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Quarterly Services Survey

Forms

OMB: 0607-0907

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0907 can be found here:

2024-03-11 - Extension without change of a currently approved collection

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OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1A

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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.)

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21953013

• 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
• If a figure is $1,030,280,456 it should be reported as

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

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-1A
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21953021

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-1A
5

Page 3

(12-01-2019)

SALES, RECEIPTS, OR REVENUE
Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.
Tax-exempt Firms
Include:
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Taxable Firms
Include:
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Market value of compensation in lieu of cash
• Franchise sales, fees, and royalties
• Sale or licensing of rights to intellectual property
protected by copyright or as industrial property
(e.g., patents, trademarks)
• Allowances for cash and other discounts

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Revenue from a domestic parent organization, or
from franchise locations owned by others
• Rents from and revenue of separately operated
departments, concessions, etc., which are leased to
others
• Revenue from customers for carrying or other credit
charges
• Commissions from vending machine operators
• Revenue of foreign subsidiaries (those located
outside the U.S. , i.e., outside the 50 states, District
of Columbia, U.S. Commonwealth Territories, or
U.S. Possessions)
• Nonoperating revenue such as income from
investments, sales of company-owned real estate
(land and building), or other assets (except
inventory held for resale), securities, gifts, loans,
contributions, or grants
• Revenue from the sale of used equipment
• Installment payments from leasing under capital,
finance, or full-payout leases
• Intracompany transfers
• Interest income
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Gross receipts of departments or concessions
operated by other companies
• Amounts transferred to operating funds from capital
or reserve funds

$ Bil.

21953039

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

CLASS OF CUSTOMER

What percentage of revenue reported in
in the

was received from the following classes of customer

Percent

1. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Business firms and not-for-profit organizations

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

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

1 00 %
7

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-1A

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21953047

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1E

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

Throughout this survey, any reference to "this firm" is referring to the EIN that is printed in the mailing address
area or the new EIN that was provided as a response in 2 . Any responses related to "this firm" should only
include data for the EIN referenced.

21952015

Include:
• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and
Construction operations) operated by this firm
• 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

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-1E
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21952023

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-1E
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.

21952031

Tax-exempt Firms
Include:
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

$ Bil.

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

CONTINUE ON PAGE 4

Form QSS-1E
6

Page 4

(12-01-2019)

CLASS OF CUSTOMER
What percentage of revenue reported in
in the

was received from the following classes of customer

Percent

2. Business firms and not-for-profit organizations

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

1. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .

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

1 00 %

Not Applicable.

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

21952049

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1pA

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21955018

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

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21955026

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-1pA

SALES, RECEIPTS, OR REVENUE

$ Bil.

Mil.

Thou.

Dol.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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

Page 3

(12-01-2019)

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

CLASS OF CUSTOMER

What percentage of gross billings/professional service fees reported in
the following classes of customer in the

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 %

Not Applicable.

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

21955034

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-1pE

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21954011

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-1pE
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21954029

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-1pE
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

$ 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CLASS OF CUSTOMER

What percentage of gross billings/professional service fees reported in
the following classes of customer in the

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 %

Not Applicable.

21954037

CONTINUE ON PAGE 4

Form QSS-1pE

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21954045

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-2A

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21957014

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-2A
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21957022

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-2A
5

Page 3

(12-01-2019)

SALES, RECEIPTS, OR REVENUE
Tax-exempt Firms
Include:
• Operating and nonoperating revenue
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Taxable Firms
Include:
• Operating revenue
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Market value of compensation in lieu of cash
• Dues and assessments from members and affiliates

$ Bil.

Thou.

Dol.

. . . . . . . .

21957030

What was this firm's revenue in the

Mil.

