D-1 thru D-20 Draft Previews of Standard, Consolidated, and Classifica

2022 Economic Census (Stateside and Island Areas)

Attachment D

2022 Economic Census (Stateside and Island Areas)

OMB: 0607-0998

Document [pdf]
Download: pdf | pdf
Attachment D
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-0998
Draft Previews of Standard, Consolidated, and Classification Questionnaires

Instrument
Path
11500
21110
21221
21238
2132A

Attachment
D-1
D-2

Sector
11
21

D-3

22

2211A
22110
22120
22130

Instrument Path Title
Support Activities for Crop and Animal Production
Crude Petroleum, Natural Gas, and Natural Gas Liquid Extraction
Gold, Silver, Lead, Zinc, Copper and Nickle Ore Mining
All Other Nonmetallic Mineral Mining
Support Activities for Coal, Metal, and Nonmetallic Minerals (except
Fuels) Mining (Consolidated)
Hydroelectric Power Generation
Electric Power Generation, Transmission and Distribution
Natural Gas Distribution
Water, Sewage and Other Systems

D-4

23

23610
23810
23830
23890

Residential and Nonresidential Building Construction
Foundation, Structure, and Building Exterior Contractors
Building Finishing Contractors
Other Specialty Trade Contractors

D-5

31-33

33153
33242
33591
33640

Nonferrous Metal Die-Casting Foundries
Metal Can Manufacturing
Primary Battery Manufacturing
Aircraft Manufacturing

D-6

42

42311
42435
42441
42542

Motor Vehicles
Clothing and Accessories
General-Line Groceries
Pharmaceuticals, Cosmetics, and Toiletries Agents and Brokers

D-7

44-45

44211
44512
44831
45111

Furniture Stores
Convenience Stores
Jewelry Stores
Sporting Goods Stores

D-8

48-49

48100
48400
48700
4930X

Air Transportation
Truck Transportation
Scenic and Sightseeing Transportation
Warehousing and Storage (Enterprise Support)

D-9

51

5160C
51213
51224
51314

Motion Picture and Video Production and Distribution and
Broadcasting Services (Classification)
Motion Picture and Video Exhibition
Sound Recording Studios and Other Sound Recording Industries
Directory and Mailing List Publishing

Attachment Sector
D-10
52

Instrument
Path
52111
52230
52321
52410

55111
5611C
56120
56150
5622X

Instrument Path Title
Monetary Authorities - Central Bank
Financial Transactions Processing and Other Activities Related to
Credit Intermediation
Securities and Commodity Exchanges
Health and Medical Insurance Carriers
Offices of Real Estate Agents and Brokers and Activities Related to
Real Estate
Real Estate Lessors
Automotive Equipment Rental and Leasing (Without Drivers)
Lessors of Nonfinancial Intangible Assets (except Copyrighted
Works)
Architectural and Landscape Architectural Services (Enterprise
Support)
Specialized Design Services
Computer Systems Design and Related Services and Management,
Scientific, and Technical Consulting Services (Classification)
Environmental Consulting and Other Scientific and Technical
Consulting Services
Corporate, Subsidiary, and Regional Managing Offices (Enterprise
Support)
Holding Companies
Office Administrative Services (Classification)
Facilities Support Services
Travel Arrangement and Reservation Services
Waste Treatment and Disposal (Enterprise Support)

61

6100C
61140
61150
61170

Educational Services (Classification)
Business Schools and Computer and Management Training
Technical and Trade Schools
Educational Support Services

D-16

62

6210C
6230C
62412

D-17

71

D-18

72

Ambulatory Health Care Services (Classification)
Nursing and Residential Care Facilities (Classification)
Services for the Elderly, Disables, and Intellectually and
Developmentally Disabled
Child Day Care Services
Spectator Sports
Promoters of Performing Arts, Sports, and Similar Events
Agents and Managers for Artists, Athletes, Entertainers, and Other
Public Figures
Museums, Historical Sites, and Similar Institutions
Accommodation, Food Services, and Drinking Places (Classification)
Traveler Accommodation
Rooming and Boarding Houses
Special Food Services

D-11

53

53100
53110
53210
53300

D-12

54

5403X
54140
5415C
54162

D-13

55

D-14

56

D-15

5511X

62441
71120
71130
71140
71210
7200C
72110
72130
72230

Attachment Sector
D-19
81

D-20

N/A

Instrument
Path
81210
81230
8127X
81349
92104
92304
93104
94204
94404
95104
95204
97204

Instrument Path Title
Personal Care Services
Drycleaning and Laundry Services
Parking Lots and Garages (Enterprise Support)
Civic, Social, and Other Membership Organizations
American Samoa - Mining, Utilities, Transportation, and
Warehousing
American Samoa - Construction
American Samoa - Manufacturing
American Samoa - Wholesale Trade
American Samoa - Retail Trade
American Samoa - Services
American Samoa - Finance, Insurance, Real Estate, Rental and
Leasing
American Samoa - Accommodation and Food Services

Instrument Search Functionality

User enters a write-in under "Specify additional product or service" label, user clicks the "Search"
button, user gets the table of search results, user selects products and services to add (if none apply the
user can select "None of these:.." with the write-in text at the end of the table of search results), and the
user clicks the "Add Selected Products/Services" to add the selected products and services.

Attachment D-1
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 11

Attachment Sector

Instrument
Path
Instrument Path Title

D-1

11500

11

Support Activities for Crop and Animal Production

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Agricultural Services
Cotton ginning

115111 001

Soil preparation, planting, and cultivating support services for crop production - including crop dusting and spraying, plowing, fertilizer
application, seeding, planting, thinning, and transplanting, pollinating, cultivating, weed and pest control, etc.

115112 001

Crop harvesting (primarily by machine) support services for crop production - including harvesting, combining, picking, threshing, hay
mowing, raking, baling, chopping, and silo filling

115113 001

Postharvest crop activities (except selling and cotton ginning) - including crop cleaning, sun drying, irradiation, shelling, fumigating, curing,
sorting, grading, packing, waxing, and cooling

115114 001

Farm labor contractors and crew leaders - supplying labor for agricultural production or harvesting (without providing farm operation
management services)

115115 001

Farm operation management services, on a contract or fee basis

115116 001

Support activities for animal production - including semen collection, breeding services for animals (except for sale), pedigree record
services, boarding and training horses (except racehorses), farrier services, poultry catching, poultry house cleaning, dairy herd
improvement activities, livestock spraying, sheep dipping and shearing, etc.

115210 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 943 (Employer's Annual Federal Tax Return for Agricultural Employees)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 28: Special Items - Primary Products or Services
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form
941, Employer’s Quarterly Federal Tax Return or Internal Revenue Service Form 943, Employer’s Annual Federal Tax Return for Agricultural Employees, and filed under the
Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.
A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

2022
$

,000.00

$

,000.00

19

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

20

Item 28: Special Items - Primary Products or Services

ITEM 28: SPECIAL ITEMS - PRIMARY PRODUCTS OR SERVICES
Please describe the three products or services that generated the largest sales, shipments, receipts, or revenue for this establishment in 2022.
Product or service #1

Product or service #2

Product or service #3

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

21

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

1000

characters remaining

22

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_AG-11500_su.pdf Generated 2022-02-23 17:07:18

,000.00

23

Attachment D-2
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 21

Attachment Sector

D-2

21

Instrument
Path
Instrument Path Title

21110
21221
21238
2132A

Crude Petroleum, Natural Gas, and Natural Gas Liquid Extraction
Gold, Silver, Lead, Zinc, Copper and Nickle Ore Mining
All Other Nonmetallic Mineral Mining
Support Activities for Coal, Metal, and Nonmetallic Minerals (except
Fuels) Mining (Consolidated)

Location Information

DEFINITION OF DOMESTIC REPORTING UNIT
The reporting unit for this questionnaire is an oil and gas field mineral domestic reporting unit. An oil and gas field mineral domestic reporting unit represents oil and gas field activities
in one state or offshore area operated by the reporting company.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION

Where is the physical location of this domestic reporting unit?
Answer A if operations of this domestic reporting unit are physically located onshore. Answer B if operations are located offshore.
A. Onshore
(Select name of state from the drop-down list.)

B. Offshore
Complete a separate report for offshore exploration, drilling, and production operations for each of the following areas in which your company had offshore operations. An offshore well
is one that is bottomed at, or producing from, a point that lies seaward of the coastline. In general, the term "coastline" means the line of ordinary low water along that portion of the
coast that is in direct contact with the open sea and the line marking the seaward limit of inland waters.
(For offshore areas, please see: https://www2.census.gov/programs-surveys/economic-census/2017/reference-maps/mining-offshore-area-map.docx)

For Census Bureau Use Only

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

1

CFN

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this domestic reporting unit's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this domestic reporting unit’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

9

Item 2F: Number of Domestic Reporting Units

ITEM 2F: NUMBER OF DOMESTIC REPORTING UNITS

2022
How many domestic reporting units operated under EIN at the end of 2022?

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this domestic reporting unit's operational status at the end of 2022?

In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

11

Item 3A: Operational Status - Ceased Operation Date

If this domestic reporting unit ceased operation or was sold or leased to another operator, what was the date?
MMDDYYYY
MMDDYYYY



2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

12

Item 3A: Operational Status - New Owner or Operator Information

If this domestic reporting unit was sold or leased to another operator, what is the name, address, and 9-digit Employer Identification Number (EIN) of this domestic reporting unit's new
owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the domestic reporting unit's
primary business or activity.
Select only ONE.

Crude petroleum extraction

211120 001

Natural gas extraction, including natural gas liquids

211130 101

Drilling oil and gas wells, on a contract basis

213111 001

Support activities for oil and gas operations on a contract basis (excluding drilling wells), e.g., cementing wells, exploration services,
hydraulic fracturing, gathering services, etc.

