QSS-1pA Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 09/30/2018
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1pA

(04-14-2017)

FO
D R
O M
N AT
O
T IO
U NA
SE L
TO CO
P
R Y
EP O
O NL
R
T Y

Due Date

Need help or have questions?
Call 1-800-772-7851
(8:30 a.m. - 5:00 p.m. ET, M-F)
or Visit
https://econhelp.census.gov/qss

Title 13 United States Code (U.S.C.),
Sections 131 and 182, authorizes the
Census Bureau to conduct this collection.
The U.S. Census Bureau is required by
Section 9 of the same law to keep your
information confidential and can use
your responses only to produce statistics.
The Census Bureau is not permitted
to publicly release your responses in a
way that could identify your business,
organization, or institution. Per the
Federal Cybersecurity Enhancement Act
of 2015, your data are protected from
cybersecurity risks through screening of
the systems that transmit your data.
This collection has been approved by
the Office of Management and Budget
(OMB). The eight-digit OMB approval
number is 0607-0907 and appears at
the upper right of this page. Without
this approval, we could not conduct this
survey.

(Please correct any errors in name, address, and ZIP Code.)

Return via Internet:
https://econhelp.census.gov/qss

Return via Fax:
1-800-447-4613

To view Survey Results:
https://www.census.gov/services

Username:
Password:

GENERAL INSTRUCTIONS

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

IN

21955018

• 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

We estimate this survey will take an average of 15 minutes to complete. More information about this estimate and an address where you may
write with comments is on the back of this form.

CONTINUE ON PAGE 2

Form QSS-1pA
1

Page 2

(04-14-2017)

SURVEY COVERAGE

FO
D R
O M
N AT
O
T IO
U NA
SE L
TO CO
P
R Y
EP O
O NL
R
T Y

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

4

REPORTING PERIOD

IN

21955026

-

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-1pA

SALES, RECEIPTS, OR REVENUE

FO
D R
O M
N AT
O
T IO
U NA
SE L
TO CO
P
R Y
EP O
O NL
R
T Y

5

Page 3

(04-14-2017)

$ 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

Percent

A. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

B. Business firms and not-for-profit organizations

%

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

%

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

1 00 %

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

IN

21955034

Name of person to contact regarding this report (Please print)

Telephone

Area code

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.
We estimate this survey will take an average of 15 minutes to complete, 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 voluntary collection of information, including suggestions for reducing this burden, to: EID Survey Comments 0607-0907, U.S. Census Bureau, 4600 Silver
Hill Road, Room EID-8K175, Washington, DC 20233. You may email comments to [email protected]. Be sure to use "EID Survey Comments 0607-0907" as the
subject.