CONTINUE ON PAGE 4

Form QSS-2A
6

Page 4

(12-01-2019)

INPATIENT DAYS AND DISCHARGES

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Inpatient Days - The unit of measure in which lodging was provided and services rendered to inpatients.
- A patient who is formally admitted and who is discharged or dies on the same day is counted as one patient day,
regardless of the number of hours the patient occupies a hospital bed. For patients switched from observation to
inpatient status, the patient day count should begin on the day the patient was officially admitted as an inpatient.
For inpatient admissions occurring before the current quarter or extending after the current quarter, record only
those days that occur during the second quarter and exclude days occurring before or after the quarter. Do not
include nursery discharges unless they are related to neonatal intermediate or intensive care units.
Include:
Exclude:
• Inpatient acute and sub-acute days
• Nursery days
• Swing bed days
• Newborn days
• Distinct part unit days
• Skilled nursing facilities days
• Long term care days
Discharges - The termination of the granting of lodging in the hospital and the formal release of the patient
(including patients admitted and discharged on the same day).
- If a patient is discharged from an acute care unit and transferred to a swing bed or distinct part unit, one
discharge would be recorded when the patient is discharged from the acute care unit and a second discharge
recorded when the patient is discharged from the swing bed or distinct part unit. Do not include nursery
discharges unless they are related to neonatal intermediate or intensive care units.
Include:
• Inpatient acute and sub-acute discharges
• Swing bed discharges
• Distinct part unit discharges
• Skilled nursing facility discharges
• Long term care discharges

A. What were this firm's inpatient days in the
B. What were this firm's discharges in the

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

OPERATING EXPENSES

Include:
• Payroll and employee benefits
• Supplies used for operating your business, cost of
merchandise sold, and other expenses allocated to
operations during the year
• Contracted or purchased services
• Fees paid to other organizations for fundraising
• Depreciation expenses
• Expenses of locations providing support services
(e.g., repair services, administrative services, etc.)
for your service establishments

21957048

. . . . . . . . . . .

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Outlays for the purchase of real estate (land and
buildings); for construction; for additions, major
alterations, and improvements to existing facilities;
and all other capital expenditures
• Funds invested
• Interest expense
• Bad debt
• Impairment
• Income taxes
• Assessments (dues) paid to the parent or other
chapters of the same organization
• For establishments engaged in raising funds - funds
transferred to charities or other organizations

$ Bil.

What were this firm's expenses in the

Mil.

Thou.

Dol.

. . . . . . .

CONTINUE ON PAGE 5

Form QSS-2A

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 5

(12-01-2019)

CONTACT INFORMATION

21957055

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-2E

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21956016

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-2E
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21956024

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-2E
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

21956032

Tax-exempt Firms
Include:
• Operating and nonoperating revenue
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

$ Bil.

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

CONTINUE ON PAGE 4

Form QSS-2E
6

Page 4

(12-01-2019)

INPATIENT DAYS AND DISCHARGES

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

A. What were this firm's inpatient days in the
B. What were this firm's discharges in the

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

OPERATING EXPENSES

21956040

. . . . . . . . . . .

$ Bil.

What were this firm's expenses in the

Mil.

Thou.

Dol.

. . . . . . .

CONTINUE ON PAGE 5

Form QSS-2E

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 5

(12-01-2019)

CONTACT INFORMATION

21956057

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-3A

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21959010

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-3A
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21959028

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-3A
5

Page 3

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

21959036

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-3A
7

Page 4

(12-01-2019)

OPERATING EXPENSES
Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Outlays for the purchase of real estate (land and
buildings); for construction; for additions, major
alterations, and improvements to existing facilities;
and all other capital expenditures
• Funds invested
• Interest expense
• Bad debt
• Impairment
• Income taxes
• Assessments (dues) paid to the parent or other
chapters of the same organization
• For establishments engaged in raising funds - funds
transferred to charities or other organizations

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What were this firm's expenses in the

Thou.

Dol.

. . . . . . .

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

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

21959044

Mil.

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-3E

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21958012

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-3E
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21958020

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-3E
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

21958038

$ Bil.

What was this firm's revenue in the
6

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-3E
7

Page 4

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What were this firm's expenses in the

Thou.

Dol.

. . . . . . .

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

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

21958046

Mil.