213112 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

2036

,000.00

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations (domestic reporting units) operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the domestic reporting unit listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each domestic reporting unit individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

17

Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What was the total value of products shipped and other receipts for this domestic reporting unit?
(Report details in Item 22.)
Include:
All products physically shipped during 2022
Receipts for services
Value of resales
Interplant transfers
Exports
Other miscellaneous receipts
Exclude:
Non-operating income such as royalties, interest, dividends, or the sale of fixed assets
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

$

,000.00

B. What was the value of products shipped for export for this domestic reporting unit?
(This is a breakout of the $,000.00 reported in A.)
Include:
Shipments going directly for export including shipments to foreign subsidiaries or foreign divisions of your
company and their affiliates:
Shipments to customers in the Panama Canal Zone, the Commonwealth of Puerto Rico, and U.S.
possessions
Shipments of your products to export firms and to other customers who export these items
Sales to the U.S. government to be shipped to foreign nations under military and economic assistance
programs
Exclude:
Sales to the U.S. Government overseas

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

18

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL
Include:
Full- and part-time employees (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941, Employer's Quarterly Federal
Tax Return, and filed under the Employer Identification Number (EIN)
Persons on paid sick leave, paid holidays, and paid vacations during the year
Officers, if a corporation
Persons at a general office serving two or more plants if located at or near this domestic reporting unit
Employees paid on a per ton, car, or yard basis
Exclude:
Members of the Armed Forces and pensioners carried on your active payrolls
Proprietor or partners, if an unincorporated concern
Workers at manufacturing plants (including petroleum refineries), company stores, boardinghouses, bunkhouses, recreational centers, and auxiliary offices
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report these values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report these values in Item 16, line C1.)
Purchased professional and technical services (Report these values in Item 16, line C9.)
Contractors and subcontractors and their employees (Report the cost of contract work in Item 16,line A3.)
A. EMPLOYMENT
1. What was the number of mining, production, development, and exploration workers (direct labor including
first-line supervisors) at this domestic reporting unit for the pay period including March 12 (Q1)?
Include:
Workers engaged in services closely associated with production and development operations such as:
Manual work
Tool use and machine operation
Materials and products, loading and hauling
Mineral properties care
Exploration and development work
Storage, shipping, maintenances, repair, and guard services
Auxiliary production for own use (i.e. power plant) record keeping
Regular maintenance and repair
Drilling and maintaining wells
Seismic testing or cementing walls
Exclude:
Supervisory employees above the first-line level (Report these in A2.)
Employees of contractors or subcontractors

Check
if
None

2022 Number

2. What was the number of other employees at this domestic reporting unit for the pay period including March 12
(Q1)?
Include:
Force-account construction employees and your payroll engaged in construction of major additions or
alterations to your facilities that are utilized as a separate work force
Nonproduction personnel engaged in supervision above the working supervisor level and employees
engaged in activities such as:
Sales, advertising, purchasing, finance
Highway trucking and other transportation
Credit, collection, executive, legal, clerical, and routine office functions
Personnel including cafeteria, medical, etc.
Professional (engineers, geologists, etc.) and technical workers
Exclude:
Proprietors and partners
Temporary staff and leased employees
Employees of contractors or subcontractors

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

19

TOTAL (Add lines A1 and A2.)

B. HOURS WORKED
What was the annual number of hours worked by the mining, production, development, and exploration workers
(direct labor including first-line supervisors) at this domestic reporting unit reported in A1?
Include:
All hours worked or paid (except hours paid for vacations, holidays, or sick leave)
Overtime hours (Report actual hours worked, not straight-time equivalent hours.)
Actual hours worked by an employee who elects to work during a vacation period
All hours worked for the entire year by a full and part-time mining, production, development, and
exploration workers of the type reported in A1
Exclude:
Hours of proprietors or partners
Hours worked by temporary staff or leased employees
Hours worked by employees of contractors or subcontractors

Check
if
None

2022 Hours
,000

C. PAYROLL
Report the gross earnings paid in calendar year 2022 to employees prior to such deductions as employee’s Social Security contributions, withholding taxes, group insurance
premiums, union dues, and savings bonds.
Payroll should equal the taxable Medicare wages and tips reported on the Internal Revenue Services (IRS) Form 941, Employer’s Quarterly Tax Return and definitions as described in
Circular E, Employer’s Tax Guide.
Include:
Commissions, dismissal pay and paid bonuses
Employee contributions to pension plans such as a 401(k) plan
Vacation and sick-leave pay
Salaries of officers
Spread on stock options that are taxable to employee as wages
Cash equivalent of compensation paid in kind such as:
Board and housing
Payments in the form of shared profits and special stock purchases that are subject to withholding tax
Exclude:
Payroll for temporary staff and leased employees
Payments to proprietor or partners
Payments to members of Armed Forces and pensioners carried on your active payroll
Royalty payments to unions
Payments to contract or subcontractors who performed work for you
Employer-paid annual cost for fringe benefits (Report these costs in D1 through D3.)
Check
if
None

2022

1. What was the annual payroll before deductions for mining, production, development, and exploration workers
(direct labor including first-line supervisors) of the type reported in A1 at this domestic reporting unit?

$

,000.00

2. What was the annual payroll before deductions for all other employees of the type reported in A2 at this domestic
reporting unit?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $,000.00 reported above, what was the first quarter payroll at this domestic reporting unit before
deductions (January - March 2022)?

$

,000.00

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

20

Item 7: Employment and Payroll - Continued

ITEM 7: EMPLOYMENT AND PAYROLL

D. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS
This is the employer’s annual cost at this domestic reporting unit for legally required programs and programs not required by law.
1. What were the employer’s annual costs at this domestic reporting unit for health insurance? (insurance premiums on
hospitals, medical plans, and single service plans such as dental, vision, and prescription drug plans)
Include:
Premium equivalents for self-insured plans and fees paid to third-party administrators (TPAs)
Exclude:
Employee contributions
Disbursements from trusts or funds to satisfy health insurance claims

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Retirement plans:
a. What were the employer’s annual costs at this domestic reporting unit for defined benefit pension plans? (Costs
include both qualified and nonqualified defined pension plans, as well as plans that specify the benefit to be
paid to employee upon retirement, generally either as a specified amount or a percentage of compensation.
Employer contributions are based on actuarial computations that include the employee's compensation and years
of service and are not allocated to specific accounts maintained for employees.)

b. What were the employer’s annual costs at this domestic reporting unit for defined contribution plans? (These
are plans that define the employer contributions to a separate account provided for each employee. The
employee "benefit" at retirement depends on the amount contributed and the results of the account's activity.)
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

3. What were the employer’s annual costs at this domestic reporting unit for employer-paid payroll taxes, insurance
premiums, and all other employer-paid benefits?
Include:
Life insurance benefits
“Quality of life” benefits (e.g., childcare assistance, subsidized commuting, etc.)
Education assistance
Legally-required fringe benefits
Social Security
Workers' compensation insurance
Unemployment tax
State disability insurance programs (long- and short-term disability – LTD and STD)
Medicare
Exclude:
Disbursements from trusts or funds to satisfy health insurance claims

TOTAL (Add lines D1 through D3.)

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

21

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

22

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES

Report inventories at cost or market using generally accepted accounting practices. Report the value of all inventories that are attributable to the domestic reporting unit’s operations
regardless of where the inventories are held or stored.
What was the value of mined products and supplies owned by this domestic reporting unit as of December 31 before Last-In, First-Out (LIFO) adjustment (if any) for:
A. Crude petroleum, including lease condensate?
Include:
Stocks of raw products awaiting treatment or
processing
Stockpiles of products ready for shipment

Check
if
None

Check
if
None

2022

2021

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

B. Materials, parts, supplies, fuels, etc.?
Include:
Natural gas and natural gas liquids received from
other domestic reporting units for processing
Cost of items to be used for extracting and
beneficiating

TOTAL (Add lines A and B.)

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

23

Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this domestic reporting unit as of December 31, 2022 and the $,000.00 reported in Item 9 as the total
value of inventories owned by this domestic reporting unit as of December 31, 2021:
Check
if
None

Check
if
None

2022

2021

A. What was the amount subject to Last-In, First-Out (LIFO)
gross (gross LIFO amount)?

$

,000.00

$

,000.00

B. What was the amount not subject to LIFO valuation
method?

$

,000.00

$

,000.00

TOTAL (Sum of lines A and B should equal TOTAL in Item
9.)

$

,000.00

$

,000.00

C. What was the amount of LIFO reserve (if any)? [LIFO
reserve represents the excess of current period cost over
the LIFO carrying value. LIFO reserve is the difference
between the current cost (i.e., FIFO) of inventories (gross
value) and the LIFO carrying value (net value).]

$

,000.00

$

,000.00

Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

24

Item 13: Capital Expenditures

ITEM 13: CAPITAL EXPENDITURES

Report the actual outlays during 2022, not the final value of buildings or other structures completed or equipment put in place during the year. These expenditures are of the type for which
depreciation or amortization accounts are ordinarily maintained.
Capital expenditures during 2022 may be determined by the following computation:
(a) Cost of additions completed during the year, plus
(b) Work-in-progress at the end of the year, minus
(c) Work-in-progress at the beginning of the year.
Include labor and installation costs whether on contract or by your own forces
Exclude the cost of maintenance and repairs charged as current operating expense
A. What were the capital expenditures for new and used buildings, structures, machinery, and equipment for this domestic
reporting unit?
Include:
Buildings and structures directly related to mineral exploration, development, and production
Machinery, such as hoists, cranes, crushers, separators, and power plants
Exploration, development, production, and processing plant machinery
Value of the equipment produced and used
Equipment such as excavators, loaders, locomotives, tractors, hoists, drills, compressors, pumps
Transportation equipment, such as automobiles, trucks, and similar equipment
Office equipment, such as computers and peripheral data processing equipment, as well as furniture and fixtures
for offices, cafeterias, and change rooms
Replacements as well as additions to new capacity
Values from construction by your own employees, where capitalized
Value of improvements and capitalized repairs to machinery and equipment including those done to assets
transferred from other domestic reporting units of this company
Expenditures for old or existing plants and for second-hand equipment acquired from others (including U.S.
Government)
Gross book value of machinery or equipment transferred from other domestic reporting units of your company
Exclude:
Company houses and general recreational facilities
Value of land
Cost of maintenance and repairs charged as current operating expense

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. What were the capital expenditures for mineral exploration and development for this domestic reporting unit?
Include:
All intangible development and exploration outlays that were charged to a capital or Office of Minerals Exploration
account
Capitalized expenditures for entries, shafts, rail and other road construction, test boring, surveying, etc.
Capitalized expenditures for oil and gas field exploration and for drilling oil, gas, dry, and service wells through
completion of the well

TOTAL (Add lines A and B.)

