
Include:
•
Buildings and Other Structures
•
Machinery and Equipment
Exclude:
•
Land

Check
if None

2016

$

2015

,000.00

$

,000.00

RENTAL PAYMENTS
RENTAL PAYMENTS
What were the total cost for rental or lease of buildings
and other structures, machinery and equipment?
Include:
•
Land
•
Operating leases
•
Construction equipment
•
Tools
•
Office equipment
•
Furniture
•
Vehicles
Exclude:
•
Capital leases (leases with a contract
to own at the end of the lease)

Check
if None

2016
$

2015
,000.00

$

,000.00

SELECTED EXPENSES
SELECTED EXPENSES
What were the total production related
costs in 2016?
Include:
• Materials, parts, containers, packaging, etc. used
• Products bought and sold without further processing
(Report sales in code 9998991 in the
DETAILS SALES, SHIPMENTS, REVENUE, RECEIPTS section)
• Purchased fuels consumed for heat, power,
or the generation of electricity
• Purchased electricity;
Check if
• Work done by you or others on your materials
None
2016
$

9

2015
,000.00 $

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:

DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?

,000.00 reported in total value of products shipped and other receipts
(This is a breakout of the $
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below:
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products via the ‘Add Additional Products’ button
below).

•

Should NOT BE COMBINED with other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials owned
by others
o Should not include the amount of products made by others for you from their own materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold without further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in the SELECTED EXPENSES section

Code

Description

2016 Value

10

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?
,000.00 reported in total value of products shipped and other receipts
(This is a breakout of the $
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below:
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products via the ‘Add Additional Products’ button
below).

•

Should NOT BE COMBINED with other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials owned
by others
o Should not include the amount of products made by others for you from their own materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold without further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in the SELECTED EXPENSES section

Code

Description

2016 Value

11

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What are the Details of Sales, Shipments, Receipts, or Revenue in 2016?
,000.00 reported in total value of products shipped and other receipts
(This is a breakout of the $
in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE area)
Value of products and services listed below:
•

Reflect those generally made in your industry
(If you made products that are not listed below, please add these products via the ‘Add Additional Products’ button
below).

•

Should NOT BE COMBINED with other product lines

•

Should reflect the net selling value, f.o.b. plant to customer
(i.e. after discounts, and allowances, and exclusive of freight charges and excise taxes)

•

Should include value of products exports and interplant transfers
(Exports and Interplant transfers are also reported in the SALES, SHIPMENTS, RECEIPTS, OR REVENUE section)

•

For Contract Work Code 9998992:
o Should include the amount received for ‘commission or contract receipts’ of products made from materials owned
by others
o Should not include the amount of products made by others for you from their own materials
(These amounts should be reported on the specific products codes listed below as if they were made in this
establishment)

•

For Resales Code 9998991:
o Should include the value of products bought and sold or transferred from other establishments of your company
and sold without further manufacture.
(These values should not be reported in any other specific product code).
• A corresponding cost should be reported in the SELECTED EXPENSES section

Code

7700000

Description

2016 Value

TOTAL

12

2015 Value

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2016 Annual Survey of Manufactures (ASM)
CFN:

REMARKS
REMARKS

(Please use this space for any explanations that may be essential in understanding your reported data.)

CERTIFICATION
CALENDAR YEAR TIME PERIOD
Is the time period covered by this report a calendar year?
Yes
No

CERTIFICATION
TIME PERIOD COVERED
What time period does this report cover?
Month
From:

Year

Month

Year

To:

CERTIFICATION
CERTIFICATION
I certify that this report is substantially accurate and was prepared in accordance with the instructions
Name of person to contact regarding this report:

Title:

Phone Number:

Fax Number:

E-mail address:

Date Completed: MMDDYYYY:

13

2016 Annual Survey of Manufactures (ASM)
CFN:
SUBMISSION CONFIRMATION
SUBMISSION CONFIRMATION
Thank you for completing the 2016 Annual Survey of Manufactures.
Please print or save this page for your records.
ID:

Company Contact Person:

Company Information:
Phone:

Your filing status will update in 2-3 business days. To check your filing status:
•
Go to econhelp.census.gov
•
Click “Self-Service Log In”
•
Enter your User ID and Password
•
Click “Log in”
•
Click “Filing Status”

14

ADDED LOCATIONS
2016 Annual Survey of Manufactures (ASM)
CFN:
NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00

2016 Annual Survey of Manufactures (ASM)

NUMBER OF ESTABLISHMENTS
ADDED ESTABLISHMENT INFORMATION
Name:
Secondary Name:

Store/Plant Number:

Physical Location (Number and street):
City, town village:

State:

ZIP:

Describe kind of business at this location:

Number of employees for
Pay period including March 12:

2016
Number

For employees that worked at more than one
location, report the employment and payroll data
for employees at the ONE location where they
spent most of their working time.

2016

First Quarter Payroll
(Jan-March)

$

,000.00

Annual Payroll

$

,000.00

Sales, Shipments,
Receipts, or Revenue

$

,000.00