NC-99001(S) Reportof Organization

Attachment J
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2020-2022 Report of Organization
OMB Control Number 0607-0444
Form NC-99001(S)

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2020 Report of Organization
NC-99001(S) - Report of Organization
Mailing Address Additional Information

MAILING ADDRESS
ATTN

Name 1

Name 2

Street

State

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City

ZIP Code
99999-9999

For Census Bureau Use Only
CFN

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1

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1A: Ownership or Control

,
CFN:

ITEM 1A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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2

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1B: Ownership or Control - Voting Stock Validation

,
CFN:

ITEM 1B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

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3

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1C: Ownership or Control - Management and Policy

,
CFN:

ITEM 1C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1D: Ownership or Control - Percent of Voting Stock Held

,
CFN:

ITEM 1D: OWNERSHIP OR CONTROL - PERCENT OF VOTING STOCK HELD
What percent of voting stock was held by the owning or controlling company?
Less than 50%
50%

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1E: Ownership or Control - Company Information Additional Information

,
CFN:

ITEM 1E: 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

City, town, village, etc.

State
Select State or Territory

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Home office address (Number and
street)

ZIP Code
99999-9999

EIN
99-9999999

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6

Do Not Submit - For Informational Purposes ONLY
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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1F: Foreign Ownership or Control

,
CFN:

ITEM 1F: FOREIGN OWNERSHIP OR CONTROL
Does a foreign entity (company, individual, government, etc.) own directly or indirectly 10 percent or more of the voting stock or other equity rights
of your company?
Yes
No

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Do Not Submit - For Informational Purposes ONLY
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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1G: Foreign Ownership or Control - Company Information

,
CFN:

ITEM 1G: FOREIGN OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and country of the foreign entity (company, individual, government)?
Name of foreign beneficial owner

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Home office address (Number and
street)

City

Country

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1H: Foreign Ownership or Control - Percent of Voting Stock Owned Additional Information

,
CFN:

ITEM 1H: FOREIGN OWNERSHIP OR CONTROL - PERCENT OF VOTING STOCK OWNED
What percent of voting stock was owned directly or indirectly by a foreign entity (company, individual, government)?
10% to 24%
25% to 49%
50%

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51% to 99%
100%

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 1I: Foreign Affiliates

,
CFN:

ITEM 1I: FOREIGN AFFILIATES
Does this company alone, or with its domestic affiliates, own 10 percent or more of the voting stock of an incorporated foreign business enterprise, or
an equivalent interest in an unincorporated business enterprise, including ownership of real estate?
Yes
No

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NC-99001(S) - Report of Organization
Item 2A: Research and Development Additional Information

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CFN:

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ITEM 2A: RESEARCH AND DEVELOPMENT
Did your company perform or fund research and development (R&D) in 2020?
Yes
No

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NC-99001(S) - Report of Organization
Item 2B: Research and Development Expenses

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CFN:

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ITEM 2B: RESEARCH AND DEVELOPMENT EXPENSES
What were your company's worldwide expenses for research and development (R&D) in 2020?
Less than $3 million
$3 million or more

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NC-99001(S) - Report of Organization
Item 3A: Professional Employer Organization

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CFN:

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ITEM 3A: PROFESSIONAL EMPLOYER ORGANIZATION
Did your company lease 50 percent or more of its permanent full-and part-time workforce from a Professional Employer Organization during 2020?
(Permanent workforce excludes temporary staffing from a staffing service and contractors)
Yes
No

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NC-99001(S) - Report of Organization
Item 3B: Business Cooperative

,
CFN:

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ITEM 3B: BUSINESS COOPERATIVE
A cooperative is a business or organization owned by, controlled by, and operated for the benefit of members using its services. Members (also
known as user-owners) can be individuals or organizations, and benefit from the use of services, products, and/or earnings generated by the co-op.
This includes purchasing co-ops, member/patron organizations, member-controlled non-profits, consumer co-ops, marketing co-ops, worker co-ops,
etc.

Yes
No

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Is this company a cooperative?

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NC-99001(S) - Report of Organization
Item 4A: Certification

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CFN:

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2020 Report of Organization

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ITEM 4A: CERTIFICATION
This report is substantially accurate and was prepared in accordance with the instructions.
Is the time period covered by this report a calendar year?
Yes
No - Enter time period covered below
Enter To Date:

MM

YYYY

MM

YYYY

Select Month

Select Year

Select Month

Select Year

Name of person to contact regarding
this report

Title

Phone Number

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Enter From Date:

Fax Number

E-mail address

MMDDYYYY

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Date Completed:
MMDDYYYY

15

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 4B: Remarks

,
CFN:

ITEM 4B: REMARKS (Optional - Enter remarks only if necessary)
Please use this space only for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

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You have 1000 characters remaining

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16

OMB No.: 0607-0444

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2020 Report of Organization
NC-99001(S) - Report of Organization
Item 5B: Additional Locations of Operation Additional Information

ITEM 5B: ADDITIONAL LOCATIONS OF OPERATION
A. LOCATION INFORMATION
What is this establishment's physical location?
(P.O. Box and rural route addresses are not physical locations)
CFN

EIN
99-9999999
Name

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Secondary Name

Store or plant
No.

Physical Location (Number and Street)

City, town, village, etc.

State
Select State or Territory

ZIP Code
99999-9999

Date establishment
opened or is expected to
open
MMDDYYYY

B. EMPLOYMENT AND PAYROLL

2020
What was the number of employees for pay period including March 12?
2020
What was the annual payroll?

$

,000.00

2020
What was the first quarter payroll (January-March 2020)?

$

,000.00

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Include the number of employees and payroll for 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
Include part-year operations
Do not combine data for establishments
If book figures are not available for employment and payroll for each establishment, please provide your best estimates.

17

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NC-99001(S) - Report of Organization
C. MAJOR ACTIVITY CODE
Select the ACTIVITY CODE that best describes the activity of this establishment and what were the principal products or services?
Activity Code

Principal products or services

D. FORMER OWNER OR OPERATOR INFORMATION
If this establishment was acquired, who was the former owner or operator, and when was this establishment acquired?

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Name of former owner or operator

Mailing Address (Number and Street,
P.O. Box, etc.)

State
Select State or Territory

Month
Acquired

Year
Acquired

ZIP Code
99999-9999

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City, town, village, etc.

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18