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

25

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS
Report rental payments made to other companies for use of depreciable assets such as buildings, other structures, machinery, and equipment. Include rental payments for land.
Domestic reporting units involved with leasing arrangements for equipment and/or buildings, report lease equipment according to the type of lease negotiated with the producer or the
lessor.
Include:
Operating leases (Report the periodic payments made to the producer or lessor.)
Exclude:
Capital leases (leases with a contract to own at the end of the lease) (Report cost, at market value, of acquisitions of building and equipment during the year as a capital
expenditure, Item 13.)
At this domestic reporting unit, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production machinery and equipment
Loading machinery and equipment
Transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles

TOTAL (Add lines A and B.)

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

26

Item 15: Mineral Property Expenses

ITEM 15: MINERAL PROPERTY EXPENSES

Report mineral property expenses charged to current accounts.

Check
if
None
A. What were the lease rents for mineral properties for this domestic reporting unit?

2022
$

,000.00

B. Current Operation Expenses
Include:
Acquisition costs for mineral land and rights that were not capitalized
Cost of royalty payments related to mineral production
Labor costs whether on a contract basis or by your own forces associated with exploration and development or the acquisition of mineral properties
Intangible development and exploration outlays charged to a current account
Expenses for mineral properties charged to current accounts, such as:
all supplies, machinery, equipment, parts, fuel, power, etc., used for development or exploration (whether purchased or received from other domestic reporting units of
your company) and charged as current operating expenses
cost of maintenance and repairs associated with development or exploration activity that is charged to current accounts
Exclude:
Lease rents (Report separately in A.)
1. What were the current operating expenses for exploration, development, and mineral land and rights for this
domestic reporting unit?

$

,000.00

2. What were the current operating expenses for royalty payments for this domestic reporting unit?

$

,000.00

TOTAL (Add lines B1 and B2.)

$

,000.00

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

27

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

SELECTED EXTRACTION/MINING/QUARRYING COSTS AND ELECTRICITY
Include costs incurred in mining processes such as supplies, resales, contract work, fuels, and electricity.

A. What were the extraction/mining/quarrying-related costs in 2022 for this domestic reporting unit for:

1. Materials, parts, and supplies used; and minerals received for preparation? (Report detail in Item 18.)
Include:
Cost of extraction/mining/quarrying-related materials purchased for other companies (contractors)
Cost of materials purchased or received from other domestic reporting units of your company
Exclude:
Non-extraction/mining/quarrying-related expenses that were paid to other companies (Report these
expense details in C.)

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Products bought and sold without further processing (products bought and resold in the same condition as when
purchased)? (Report these sales in Wholesaling Services product codes in Item 22.)
Exclude:
oil, gas or natural gas liquids (if applicable)

3. Work done for you by others on your materials (work contracted to others)? [Report in A1 the materials, parts, and
supplies purchased for other companies (contractors).]
4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report detail in Item 19.)
Report the total amount actually paid or payable for all purchased fuels consumed.
Include:
Fuels or coal consumed at this domestic reporting unit, but produced at another domestic reporting unit of
your company (Assign commercial values to them.)
Fuel used to power on-site trucks, forklifts, or motor vehicles
Anthracite, lignite, bituminous, and subbituminous coal, coke, natural and manufactured gas, gasoline,
wood, purchased steam, and all other fuels
Exclude:
Gas purchased for gas lift
Crude petroleum, natural gas, and coal produced at the domestic reporting unit and used for heat, power,
or the generation of electricity

5. Purchased electricity? (Report comparable quantity in B1.)
Report total amount actually paid or payable for electric energy purchased during 2022 from other companies or
received from other domestic reporting units of your company.
Exclude value of electricity generated and used at this domestic reporting unit

TOTAL (Add lines A1 through A5.)

B. For this domestic reporting unit, what was the quantity of:

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

28

Check
if
None
1. Purchased electricity? (quantity comparable to cost reported in A5)

2022 Kilowatt Hours
,000

2. Generated electricity? (gross less generating station use)
When a figure is reported on this line, include data relating to the activity of the power stations in other sections of
this questionnaire. For example, include the number of employees assigned to the power station, their wages, and
hours worked in the figures reported in Item 7 and the cost of fuels used to generate electricity, in Item 16, line A4
and Item 18.
Include energy generated at the drilling site that was used for lighting or other purposes.

3. Electricity sold or transferred to other domestic reporting units? (Also include quantity in B1 and/or B2.)

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

,000

,000

29

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

OTHER OPERATING EXPENSES
C. What were the other operating expenses paid by this domestic reporting unit in 2022 for:
Include:
Costs for each of these services purchased from other companies that are paid directly by this domestic reporting unit
Expenses normally considered nonproduction related costs
Exclude:
Salaries paid to employees of this domestic reporting unit for any of the specified services (Report in Item 7.)
Cost of mining activities contracted or subcontracted to others (Report on A3.)
1. Temporary staff and leased employees? [total costs paid to Professional Employer Organizations (PEOs) and
staffing agencies for personnel]
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report in 3.)
Leased and rented equipment (Report in Item 14, line B.)

3. Expensed purchases of software? (purchases of prepackaged, custom-coded or vendor-customized software)
Include:
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Credit card transaction fees
Other wired and wireless communication services

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

30

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other domestic reporting units of this company (such as a separate central data
processing unit)
Expensed integrated systems (Report in 4.)
Repair and maintenance of computer equipment (Report in 6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in 9 and credit card
transaction fees in 4.)
Expenses for telecommunication services, e.g., Internet, connectivity, telephone, etc. (Report in 4.)

$

,000.00

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof, replacing parts, over-hauling of equipment, and other repairs chargeable as
current operating costs
Cost of repair and maintenance of any leased property if the domestic reporting unit assumes the cost
Exclude:
Materials, parts, and supplies used for repairs and maintenance performed by this domestic reporting unit’s
employees (Report in A1.)
Extensive “repairs” or reconstruction that is capitalized (Report these as a capital expenditure in Item 13.)
Costs incurred directly by this domestic reporting unit in using its own work force to perform repairs and
maintenance work
Repairs and maintenance provided by the building or machinery owner as part of the rental contract

7. Water, sewer, refuse removal, and other non-electric utility payments? (Report electric utility payments on line
A5. If the cost of these utilities is included in a lease or rental payment, report in Item 14 line A.)
Include:
Cost of hazardous waste removal

8. Purchased advertising and promotional services?
Include:
Printed materials
Media coverage
Marketing and public relations services
Exclude:
All salaries paid to employees of the domestic reporting unit for advertising work

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

31

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other professional services
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

$

,000.00

10. Governmental taxes and licensing fees? (payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

11. All other operating expenses not reported elsewhere?
Exclude:
Purchases of merchandise for resale (Report on line A2.)
Non-operating expenses

Describe

TOTAL (Add lines C1 through C11.)

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32

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
Report:
Delivered cost of individual items listed below. Delivered cost is the amount paid or payable after discounts and including freight and other direct charges incurred by the
domestic reporting unit in acquiring the materials. The figures reported should represent the total purchase cost of supplies, minerals received for preparation, etc., actually used
or processed during 2022. Include purchases, interplant transfers, and withdrawals from inventories. Do not combine material lines. If the information is not directly available
from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Estimated quantity and cost of minerals received for processing on a custom or toll basis, as if purchased.
Minerals mined and also processed at this domestic reporting unit.
Include:
Minerals received from other domestic reporting units for preparation which were used or processed during 2022
Cost of materials and supplies not covered in the pre-listed material codes (Report these in material code 00970098 - "All other supplies".)
Supplies purchased by this domestic reporting unit for use by companies performing contract work at this domestic reporting unit
Exclude:
Associated labor costs of the kind reported in Item 7 and Item 16, line A3
Payments made for contract services performed, including payments for supplies and equipment furnished by the contractor incidental to this work

Unit of
Measure

Description

Quantity

1. Parts and attachments for mining, mineral preparation, construction, and
conveying machinery and equipment

Census
Material
Code

Value

$

,000.00

33300009

$

,000.00

33351506

3. Metal valves, pipe fittings, and related assemblies, excluding fluid power and
forgings

$

,000.00

33291000

4. Miscellaneous iron, steel, and ferroalloy ingot, shapes, and forms (excluding
castings, forgings, bars, structural shapes, wire, sheet, strip, and semifinished
shapes)

$

,000.00

33110090

5. Cement

$

,000.00

32730020

6. Drilling fluids (drilling mud and drilling mud materials; mud thinners, thickeners,
and purifiers)

$

,000.00

32599803

7. All basic organic and inorganic chemicals, excluding petrochemicals

$

,000.00

32518000

8. Petroleum lubricating oil and greases, including hydraulic oils

$

,000.00

32419100

9. Refined petroleum products, including coke, solvents, oils, and waxes

$

,000.00

32411000

10. Nonmetallic minerals, including stone, sand, refractory minerals, and chemical
materials, excluding fertilizer materials

$

,000.00

21230000

2. Drill bits and reamers

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

33

1000 bbl

$

,000.00

21111201

1000 bbl

$

,000.00

21111103

mil ft3

$

,000.00

21111011

14. Water purchased

$

,000.00

00999828

15. All other supplies

$

,000.00

00970098

$

,000.00

11. Natural gas liquids received for further processing

12. Domestic crude petroleum

13. Natural gas processed

Describe

TOTAL

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

77100000

34

Item 19: Fuels Used

ITEM 19: FUELS USED
Of the $,000.00 of purchased fuels in 2022, reported on Item 16, line A4, how much was for the following specified fuels?
Report:
Delivered cost of fuels received, not cost per unit. Delivered cost is the amount paid or payable after discounts, including freight and other direct charges incurred by the
domestic reporting unit in acquiring the fuels. Do not combine fuel lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Include:
Fuels purchased from other companies or transferred from other domestic reporting units of your company and used at this domestic reporting unit for the production of heat,
power, or generated electricity. The fuels transferred from other domestic reporting units of your company should be estimated at market value.
Cost of fuels not covered in the pre-listed fuel codes (Report these in fuel code 00960018 - "Other fuels".)

