Form QFR-200(MT) Quarterly Financial Report

OMB No. 0607-0432: Approval Expires 11/30/2018
FORM QFR-200(MT)
(3-15-2017)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY FINANCIAL
REPORT

NOTICE – YOUR RESPONSE IS REQUIRED BY LAW. Title 13 United States Code (U.S.C.), Section 91, authorizes this collection and
requires your response. 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 0607-0432 and appears at the upper right of this page. Without this approval, we
could not conduct this survey. We estimate this survey will take 3 hours to complete. More information about this estimate and an address
where you may write with comments is in the instructions that accompany this form.

MANUFACTURING,
MINING, RETAIL, AND
WHOLESALE TRADE
Please read the accompanying instructions
before answering the questions.
NEED HELP?
Use Secure Messaging Center at Internet
Website:
econhelp.census.gov/qfr/contactus
Call 1 (800) 272–4250 between
8 a.m. and 5 p.m. Eastern time
Monday through Friday
Note – Audited figures are not required.
Estimates are acceptable for line items where
actual data are not available.
Submit VIA Internet Reporting at:
econhelp.census.gov/qfr
or Mail to: U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
or FAX to: 1 (800) 447–4613

INTERNET REPORTING — You may complete this survey online at:

econhelp.census.gov/qfr

Username:

Use your firm’s unique username and original password.

Password:

1 Person to contact regarding this report – Print or type
●
011

012

Name and title
Area code

013

Telephone

(

Extension

Number

)

014

–

e-mail address
Area code
Fax

(

Number

–

)

ITEMS 2 THROUGH 7 REFER TO THE CORPORATION NAMED IN THE ADDRESS BOX
Month

2 a. Annual closing date of this corporation
●

Day

021

b. Federal Employer Identification Number (FEIN)

–

022

3 Corporation status – Mark "X" only ONE box. Insert discontinued or merged date if corporation is no longer operating.
●
Month
a. Active

b. Discontinued

Day

Year

Month
c. Merged

034

Day

Year

035

4 Is this corporation owned more than 50 percent by another corporation? (Mark "X" only ONE box.)
●
a. No
043

Name

b. Yes

– Provide the name, FEIN, and address assigned to this corporation below.
044

045

FEIN

Address

–
5 Does this corporation own more than 50 percent of any other corporation – Mark "X" only ONE box.
●
a. Yes

STOP! Read Consolidation Rules below.

b. No

– Proceed to page 2.

6 What is the total number of domestic and foreign corporations directly or indirectly (all tiers) owned
●
more than 50 percent by this corporation?
a.
7
● After reviewing the Consolidation Rules below, how many corporations are consolidated in this report?
b. How many corporations are not consolidated in this report?

Number
061
071
072

CONSOLIDATION RULES: This is a domestic-only consolidation. Nonconsolidated subsidiaries must be reported using either the
equity or cost method of accounting. Fully consolidate the operations of every majority-owned domestic subsidiary (including majorityowned subsidiaries of these subsidiaries) that are taxable under the U.S. Internal Revenue Code. Consolidated subsidiaries should
include 1120S corporations.
EXCEPTION: Do not fully consolidate domestic subsidiaries that are primarily engaged in foreign operations, banking, finance,
or insurance (as defined in the North American Industry Classification System (NAICS) Sector 52, United States, 2007).
Do not fully consolidate foreign subsidiaries or foreign operations. Nonconsolidated subsidiaries must be reported using
the equity method or cost method of accounting.
Equity method of accounting – Report net equity earnings (losses) of all nonconsolidated domestic and foreign operations on 8
line I of the Income Statement. Report the investment on 9 line I on the Balance Sheet. For purposes of this report, domestic
operations refer to operations that are within the 50 United States and the District of Columbia. Commonwealths such as Puerto Rico
and territories such as the Virgin Islands are not considered domestic.

CONTINUE ON PAGE 2

PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
BEFORE COMPLETING THIS REPORT, READ THE CONSOLIDATION RULES ON THE PREVIOUS PAGE
AND THE ACCOMPANYING INSTRUCTIONS.
REPORT ALL DOLLAR FIGURES IN THOUSANDS. AUDITED FIGURES ARE NOT REQUIRED.
ESTIMATES ARE ACCEPTABLE FOR LINE ITEMS WHERE ACTUAL DATA ARE NOT AVAILABLE.

8
●

Schedule A – Statement of Income and Retained
Earnings for your 3-MONTH PERIOD (inclusive)

401 FROM: Month

Year

Day

402

TO: Month

Day

Year

A Sales, receipts, and operating revenues (net of returns and allowances, and excise and sales taxes)1 . . . . . . . . . . . . . . . . . . . .
B Depreciation, depletion, and amortization of property, plant, and equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C All other operating costs and expenses – Include cost of goods sold (net of purchase discounts), selling, general and administrative
expenses, and amortization of intangible assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D Income (loss) from operations — 8 line A less the sum of lines B and C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E Interest expense — Do not net interest income with interest expense. Report interest income in 8 line G. . . . . . . . . . . . . . . . .
F
G
H
I
J
K

L
M
N
O
P

Dividend income — Domestic and foreign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other recurring nonoperating income (expense) — Include interest income, minority interest, etc. 2 . . . . . . . . . . . . . . . . . . . . .
Nonrecurring items — Include gain (loss) on sale of assets, restructuring costs, asset writedowns, disposal of business segments, etc. 2.
Income (loss) of foreign branches and equity in earnings (losses) of domestic and foreign nonconsolidated subsidiaries and other
investments accounted for by the equity method, net of foreign taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income (loss) before income taxes — Sum of 8 lines D, F, G, H, and I less line E. . . . . . . . . . . . . . . . . . . . . . . . . . .
Provision for current and deferred domestic income taxes (accrue payable in 10 lines D and H)
1. Federal 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. State and local 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income (loss) before extraordinary items and cumulative effect of accounting changes — 8 line J less lines K-1 and K-2 .
Extraordinary gains (losses), net of taxes 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Cumulative effect of accounting changes, net of taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Net income (loss) for quarter — Sum of 8 lines L, M, and N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retained earnings at beginning of quarter — If not the same as 10 lines I-2 of preceding quarter, explain below. . . . . . . . . . . . . .