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4A

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21963012

We estimate this survey will take an average of 10 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-4A
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21963020

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-4A
5

Page 3

(12-01-2019)

SALES, RECEIPTS, OR REVENUE
Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.
Tax-exempt firms
Include:
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, State, or Federal tax agency
• Gross receipts of departments or concessions
operated by other companies
• Amounts transferred to operating funds from capital
or reserve funds

$ Bil.

21963038

What was this firm's revenue in the

6 and 7

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-4A

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21963046

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

Area code

Telephone

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 10 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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4E

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21962014

We estimate this survey will take an average of 10 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-4E
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21962022

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-4E
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.

21962030

Tax-exempt firms
Include:
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities

$ Bil.

What was this firm's revenue in the
6 and 7

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.
CONTINUE ON PAGE 4

Form QSS-4E

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21962048

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4fA

(01-30-2020)

Due Date

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21965017

We estimate this survey will take an average of 10 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-4fA
1

Page 2

(01-30-2020)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21965025

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-4fA
5

Page 3

(01-30-2020)

SALES, RECEIPTS, OR REVENUE
Firms operating on a commission basis should report commissions, fees, and other operating revenue income,
not gross billings or sales.

EXCLUDE
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Revenue from a domestic parent organization, or
from franchise locations owned by others
• Revenue of departments or concessions operated
by other companies at this establishment
• Revenue of foreign subsidiaries (those located
outside the U.S. , i.e., outside the 50 states, District
of Columbia, U.S. Commonwealth Territories, or
U.S. Possessions)
• Intracompany transfers
• Commissions from vending machine operators
• Revenue from the sale of used equipment

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

INCLUDE
• Net realized gains as well as losses within
specified area(s) of activity
• Earned interest
• Commissions and fees received from all sources,
including fees earned for exchanging currencies,
selling money orders, and cashing checks
• Net gains (losses) from the sale of real property
owned by this establishment for investment, rent, or
lease (NOT gross sales)
• Gross sales (NOT net gains (losses)) of real property
developed or buildings built by this establishment
for sale
• Gross rents from real property leased by this
establishment to others
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Rents from departments or concessions operated by
other companies at this establishment
• Franchise sales, fees, and royalties
• Sale or licensing of rights to intellectual property
protected by copyright or as industrial property
(e.g., patents, trademarks)
• Dues and assessments from members and affiliates

$ Bil.

A. What was this firm's revenue in the
B. Does the revenue reported in

Mil.

Thou.

Dol.

. . . . . . .

A represent book figure(s) or estimate(s)?

Book figures
Estimates

Not Applicable.

21965033

6 and 7

CONTINUE ON PAGE 4

Form QSS-4fA

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Page 4

(01-30-2020)

CONTACT INFORMATION

21965041

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4fE

(01-30-2020)

Due Date

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21964010

We estimate this survey will take an average of 10 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-4fE
1

Page 2

(01-30-2020)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21964028

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-4fE
4

Page 3

(01-30-2020)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

Month

End Date
Day
Year

SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income,
not gross billings or sales.
INCLUDE
• Net realized gains as well as losses within
specified area(s) of activity
• Earned interest
• Commissions and fees received from all sources,
including fees earned for exchanging currencies,
selling money orders, and cashing checks
• Net gains (losses) from the sale of real property
owned by this establishment for investment, rent, or
lease (NOT gross sales)
• Gross sales (NOT net gains (losses)) of real property
developed or buildings built by this establishment
for sale
• Gross rents from real property leased by this
establishment to others
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Rents from departments or concessions operated by
other companies at this establishment
• Franchise sales, fees, and royalties
• Sale or licensing of rights to intellectual property
protected by copyright or as industrial property
(e.g., patents, trademarks)
• Dues and assessments from members and affiliates

$ Bil.

A. What was this firm's revenue in the
B. Does the revenue reported in

Mil.

Thou.

Dol.

. . . . . . .

A represent book figure(s) or estimate(s)?

21964036

Book figures
Estimates

6 and 7

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-4fE

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

Page 4

(01-30-2020)

CONTACT INFORMATION

21964044

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-5A

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21969019

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-5A
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21969027

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-5A
5

Page 3

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

Thou.

Dol.

. . . . . . . .