Unit of
Measure

Description

1. Diesel fuel

2. Gasoline used as a fuel

3. Gas (natural, manufactured, and mixed) used as a fuel

Quantity
Consumed

Cost, including delivery cost
(freight-in)

Census
Fuel Code

barrels

$

,000.00

32411021

1000 gal

$

,000.00

32411015

mil ft3

$

,000.00

21111015

$

,000.00

00960018

4. Other fuels (liquefied petroleum gas, coke, wood, etc.)
Describe

5. Crude petroleum produced and used in the same plant as a fuel

6. Natural gas produced and used in the same plant as a fuel

7. Residue gas produced and used at this plant as a fuel

TOTAL

1000 bbl

21111101

mil ft3

21111003

3
ft

21111029

mil

$

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

,000.00

00772000

35

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The mined products and services listed below are generally produced in your industry. They include products shipped and services performed by this domestic reporting unit. Select
the items that apply to your domestic reporting unit. If you mine products or have revenue from other sources not listed, you will report them in the next section.

Description

Select

1. Extraction of crude petroleum, including lease condensate (volumes corrected to 60 degrees F)

2. Extraction of natural gas (volumes adjusted to a pressure base of 14.73 lb absolute at 60 degrees F)

3. Extraction of residue gas (volumes adjusted to a pressure base of 14.73 lb absolute at 60 degrees F) from natural gas liquids

Product Code

1000350000

1000025000

1000050000

1000425000

4. Extraction of isopentane and natural gasoline

1000450000

5. Extraction of propane (C3) (at least 80 percent purity)

1000475000

6. Extraction of butane (C4) (at least 80 percent purity)

7. Extraction of plant condensate from natural gas liquids plants

1000500000

1000525000

8. Extraction of ethane (C2) (at least 80 percent purity)

9. Extraction of gas mixtures (C2, C3, and C4) from natural gas liquids plants

10. Extraction of other natural gas liquids, including raw or unfractionated natural gas liquid streams with less than 80 percent purity

1000550000

1000575000

1001100000

11. Recovered elemental sulfur from natural gas

1001600000

12. Oil and gas well directional drilling control

13. Drilling oil and gas wells, including drilling in, spudding in, or tailing in

1001625000

1001650000

14. Reworking oil and gas wells

15. Oil and gas field exploration services, excluding mapping and surveying services

1001675000

1001700000

16. Cementing oil and gas wells

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

36

1001725000

17. Oil and gas well logging

1001750000

18. Hydraulic fracturing of oil and gas wells

19. Running, cutting, and pulling casings, tubes, or rods for oil and gas wells

1001775000

1001800000

20. Oil and gas field gathering services

1001825000

21. Perforating oil and gas well casings

22. Installing oil and gas field production equipment, including wellhead fittings, pumps, and engines

1001850000

1001875000

23. Pumping oil and gas wells but not operating leases

1001900000

24. Other oil and gas field repair and maintenance services

1001925000

25. All other oil and gas field services
All other sales, shipments, receipts, or revenue from this domestic reporting unit

26. Wholesale sales of oil well and pipeline machinery and equipment

4002125000

4003325000

27. Wholesale sales of crude oil

28. Natural gas distribution and support services (except marketing and brokering)

29. Leasing of rights to explore for and exploit natural resources

30. Transportation of natural gas by pipeline, excluding gas field gathering services

31. Transportation of crude oil and other commodities by pipeline, excluding oil field gathering services

32. Scientific and technical consulting services, not elsewhere classified

6000030000

7010200000

7011150000

7011175000

7012270000

Add product/service not listed

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

37

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Report:
The value of the products shipped and services performed at the net selling value, free on board (FOB) quarry or plant to customer, after discounts or allowances.
Quantities in the unit of measure specified. Note: Short tons equal to 2,000 pounds.
Include:
All products mined, quarried, extracted, or leached from this domestic reporting unit
Material withdrawn from stockpiles, i.e. for leaching, sale, etc.
Products shipped on consignment
Prepared minerals from crude materials mined at this domestic reporting unit, purchased, or received from other domestic reporting units of your company
Concentrated ores, metals, and agglomerates from ores mined at this domestic reporting unit, or purchased or received from other domestic reporting units of your company
Estimated value of products treated on a custom or toll basis
Products transferred to other domestic reporting units of your company for treatment, preparation, milling, or other use
Bonuses or other credits for minerals contained, as well as royalties
Quantity of production of crude ore mined for treatment at this domestic reporting unit
Exclude:
Penalties for impurities
Wholesaling products (previously Resales), which include products that are bought from other domestic reporting units or transferred from other domestic reporting units of your
company and then sold without further treatment, processing, preparation, or milling by this domestic reporting unit. Report these products in the appropriate wholesaling
product line(s) you selected or else "Add product/service not listed" at the end of this item.
Freight charged
Excise taxes

Description

Quantity
Shipped

Unit of
Measure

Quantity
Produced

Unit of
Measure

Product
Code

Value

1. Extraction of crude petroleum, including
lease condensate (volumes corrected to
60 degrees F)

1000 bbl

$

,000.00

1000350000

2. Extraction of natural gas (volumes
adjusted to a pressure base of 14.73 lb
absolute at 60 degrees F)

mil ft3

$

,000.00

1000025000

3. Extraction of residue gas (volumes
adjusted to a pressure base of 14.73 lb
absolute at 60 degrees F) from natural
gas liquids

mil ft3

$

,000.00

1000050000

4. Extraction of isopentane and natural
gasoline

1000 bbl

1000 bbl

$

,000.00

1000425000

5. Extraction of propane (C3) (at least 80
percent purity)

1000 bbl

1000 bbl

$

,000.00

1000450000

6. Extraction of butane (C4) (at least 80
percent purity)

1000 bbl

1000 bbl

$

,000.00

1000475000

7. Extraction of plant condensate from
natural gas liquids plants

1000 bbl

1000 bbl

$

,000.00

1000500000

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

38

8. Extraction of ethane (C2) (at least 80
percent purity)

1000 bbl

1000 bbl

$

,000.00

1000525000

9. Extraction of gas mixtures (C2, C3, and
C4) from natural gas liquids plants

1000 bbl

1000 bbl

$

,000.00

1000550000

10. Extraction of other natural gas liquids,
including raw or unfractionated natural
gas liquid streams with less than 80
percent purity

1000 bbl

1000 bbl

$

,000.00

1000575000

11. Recovered elemental sulfur from natural
gas

$

,000.00

1001100000

12. Oil and gas well directional drilling
control

$

,000.00

1001600000

13. Drilling oil and gas wells, including
drilling in, spudding in, or tailing in

1000 ft

$

,000.00

1001625000

14. Reworking oil and gas wells

$

,000.00

1001650000

15. Oil and gas field exploration services,
excluding mapping and surveying
services

$

,000.00

1001675000

16. Cementing oil and gas wells

$

,000.00

1001700000

$

,000.00

1001725000

18. Hydraulic fracturing of oil and gas wells

$

,000.00

1001750000

19. Running, cutting, and pulling casings,
tubes, or rods for oil and gas wells

$

,000.00

1001775000

20. Oil and gas field gathering services

$

,000.00

1001800000

$

,000.00

1001825000

22. Installing oil and gas field production
equipment, including wellhead fittings,
pumps, and engines

$

,000.00

1001850000

23. Pumping oil and gas wells but not
operating leases

$

,000.00

1001875000

24. Other oil and gas field repair and
maintenance services

$

,000.00

1001900000

25. All other oil and gas field services

$

,000.00

1001925000

17. Oil and gas well logging

21. Perforating oil and gas well casings

All other sales, shipments, receipts, or revenue from this domestic reporting unit

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

39

26. Wholesale sales of oil well and pipeline
machinery and equipment

$

,000.00

4002125000

27. Wholesale sales of crude oil

$

,000.00

4003325000

28. Natural gas distribution and support
services (except marketing and
brokering)

$

,000.00

6000030000

29. Leasing of rights to explore for and
exploit natural resources

$

,000.00

7010200000

30. Transportation of natural gas by pipeline,
excluding gas field gathering services

$

,000.00

7011150000

31. Transportation of crude oil and other
commodities by pipeline, excluding oil
field gathering services

$

,000.00

7011175000

32. Scientific and technical consulting
services, not elsewhere classified

$

,000.00

7012270000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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40

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this domestic reporting unit a cooperative?
Yes
No

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Item 28: Special Items - Multiple Investors

ITEM 28: SPECIAL ITEMS - MULTIPLE INVESTORS
Does this location have multiple investors?
Yes
No

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42

Item 28: Special Items - Multiple Investors - Continued

ITEM 28: SPECIAL ITEMS - MULTIPLE INVESTORS
1. List each investor, their address, and their percentage of investment in 2022
Name