Q Cash dividends charged to retained earnings this quarter — Include 1120S cash distributions. . . . . . . . . . . . . . . . . . . . . . . . .
2
R Other direct credits (charges) to retained earnings — Include stock and other non-cash dividends, etc. . . . . . . . . . . . . . . . . . .
S Retained earnings at end of quarter — Sum of 10
8 lines O, P, and R less line Q (same as 10 lines I-2). . . . . . . . . . . . . . .

9
●

403 Month

Schedule B1 – Balance Sheet – Assets

A 1. Cash and demand deposits in the U.S.

Day

AMOUNT
(in thousands)
101
102
103
104
105
106
107
108
109

111
112
113
115
116
117
118
119
120
121
123

Year

AMOUNT
(in thousands)

Balance Sheet date as of

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

2. Time deposits (certificates of deposit) in the U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Cash and deposits outside the U.S. . . . . . . . . . . . . . . . . . . . . . . . .
B 1. U.S. Treasury and Federal agency securities — Subject to agreements to sell.
2. U.S. Treasury and Federal agency securities — Other, due in one year or less.
C 1. Commercial and finance company paper of U.S. issuers . . . . . . . . . . . . .
2. State and local government securities, due in one year or less. . . . . . . . .
3. Foreign securities, due in one year or less. . . . . . . . . . . . . . . . . . . .

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4. Other short-term financial investments — Include financial derivatives and hedging activity.
4
D 1. Trade receivables from the U.S. Government . . . . . . . . . . . . . . . . . . . . . . . . .
2. Other trade accounts and trade notes receivable (less allowance for doubtful accounts) 4 . .
E Inventories 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4

F All other current assets — Include prepaid expenses and income taxes receivable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

201
202
203
204
205
206
207
208
209
211
212
214
215

216

G 1. Property, plant, and equipment — Include construction in progress. . . . . . . . . . . . . . . . . . . . . . .
217
2. Land and mineral rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
218
3. Accumulated depreciation, depletion, and amortization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Net property, plant, and equipment — Sum of 10
9 lines G-1 and G-2 less line G-3 . . . . . . . . . . . . . . . . . . . . . . . . .
H U.S. Treasury and Federal agency securities, due in more than one year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I All other noncurrent assets — Include investment in nonconsolidated entities, long-term investments, intellectual property, etc. . . . .
J TOTAL ASSETS – Sum of 10
9 lines A-1 through F, G-4, H, and I (must equal 10 line J)

10
●

219
220
221
223

Schedule B2 – Balance Sheet – Liabilities and Stockholders’ Equity

{

1. Loans from banks. . . .
A Short-term debt (original maturity of one year or less) — Include overdrafts. . . . . . . . .
2. Commercial paper . . .
3.Other short-term loans.
4
B Advances and prepayments by the U.S. Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C Trade accounts and trade notes payable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D Domestic income taxes accrued, prior and current years, net of payments —
Include overpayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

{

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

1. Federal. . . . . . . . . . . . . . . . .
2. State and local . . . . . . . . . . . . .

1. Loans from banks. . . .
E Current portion of long-term debt — Classify noncurrent portion in 10 line G. . . . . . . . .
2. Bonds and debentures .
3. Other long-term loans .
All
other
current
liabilities
—
Include
excise
and
sales
taxes,
accrued
expenses,
and
current
portion
of capital leases 4. . .
F
1. Loans from banks . . .
G Long-term debt, due in more than one year — Classify current portion in 10 line E.. . . . .
2. Bonds and debentures .
3. Other long-term loans .

{
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301
302
303
305
306
307
308
310
311
312
314
316
317
318
320

H All other noncurrent liabilities — Incl. deferred taxes, minority stockholders’ interest, and long-term portion of capital leases. . . . . . . .
I

1. Capital stock and other capital — Include additional paid in capital . . . . . . . . . . . . . . . . . . . . . . .
8 line S). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Retained earnings (same as 10
3. Cumulative foreign currency translation adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Other stockholders’ equity items — Include unearned compensation and ESOP debt guarantees. . . . . . . .

321
322
323
324
325

J

5. Treasury stock at cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Stockholders equity — Sum of 10 lines I-1 through I-4 less lines I-5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL LIABILITIES AND STOCKHOLDERS’ EQUITY — Sum of 10 lines A-1 through H and I-6

327
328

Report sales and costs from the normal business activities of discontinued operations in the same manner as sales and costs from continuing operations.
Attach a list and explain, on a separate sheet, the principal debits and credits reflected during the quarter.
3 Attach a brief explanation on a separate sheet if tax provision is not shown (e.g., "net operating loss," "1120S," etc.).
4 Progress payments and billings from U.S. Government and others should not be deducted from 10
9 lines D-1, D-2, E, and F; but included in 10 lines B and F.
1
2

IMPORTANT: IN ALL CORRESPONDENCE WITH US, PLEASE REFER TO THE 10-DIGIT USERNAME LOCATED ON THE FRONT OF THIS FORM.
FORM QFR-200(MT) (3-15-2017)

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