21969035

What was this firm's revenue in the

Mil.

CONTINUE ON PAGE 4

Form QSS-5A
6

Page 4

(12-01-2019)

SOURCE OF REVENUE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Admissions - Gross receipts from the sale of general or specific event admissions tickets exclusive of any state
or local admissions taxes (include theater or facilities owners' share, if any). Include receipts from all home, hall or
tour subscriptions, and other minimum guarantee and percentage arrangements. Dinner theatres should include
all combined admission/dinner receipts. Professional athletic clubs should report total receipts form admissions to
their home games, including visiting teams' share (both league and nonleague). Exclude admissions taxes.
How much of the revenue reported in
the

was received from the following sources of revenue in

Percent

A. Admissions revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. All other operating revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

1 00 %

Not Applicable.

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

21969043

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-5E

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21968011

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-5E
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21968029

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-5E
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.

21968037

$ Bil.

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

CONTINUE ON PAGE 4

Form QSS-5E
6

Page 4

(12-01-2019)

SOURCE OF REVENUE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

was received from the following sources of revenue in

Percent

A. Admissions revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. All other operating revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

1 00 %

Not Applicable.

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

21968045

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-3sE

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21960018

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-3sE
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21960026

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-3sE
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

21960034

$ Bil.

What was this firm's revenue in the

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-3sE
7

Page 4

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What were this firm's expenses in the

Thou.

Dol.

. . . . . . .

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

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

21960042

Mil.

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-3sA

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21961016

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-3sA
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21961024

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-3sA
5

Page 3

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What was this firm's revenue in the

Thou.

Dol.

. . . . . . . .

Not Applicable.

21961032

Mil.

CONTINUE ON PAGE 4

Form QSS-3sA
7

Page 4

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What were this firm's expenses in the

Thou.

Dol.

. . . . . . .

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

CONTACT INFORMATION

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

21961040

Mil.

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4sA

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21967013

We estimate this survey will take an average of 10 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-4sA
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

Not Applicable.

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

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

21967021

REPORTING PERIOD

What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Month

End Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

CONTINUE ON PAGE 3

Form QSS-4sA
5

Page 3

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

$ Bil.

What was this firm's revenue in the

Thou.

Dol.

. . . . . . . .

Not Applicable.

21967039

6 and 7

Mil.

CONTINUE ON PAGE 4

Form QSS-4sA

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21967047

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

Area code

Telephone

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.

OMB No. 0607-0907: Approval Expires: 07/31/2021
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-4sE

(12-01-2019)

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L

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://www.census.gov/services/qss/
respondent-information.html

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to
complete this survey online at: https://portal.census.gov
Authentication Code:

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

GENERAL INSTRUCTIONS

21966015

We estimate this survey will take an average of 10 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-4sE
1

Page 2

(12-01-2019)

SURVEY COVERAGE

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Does this firm report payroll under EIN
Yes

EIN (9 digits)

No - Enter current 9-digit EIN AND date payroll was first
reported for this EIN . . . . . . . . . . . . . . . . . . . . . . . . .

Month

Day

Year

ORGANIZATIONAL CHANGE

A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes

No - Go to

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

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND

Enter detailed information below

21966023

Divestiture

Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

CONTINUE ON PAGE 3

Form QSS-4sE
4

Page 3

(12-01-2019)

REPORTING PERIOD
What time period is covered by the data provided in this report?
Month

Beginning Date
Day
Year

Month

End Date
Day
Year

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Calendar quarter
Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .

SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income, not
gross billings or sales.

21966031

$ Bil.

What was this firm's revenue in the

6 and 7

Mil.

Thou.

Dol.

. . . . . . . .

Not Applicable.

CONTINUE ON PAGE 4

Form QSS-4sE

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

IN
D FO
O R
N M
O A
T T
U IO
SE N
A
TO L
C
R OP
EP Y
O O
R N
T L
Y

Page 4

(12-01-2019)

CONTACT INFORMATION

21966049

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

Area code

Telephone

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.

File Type	application/pdf
Author	cogan300
File Modified	2021-01-25
File Created	2021-01-25