Street

City

ZIP Code

State

99999-9999

2022
.00%

2. List each investor, their address, and their percentage of investment in 2022
Name

Street

City

ZIP Code

State

99999-9999

2022
.00%

3. List each investor, their address, and their percentage of investment in 2022
Name

Street

City

State

ZIP Code
99999-9999

2022
.00%

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

43

4. List each investor, their address, and their percentage of investment in 2022
Name

Street

City

ZIP Code

State

99999-9999

2022
.00%

5. List each investor, their address, and their percentage of investment in 2022
Name

Street

City

State

ZIP Code
99999-9999

2022
.00%

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

44

Item 28: Special Items - Water Use

ITEM 28: SPECIAL ITEMS - WATER USE
1. What was this domestic reporting unit’s water intake in 2022, that is, the quantity of new water introduced into the domestic reporting unit for the first time, regardless of source or
quality?
Include water used in the production process and auxiliary operations (such as cooling and condensing, boiler feed, sanitary and domestic use). Report to the nearest thousand.
,000 gallons

2. Did this domestic reporting unit recirculate or reuse any water during 2022?
Yes
No

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45

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s gross water use in 2022, that is, the quantity of water that would have been required if no water had been recirculated or reused?
For example, if total water intake was 500 million gallons and, of these 500 million gallons, 100 million gallons were used twice for cooling purposes and once for washing products or
materials, the total water required would be 300 million gallons, plus the 400 million gallons not recirculated, for a total of 700 million gallons of gross water use (less consumption and
evaporation loss). Report to the nearest thousand.
,000 gallons

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46

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s main source of new water in 2022? Select only ONE.
Public water system includes water supplied by a water utility (whether municipally- or privately-owned) whose primary purpose is the supply of water to the general public and/or
industrial users. Self-supplied water systems include water obtained by this domestic reporting unit through its own system of pumps, pipes, hoses, etc. Also include here water obtained
from another company that is not primarily a water utility.
Public water system (municipally- or privately-owned utility)
Self-supplied surface water system (rivers, streams, lakes)
Self-supplied ground water system (wells, deep springs)
Self-supplied tide water system (estuaries, bays, oceans)
Self-supplied mine water (underground mines, quarries, open pits, water produced with oil)
Other sources (e.g., rainwater, truck deliveries)

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Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
Which of the following types of water was mainly supplied by the public water system? Select only ONE.
Potable
Reclaimed wastewater

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48

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this domestic reporting unit sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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49

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this domestic reporting unit purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this domestic reporting unit use touchscreens/kiosks for customer interface in its own operations?

Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as
registering for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this domestic reporting unit use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this domestic reporting unit use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this domestic reporting unit use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into standalone stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this domestic reporting unit use service robots in its own operations?

Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots

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51

Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots
Yes
No
Do not know
6. In 2022, did this domestic reporting unit use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?

Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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52

Item 29: Business Technologies - Touchscreens/Kiosks for customer interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this domestic reporting unit acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

53

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this domestic reporting unit acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

54

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)

How did this domestic reporting unit acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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55

Item 29: Business Technologies - Industrial Robots

ITEM 29 BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS

How did this domestic reporting unit acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

56

Item 29: Business Technologies - Service Robots

ITEM 29 BUSINESS TECHNOLOGIES - SERVICE ROBOTS

How did this domestic reporting unit acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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57

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)

How did this domestic reporting unit acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

1000

characters remaining

59

Item 32: Number of Domestic Reporting Units - Domestic Reporting Unit Information

ITEM 32: NUMBER OF DOMESTIC REPORTING UNITS - DOMESTIC REPORTING UNIT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MI-21110_su.pdf Generated 2022-02-23 16:18:55

,000.00

60

Location Information

DEFINITION OF DOMESTIC REPORTING UNIT
The reporting unit for this questionnaire is a mineral domestic reporting unit which is a location where mineral operations are performed. It represents a working or group of workings at
a given locality in which operations are conducted as a unit or are unified by common management or joint handling of some parts of the mining or concentration process.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this domestic reporting unit physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this domestic reporting unit physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this domestic reporting unit's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this domestic reporting unit’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Domestic Reporting Units

ITEM 2F: NUMBER OF DOMESTIC REPORTING UNITS

2022
How many domestic reporting units operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this domestic reporting unit's operational status at the end of 2022?

In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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Item 3A: Operational Status - Ceased Operation Date

If this domestic reporting unit ceased operation or was sold or leased to another operator, what was the date?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

If this domestic reporting unit was sold or leased to another operator, what is the name, address, and 9-digit Employer Identification Number (EIN) of this domestic reporting unit's new
owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4A: Primary Business or Activity

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this domestic reporting unit's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the domestic reporting unit's
primary business or activity.
Select only ONE.

Gold ore mining

212221 001

Silver ore mining

212222 001

Copper, nickel, lead, and zinc mining

212230 001

Uranium-radium-vanadium ore mining

212291 001

Iron ore mining

212210 001

All other metal ore mining

212299 001

Support activities for metal mining, e.g., sinking mine shafts and driving mine tunnels services, overburden stripping, etc.

213114 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

15

Item 4B: Type of Operation

ITEM 4B: TYPE OF OPERATION
What type(s) of operation occurred at this domestic reporting unit?
If mine is under development or exploration, or maintenance is being performed, indicate method most likely to be used when production is started or resumed.
Include:
Production, development, and exploration operations
A. What mining methods are used at this domestic reporting unit?
(Check ALL that apply.)
440

Surface (including open-pit, strip-pit, dredge, quarry, auger)

444

Underground

450

Other (including culm or silt bank, in-situ, well, brine well)

432

No mine or quarry or abandoned mine or quarry

B. What processing and/or treatment methods are used at this domestic reporting unit?
(Check ALL that apply.)
470

Agglomeration, concentration, or other treatment methods

474

Crushing, grinding, washing, evaporation, drying, calcining, flotation, air separation, expanding, sizing, screening, sawing,
turning, planing, etc.

468

No processing or treatment methods

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

2036

,000.00

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations (domestic reporting units) operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the domestic reporting unit listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each domestic reporting unit individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

18

Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What was the total value of products shipped and other receipts for this domestic reporting unit?
(Report details in Item 22.)
Include:
All products physically shipped during 2022
Receipts for services
Value of resales
Interplant transfers
Exports
Other miscellaneous receipts
Exclude:
Non-operating income such as royalties, interest, dividends, or the sale of fixed assets
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

$

,000.00

B. What was the value of products shipped for export for this domestic reporting unit?
(This is a breakout of the $,000.00 reported in A.)
Include:
Shipments going directly for export including shipments to foreign subsidiaries or foreign divisions of your
company and their affiliates:
Shipments to customers in the Panama Canal Zone, the Commonwealth of Puerto Rico, and U.S.
possessions
Shipments of your products to export firms and to other customers who export these items
Sales to the U.S. government to be shipped to foreign nations under military and economic assistance
programs
Exclude:
Sales to the U.S. Government overseas

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

19

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL
Include:
Full- and part-time employees (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941, Employer's Quarterly Federal
Tax Return, and filed under the Employer Identification Number (EIN)
Persons on paid sick leave, paid holidays, and paid vacations during the year
Officers, if a corporation
Persons at a general office serving two or more plants if located at or near this domestic reporting unit
Employees paid on a per ton, car, or yard basis
Exclude:
Members of the Armed Forces and pensioners carried on your active payrolls
Proprietor or partners, if an unincorporated concern
Workers at manufacturing plants (including petroleum refineries), company stores, boardinghouses, bunkhouses, recreational centers, and auxiliary offices
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report these values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report these values in Item 16, line C1.)
Purchased professional and technical services (Report these values in Item 16, line C9.)
Contractors and subcontractors and their employees (Report the cost of contract work in Item 16,line A3.)
A. EMPLOYMENT
1. What was the number of mining, production, development, and exploration workers (direct labor including
first-line supervisors) at this domestic reporting unit for the pay period including March 12 (Q1)?
Include:
Workers engaged in services closely associated with production and development operations such as:
Manual work
Tool use and machine operation
Materials and products, loading and hauling
Mineral properties care
Exploration and development work
Storage, shipping, maintenances, repair, and guard services
Auxiliary production for own use (i.e. power plant) record keeping
Regular maintenance and repair
Drilling and maintaining wells
Seismic testing or cementing walls
Exclude:
Supervisory employees above the first-line level (Report these in A2.)
Employees of contractors or subcontractors

Check
if
None

2022 Number

2. What was the number of other employees at this domestic reporting unit for the pay period including March 12
(Q1)?
Include:
Force-account construction employees and your payroll engaged in construction of major additions or
alterations to your facilities that are utilized as a separate work force
Nonproduction personnel engaged in supervision above the working supervisor level and employees
engaged in activities such as:
Sales, advertising, purchasing, finance
Highway trucking and other transportation
Credit, collection, executive, legal, clerical, and routine office functions
Personnel including cafeteria, medical, etc.
Professional (engineers, geologists, etc.) and technical workers
Exclude:
Proprietors and partners
Temporary staff and leased employees
Employees of contractors or subcontractors

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

20

TOTAL (Add lines A1 and A2.)

B. HOURS WORKED
What was the annual number of hours worked by the mining, production, development, and exploration workers
(direct labor including first-line supervisors) at this domestic reporting unit reported in A1?
Include:
All hours worked or paid (except hours paid for vacations, holidays, or sick leave)
Overtime hours (Report actual hours worked, not straight-time equivalent hours.)
Actual hours worked by an employee who elects to work during a vacation period
All hours worked for the entire year by a full and part-time mining, production, development, and
exploration workers of the type reported in A1
Exclude:
Hours of proprietors or partners
Hours worked by temporary staff or leased employees
Hours worked by employees of contractors or subcontractors

Check
if
None

2022 Hours
,000

C. PAYROLL
Report the gross earnings paid in calendar year 2022 to employees prior to such deductions as employee’s Social Security contributions, withholding taxes, group insurance
premiums, union dues, and savings bonds.
Payroll should equal the taxable Medicare wages and tips reported on the Internal Revenue Services (IRS) Form 941, Employer’s Quarterly Tax Return and definitions as described in
Circular E, Employer’s Tax Guide.
Include:
Commissions, dismissal pay and paid bonuses
Employee contributions to pension plans such as a 401(k) plan
Vacation and sick-leave pay
Salaries of officers
Spread on stock options that are taxable to employee as wages
Cash equivalent of compensation paid in kind such as:
Board and housing
Payments in the form of shared profits and special stock purchases that are subject to withholding tax
Exclude:
Payroll for temporary staff and leased employees
Payments to proprietor or partners
Payments to members of Armed Forces and pensioners carried on your active payroll
Royalty payments to unions
Payments to contract or subcontractors who performed work for you
Employer-paid annual cost for fringe benefits (Report these costs in D1 through D3.)
Check
if
None

2022

1. What was the annual payroll before deductions for mining, production, development, and exploration workers
(direct labor including first-line supervisors) of the type reported in A1 at this domestic reporting unit?

$

,000.00

2. What was the annual payroll before deductions for all other employees of the type reported in A2 at this domestic
reporting unit?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $,000.00 reported above, what was the first quarter payroll at this domestic reporting unit before
deductions (January - March 2022)?

$

,000.00

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21

Item 7: Employment and Payroll - Continued

ITEM 7: EMPLOYMENT AND PAYROLL

D. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS
This is the employer’s annual cost at this domestic reporting unit for legally required programs and programs not required by law.
1. What were the employer’s annual costs at this domestic reporting unit for health insurance? (insurance premiums on
hospitals, medical plans, and single service plans such as dental, vision, and prescription drug plans)
Include:
Premium equivalents for self-insured plans and fees paid to third-party administrators (TPAs)
Exclude:
Employee contributions
Disbursements from trusts or funds to satisfy health insurance claims

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Retirement plans:
a. What were the employer’s annual costs at this domestic reporting unit for defined benefit pension plans? (Costs
include both qualified and nonqualified defined pension plans, as well as plans that specify the benefit to be
paid to employee upon retirement, generally either as a specified amount or a percentage of compensation.
Employer contributions are based on actuarial computations that include the employee's compensation and years
of service and are not allocated to specific accounts maintained for employees.)

b. What were the employer’s annual costs at this domestic reporting unit for defined contribution plans? (These
are plans that define the employer contributions to a separate account provided for each employee. The
employee "benefit" at retirement depends on the amount contributed and the results of the account's activity.)
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

3. What were the employer’s annual costs at this domestic reporting unit for employer-paid payroll taxes, insurance
premiums, and all other employer-paid benefits?
Include:
Life insurance benefits
“Quality of life” benefits (e.g., childcare assistance, subsidized commuting, etc.)
Education assistance
Legally-required fringe benefits
Social Security
Workers' compensation insurance
Unemployment tax
State disability insurance programs (long- and short-term disability – LTD and STD)
Medicare
Exclude:
Disbursements from trusts or funds to satisfy health insurance claims

TOTAL (Add lines D1 through D3.)

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

22

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

23

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES

Report inventories at cost or market using generally accepted accounting practices. Report the value of all inventories that are attributable to the domestic reporting unit’s operations
regardless of where the inventories are held or stored.

What was the value of inventories for mined products and supplies owned by this domestic reporting unit as of December 31 before Last-In, First-Out (LIFO) adjustment (if any)
for:
A. Mined or quarried products?
Include:
Stocks of raw products awaiting treatment or
preparation
Stockpiles of products (raw, prepared minerals, or
quarried products) ready for shipment

Check
if
None

Check
if
None

2022

2021

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

B. Materials, parts, supplies, fuels, etc.?
Include:
Stockpiles of minerals received from other reporting
units for further processing
Cost of items to be used for extracting and
beneficiating

TOTAL (Add lines A and B.)

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

24

Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this domestic reporting unit as of December 31, 2022 and the $,000.00 reported in Item 9 as the total
value of inventories owned by this domestic reporting unit as of December 31, 2021:
Check
if
None

Check
if
None

2022

2021

A. What was the amount subject to Last-In, First-Out (LIFO)
gross (gross LIFO amount)?

$

,000.00

$

,000.00

B. What was the amount not subject to LIFO valuation
method?

$

,000.00

$

,000.00

TOTAL (Sum of lines A and B should equal TOTAL in Item
9.)

$

,000.00

$

,000.00

C. What was the amount of LIFO reserve (if any)? [LIFO
reserve represents the excess of current period cost over
the LIFO carrying value. LIFO reserve is the difference
between the current cost (i.e., FIFO) of inventories (gross
value) and the LIFO carrying value (net value).]

$

,000.00

$

,000.00

Describe

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25

Item 13: Capital Expenditures

ITEM 13: CAPITAL EXPENDITURES

Report the actual outlays during 2022, not the final value of buildings or other structures completed or equipment put in place during the year. These expenditures are of the type for which
depreciation or amortization accounts are ordinarily maintained.
Capital expenditures during 2022 may be determined by the following computation:
(a) Cost of additions completed during the year, plus
(b) Work-in-progress at the end of the year, minus
(c) Work-in-progress at the beginning of the year.
Include labor and installation costs whether on contract or by your own forces
Exclude the cost of maintenance and repairs charged as current operating expense
A. What were the capital expenditures for new and used buildings, structures, machinery, and equipment for this domestic
reporting unit?
Include:
Buildings and structures directly related to mineral exploration, development, and production
Machinery, such as hoists, cranes, crushers, separators, and power plants
Exploration, development, production, and processing plant machinery
Value of the equipment produced and used
All mining loading, transportation, and similar equipment for use at mines
Equipment such as excavators, loaders, locomotives, tractors, hoists, drills, compressors, pumps
Transportation equipment, such as automobiles, trucks, and similar equipment
Office equipment, such as computers and peripheral data processing equipment, as well as furniture and fixtures
for offices, cafeterias, and change rooms
Replacements as well as additions to new capacity
Values from construction by your own employees, where capitalized
Value of improvements and capitalized repairs to machinery and equipment including those done to assets
transferred from other domestic reporting units of this company
Expenditures for old or existing plants and for second-hand equipment acquired from others (including U.S.
Government)
Gross book value of machinery or equipment transferred from other domestic reporting units of your company
Exclude:
Company houses and general recreational facilities
Value of land
Cost of maintenance and repairs charged as current operating expense

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. What were the capital expenditures for mineral exploration and development for this domestic reporting unit?
Include:
All intangible development and exploration outlays that were charged to a capital or Office of Minerals Exploration
account
Capitalized expenditures for entries, shafts, rail and other road construction, test boring, surveying, etc.

C. What were the capital expenditures for mineral land and rights for this domestic reporting unit?
Include:
All capital expenditures for acquiring either undeveloped or developed acreage
Capitalized lease bonuses and any other outlays necessary to acquire leases, mineral rights, and fee lands
incident to mineral exploration, development, or production

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

26

$

TOTAL (Add lines A through C.)

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

,000.00

27

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS
Report rental payments made to other companies for use of depreciable assets such as buildings, other structures, machinery, and equipment. Include rental payments for land.
Domestic reporting units involved with leasing arrangements for equipment and/or buildings, report lease equipment according to the type of lease negotiated with the producer or the
lessor.
Include:
Operating leases (Report the periodic payments made to the producer or lessor.)
Exclude:
Capital leases (leases with a contract to own at the end of the lease) (Report cost, at market value, of acquisitions of building and equipment during the year as a capital
expenditure, Item 13.)
At this domestic reporting unit, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production machinery and equipment
Loading machinery and equipment
Transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles

TOTAL (Add lines A and B.)

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28

Item 15: Mineral Property Expenses

ITEM 15: MINERAL PROPERTY EXPENSES

Report mineral property expenses charged to current accounts.

Check
if
None
A. What were the lease rents for mineral properties for this domestic reporting unit?

2022
$

,000.00

B. Current Operation Expenses
Include:
Acquisition costs for mineral land and rights that were not capitalized
Cost of royalty payments related to mineral production
Labor costs whether on a contract basis or by your own forces associated with exploration and development or the acquisition of mineral properties
Intangible development and exploration outlays charged to a current account
Expenses for mineral properties charged to current accounts, such as:
all supplies, machinery, equipment, parts, fuel, power, etc., used for development or exploration (whether purchased or received from other domestic reporting units of
your company) and charged as current operating expenses
cost of maintenance and repairs associated with development or exploration activity that is charged to current accounts
Exclude:
Lease rents (Report separately in A.)
1. What were the current operating expenses for exploration, development, and mineral land and rights for this
domestic reporting unit?

$

,000.00

2. What were the current operating expenses for royalty payments for this domestic reporting unit?

$

,000.00

TOTAL (Add lines B1 and B2.)

$

,000.00

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29

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

SELECTED EXTRACTION/MINING/QUARRYING COSTS AND ELECTRICITY
Include costs incurred in mining processes such as supplies, resales, contract work, fuels, and electricity.

A. What were the extraction/mining/quarrying-related costs in 2022 for this domestic reporting unit for:

1. Materials, parts, and supplies used; and minerals received for preparation? (Report detail in Item 18.)
Include:
Cost of extraction/mining/quarrying-related materials purchased for other companies (contractors)
Cost of materials purchased or received from other domestic reporting units of your company
Exclude:
Non-extraction/mining/quarrying-related expenses that were paid to other companies (Report these
expense details in C.)

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Products bought and sold without further processing (products bought and resold in the same condition as when
purchased)? (Report these sales in Wholesaling Services product codes in Item 22.)
Exclude:
oil, gas or natural gas liquids (if applicable)

3. Work done for you by others on your materials (work contracted to others)? [Report in A1 the materials, parts, and
supplies purchased for other companies (contractors).]
4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report detail in Item 19.)
Report the total amount actually paid or payable for all purchased fuels consumed.
Include:
Fuels or coal consumed at this domestic reporting unit, but produced at another domestic reporting unit of
your company (Assign commercial values to them.)
Fuel used to power on-site trucks, forklifts, or motor vehicles
Anthracite, lignite, bituminous, and subbituminous coal, coke, natural and manufactured gas, gasoline,
wood, purchased steam, and all other fuels
Exclude:
Gas purchased for gas lift
Crude petroleum, natural gas, and coal produced at the domestic reporting unit and used for heat, power,
or the generation of electricity

5. Purchased electricity? (Report comparable quantity in B1.)
Report total amount actually paid or payable for electric energy purchased during 2022 from other companies or
received from other domestic reporting units of your company.
Exclude value of electricity generated and used at this domestic reporting unit

TOTAL (Add lines A1 through A5.)

B. For this domestic reporting unit, what was the quantity of:

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

30

Check
if
None
1. Purchased electricity? (quantity comparable to cost reported in A5)

2022 Kilowatt Hours
,000

2. Generated electricity? (gross less generating station use)
When a figure is reported on this line, include data relating to the activity of the power stations in other sections of
this questionnaire. For example, include the number of employees assigned to the power station, their wages, and
hours worked in the figures reported in Item 7 and the cost of fuels used to generate electricity, in Item 16, line A4
and Item 18.
Include energy generated at the drilling site that was used for lighting or other purposes.

3. Electricity sold or transferred to other domestic reporting units? (Also include quantity in B1 and/or B2.)

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

,000

,000

31

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

OTHER OPERATING EXPENSES
C. What were the other operating expenses paid by this domestic reporting unit in 2022 for:
Include:
Costs for each of these services purchased from other companies that are paid directly by this domestic reporting unit
Expenses normally considered nonproduction related costs
Exclude:
Salaries paid to employees of this domestic reporting unit for any of the specified services (Report in Item 7.)
Cost of mining activities contracted or subcontracted to others (Report on A3.)
1. Temporary staff and leased employees? [total costs paid to Professional Employer Organizations (PEOs) and
staffing agencies for personnel]
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report in 3.)
Leased and rented equipment (Report in Item 14, line B.)

3. Expensed purchases of software? (purchases of prepackaged, custom-coded or vendor-customized software)
Include:
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Credit card transaction fees
Other wired and wireless communication services

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

32

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other domestic reporting units of this company (such as a separate central data
processing unit)
Expensed integrated systems (Report in 4.)
Repair and maintenance of computer equipment (Report in 6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in 9 and credit card
transaction fees in 4.)
Expenses for telecommunication services, e.g., Internet, connectivity, telephone, etc. (Report in 4.)

$

,000.00

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof, replacing parts, over-hauling of equipment, and other repairs chargeable as
current operating costs
Cost of repair and maintenance of any leased property if the domestic reporting unit assumes the cost
Exclude:
Materials, parts, and supplies used for repairs and maintenance performed by this domestic reporting unit’s
employees (Report in A1.)
Extensive “repairs” or reconstruction that is capitalized (Report these as a capital expenditure in Item 13.)
Costs incurred directly by this domestic reporting unit in using its own work force to perform repairs and
maintenance work
Repairs and maintenance provided by the building or machinery owner as part of the rental contract

7. Water, sewer, refuse removal, and other non-electric utility payments? (Report electric utility payments on line
A5. If the cost of these utilities is included in a lease or rental payment, report in Item 14 line A.)
Include:
Cost of hazardous waste removal

8. Purchased advertising and promotional services?
Include:
Printed materials
Media coverage
Marketing and public relations services
Exclude:
All salaries paid to employees of the domestic reporting unit for advertising work

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

33

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other professional services
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

$

,000.00

10. Governmental taxes and licensing fees? (payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

11. All other operating expenses not reported elsewhere?
Exclude:
Purchases of merchandise for resale (Report on line A2.)
Non-operating expenses

Describe

TOTAL (Add lines C1 through C11.)

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34

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
Report:
Delivered cost of individual items listed below. Delivered cost is the amount paid or payable after discounts and including freight and other direct charges incurred by the
domestic reporting unit in acquiring the materials. The figures reported should represent the total purchase cost of supplies, minerals received for preparation, etc., actually used
or processed during 2022. Include purchases, interplant transfers, and withdrawals from inventories. Do not combine material lines. If the information is not directly available
from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Estimated quantity and cost of minerals received for processing on a custom or toll basis, as if purchased.
Minerals mined and also processed at this domestic reporting unit.
Include:
Minerals received from other domestic reporting units for preparation which were used or processed during 2022
Cost of materials and supplies not covered in the pre-listed material codes (Report these in material code 00970098 - "All other supplies".)
Supplies purchased by this domestic reporting unit for use by companies performing contract work at this domestic reporting unit
Exclude:
Associated labor costs of the kind reported in Item 7 and Item 16, line A3
Payments made for contract services performed, including payments for supplies and equipment furnished by the contractor incidental to this work

Unit of
Measure

Description

Quantity

Census
Material
Code

Value

1. Parts and attachments for mining, mineral preparation, construction, and
conveying machinery and equipment

$

,000.00

33300009

2. Explosive materials, including ammonium nitrate, and blasting accessories

$

,000.00

32592000

3. Lime, including quicklime and hydrated lime and dead-burned dolomite

$

,000.00

32741001

4. Tires and inner tubes

$

,000.00

32621100

5. All basic organic and inorganic chemicals, excluding petrochemicals

$

,000.00

32518000

$

,000.00

21220001

$

,000.00

00970098

6. Crude ore and residues received for concentration, excluding placer operations

short tons

7. All other supplies
Describe

8. Crude ore and residues mined and concentrated at same domestic reporting unit
and material processed in placer operations

short tons

21220002

$

TOTAL

2022_MI-21221_su.pdf Generated 2022-02-23 16:22:50

,000.00

77100000

35

Item 19: Fuels Used

ITEM 19: FUELS USED
Of the $,000.00 of purchased fuels in 2022, reported on Item 16, line A4, how much was for the following specified fuels?
Report:
Delivered cost of fuels received, not cost per unit. Delivered cost is the amount paid or payable after discounts, including freight and other direct charges incurred by the
domestic reporting unit in acquiring the fuels. Do not combine fuel lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Include:
Fuels purchased from other companies or transferred from other domestic reporting units of your company and used at this domestic reporting unit for the production of heat,
power, or generated electricity. The fuels transferred from other domestic reporting units of your company should be estimated at market value.
Cost of fuels not covered in the pre-listed fuel codes (Report these in fuel code 00960018 - "Other fuels".)

Unit of
Measure

Description

1. Diesel fuel

2. Gasoline used as a fuel

3. Gas (natural, manufactured, and mixed) used as a fuel
4. Other fuels (liquefied petroleum gas, coke, wood, etc.)

Quantity
Consumed

Cost, including delivery cost
(freight-in)

Census
Fuel Code

barrels

$

,000.00

32411021

1000 gal

$

,000.00

32411015

mil ft3

$

,000.00

21111015

$

,000.00

00960018

$

,000.00

00772000

Describe

TOTAL

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36

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The mined products and services listed below are generally produced in your industry. They include products shipped and services performed by this domestic reporting unit. Select
the items that apply to your domestic reporting unit. If you mine products or have revenue from other sources not listed, you will report them in the next section.

Description

Select

Product Code

1001200000

1. Mining of gold ore

1001225000

2. Mining of silver ore

1001250000

3. Mining of lead ore and zinc ore

1001275000

4. Mining of copper ore and nickel ore
5. Mining of crude ferroalloy ores and concentrates, including manganese and manganiferous ores, chromium, molybdenum, tungsten,
etc.

1001325000

6. Mining of miscellaneous metal ores and concentrates, including antimony, bauxite, beryllium, mercury, rare-earth metals, tin, and
titanium

1001350000

7. Metal mining exploration work, excluding prospect services, test drilling, and geophysical surveying services

1002025000

1002050000

8. Open-pit metal ores mining not for your own account

1002075000

9. Metal mining prospect services and test drilling services

10. Sinking metal mine shafts and driving metal mine tunnels services

11. Other metal mining services, including overburden stripping and repair and maintenance services

1002100000

1002125000

All other sales, shipments, receipts, or revenue from this domestic reporting unit

12. Wholesale sales of ores, except coal, gemstones, and crude oil

4003575000

Add product/service not listed

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37

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Report:
The value of the products shipped and services performed at the net selling value, free on board (FOB) quarry or plant to customer, after discounts or allowances.
Quantities in the unit of measure specified. Note: Short tons equal to 2,000 pounds.
Include:
All products mined, quarried, extracted, or leached from this domestic reporting unit
Material withdrawn from stockpiles, i.e. for leaching, sale, etc.
Products shipped on consignment
Prepared minerals from crude materials mined at this domestic reporting unit, purchased, or received from other domestic reporting units of your company
Concentrated ores, metals, and agglomerates from ores mined at this domestic reporting unit, or purchased or received from other domestic reporting units of your company
Estimated value of products treated on a custom or toll basis
Products transferred to other domestic reporting units of your company for treatment, preparation, milling, or other use
Bonuses or other credits for minerals contained, as well as royalties
Quantity of production of crude ore mined for treatment at this domestic reporting unit
Exclude:
Penalties for impurities
Wholesaling products (previously Resales), which include products that are bought from other domestic reporting units or transferred from other domestic reporting units of your
company and then sold without further treatment, processing, preparation, or milling by this domestic reporting unit. Report these products in the appropriate wholesaling
product line(s) you selected or else "Add product/service not listed" at the end of this item.
Freight charged
Excise taxes

Description

1. Mining of gold ore

2. Mining of silver ore

3. Mining of lead ore and zinc ore

4. Mining of copper ore and nickel ore

Quantity
Shipped

Unit of
Measure

Quantity
Produced

Unit of
Measure

Product
Code

Value

troy ounces

troy ounces

$

,000.00

1001200000

troy ounces

troy ounces

$

,000.00

1001225000

1000 lb

1000 lb

$

,000.00

1001250000

1000 lb

1000 lb

$

,000.00

1001275000

5. Mining of crude ferroalloy ores and
concentrates, including manganese and
manganiferous ores, chromium,
molybdenum, tungsten, etc.

$

,000.00

1001325000

6. Mining of miscellaneous metal ores and
concentrates, including antimony, bauxite,
beryllium, mercury, rare-earth metals, tin,
and titanium

$

,000.00

1001350000

7. Metal mining exploration work, excluding
prospect services, test drilling, and
geophysical surveying services

$

,000.00

1002025000

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38

8. Open-pit metal ores mining not for your
own account

$

,000.00

1002050000

9. Metal mining prospect services and test
drilling services

$

,000.00

1002075000

10. Sinking metal mine shafts and driving
metal mine tunnels services

$

,000.00

1002100000

11. Other metal mining services, including
overburden stripping and repair and
maintenance services

$

,000.00

1002125000

$

,000.00

4003575000

All other sales, shipments, receipts, or revenue from this domestic reporting unit
12. Wholesale sales of ores, except coal,
gemstones, and crude oil

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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39

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this domestic reporting unit a cooperative?
Yes
No

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Item 28: Special Items - Metal Content

ITEM 28: SPECIAL ITEMS - METAL CONTENT
Report metal content of production where both production and shipments are reported. Quantities of metals contained based on an assay content of ores reported.
1. Gold
Quantities of metals contained based on an
assay content of ores reported in Item 22
Fine troy ounces

a. Gold

b. Silver

Fine troy ounces

c. Lead/Zinc

Thousand pounds

d. Copper/Nickel

Thousand pounds

2. Silver
Fine troy ounces

a. Silver

Thousand pounds

b. Copper/Nickel

Thousand pounds

c. Lead/Zinc

Fine troy ounces

d. Gold

3. Lead/Zinc
Thousand pounds

a. Lead/Zinc

Fine troy ounces

b. Silver

Fine troy ounces

c. Gold

Thousand pounds

d. Copper/Nickel

4. Copper/Nickel

a. Copper/Nickel

Thousand pounds

b. Silver

Fine troy ounces

c. Lead/Zinc

Thousand pounds

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41

Fine troy ounces

d. Gold

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42

Item 28: Special Items - Water Use

ITEM 28: SPECIAL ITEMS - WATER USE
1. What was this domestic reporting unit’s water intake in 2022, that is, the quantity of new water introduced into the domestic reporting unit for the first time, regardless of source or
quality?
Include water used in the production process and auxiliary operations (such as cooling and condensing, boiler feed, sanitary and domestic use). Report to the nearest thousand.
,000 gallons

2. Did this domestic reporting unit recirculate or reuse any water during 2022?
Yes
No

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43

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s gross water use in 2022, that is, the quantity of water that would have been required if no water had been recirculated or reused?
For example, if total water intake was 500 million gallons and, of these 500 million gallons, 100 million gallons were used twice for cooling purposes and once for washing products or
materials, the total water required would be 300 million gallons, plus the 400 million gallons not recirculated, for a total of 700 million gallons of gross water use (less consumption and
evaporation loss). Report to the nearest thousand.
,000 gallons

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44

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s main source of new water in 2022? Select only ONE.
Public water system includes water supplied by a water utility (whether municipally- or privately-owned) whose primary purpose is the supply of water to the general public and/or
industrial users. Self-supplied water systems include water obtained by this domestic reporting unit through its own system of pumps, pipes, hoses, etc. Also include here water obtained
from another company that is not primarily a water utility.
Public water system (municipally- or privately-owned utility)
Self-supplied surface water system (rivers, streams, lakes)
Self-supplied ground water system (wells, deep springs)
Self-supplied tide water system (estuaries, bays, oceans)
Self-supplied mine water (underground mines, quarries, open pits, water produced with oil)
Other sources (e.g., rainwater, truck deliveries)

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45

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
Which of the following types of water was mainly supplied by the public water system? Select only ONE.
Potable
Reclaimed wastewater

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46

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this domestic reporting unit sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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47

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this domestic reporting unit purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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48

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this domestic reporting unit use touchscreens/kiosks for customer interface in its own operations?

Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as
registering for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this domestic reporting unit use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this domestic reporting unit use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this domestic reporting unit use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into standalone stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this domestic reporting unit use service robots in its own operations?

Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots

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49

Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots
Yes
No
Do not know
6. In 2022, did this domestic reporting unit use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?

Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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50

Item 29: Business Technologies - Touchscreens/Kiosks for customer interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this domestic reporting unit acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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51

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this domestic reporting unit acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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52

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)

How did this domestic reporting unit acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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53

Item 29: Business Technologies - Industrial Robots

ITEM 29 BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS

How did this domestic reporting unit acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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54

Item 29: Business Technologies - Service Robots

ITEM 29 BUSINESS TECHNOLOGIES - SERVICE ROBOTS

How did this domestic reporting unit acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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55

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)

How did this domestic reporting unit acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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56

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

57

Item 32: Number of Domestic Reporting Units - Domestic Reporting Unit Information

ITEM 32: NUMBER OF DOMESTIC REPORTING UNITS - DOMESTIC REPORTING UNIT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

58

Location Information

DEFINITION OF DOMESTIC REPORTING UNIT
The reporting unit for this questionnaire is a mineral domestic reporting unit which is a location where mineral operations are performed. It represents a working or group of workings at
a given locality in which operations are conducted as a unit or are unified by common management or joint handling of some parts of the mining or concentration process.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this domestic reporting unit physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this domestic reporting unit physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this domestic reporting unit's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this domestic reporting unit’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Domestic Reporting Units

ITEM 2F: NUMBER OF DOMESTIC REPORTING UNITS

2022
How many domestic reporting units operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this domestic reporting unit's operational status at the end of 2022?

In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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Item 3A: Operational Status - Ceased Operation Date

If this domestic reporting unit ceased operation or was sold or leased to another operator, what was the date?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

If this domestic reporting unit was sold or leased to another operator, what is the name, address, and 9-digit Employer Identification Number (EIN) of this domestic reporting unit's new
owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4A: Primary Business or Activity

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this domestic reporting unit's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the domestic reporting unit's
primary business or activity.
Select only ONE.

Dimension stone mining and quarrying

212311 001

Crushed and broken limestone mining and quarrying

212312 001

Crushed and broken granite mining and quarrying

212313 001

Other crushed and broken stone mining and quarrying

212319 001

Construction sand and gravel mining

212321 001

Industrial sand mining

212322 001

Kaolin and ball clay mining

212324 001

Clay and ceramic and refractory minerals mining

212325 001

Potash, soda, and borate mineral mining

212391 001

Phosphate rock mining

212392 001

Other chemical and fertilizer mineral mining, including barite, rock salt, native sulfur, fluorspar, pyrites, spodumene, mineral pigments, etc.

212393 001

All other nonmetallic mineral mining

212399 001

Other primary business or activity

779000 001

Select Sector

Describe

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Item 4B: Type of Operation

ITEM 4B: TYPE OF OPERATION
What type(s) of operation occurred at this domestic reporting unit?
If mine is under development or exploration, or maintenance is being performed, indicate method most likely to be used when production is started or resumed.
Include:
Production, development, and exploration operations
A. What mining methods are used at this domestic reporting unit?
(Check ALL that apply.)
440

Surface (including open-pit, strip-pit, dredge, quarry, auger)

444

Underground

450

Other (including culm or silt bank, in-situ, well, brine well)

432

No mine or quarry or abandoned mine or quarry

B. What processing and/or treatment methods are used at this domestic reporting unit?
(Check ALL that apply.)
470

Agglomeration, concentration, or other treatment methods

474

Crushing, grinding, washing, evaporation, drying, calcining, flotation, air separation, expanding, sizing, screening, sawing,
turning, planing, etc.

468

No processing or treatment methods

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

2036

,000.00

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations (domestic reporting units) operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the domestic reporting unit listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each domestic reporting unit individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What was the total value of products shipped and other receipts for this domestic reporting unit?
(Report details in Item 22.)
Include:
All products physically shipped during 2022
Receipts for services
Value of resales
Interplant transfers
Exports
Other miscellaneous receipts
Exclude:
Non-operating income such as royalties, interest, dividends, or the sale of fixed assets
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

$

,000.00

B. What was the value of products shipped for export for this domestic reporting unit?
(This is a breakout of the $,000.00 reported in A.)
Include:
Shipments going directly for export including shipments to foreign subsidiaries or foreign divisions of your
company and their affiliates:
Shipments to customers in the Panama Canal Zone, the Commonwealth of Puerto Rico, and U.S.
possessions
Shipments of your products to export firms and to other customers who export these items
Sales to the U.S. government to be shipped to foreign nations under military and economic assistance
programs
Exclude:
Sales to the U.S. Government overseas

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

19

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL
Include:
Full- and part-time employees (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941, Employer's Quarterly Federal
Tax Return, and filed under the Employer Identification Number (EIN)
Persons on paid sick leave, paid holidays, and paid vacations during the year
Officers, if a corporation
Persons at a general office serving two or more plants if located at or near this domestic reporting unit
Employees paid on a per ton, car, or yard basis
Exclude:
Members of the Armed Forces and pensioners carried on your active payrolls
Proprietor or partners, if an unincorporated concern
Workers at manufacturing plants (including petroleum refineries), company stores, boardinghouses, bunkhouses, recreational centers, and auxiliary offices
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report these values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report these values in Item 16, line C1.)
Purchased professional and technical services (Report these values in Item 16, line C9.)
Contractors and subcontractors and their employees (Report the cost of contract work in Item 16,line A3.)
A. EMPLOYMENT
1. What was the number of mining, production, development, and exploration workers (direct labor including
first-line supervisors) at this domestic reporting unit for the pay period including March 12 (Q1)?
Include:
Workers engaged in services closely associated with production and development operations such as:
Manual work
Tool use and machine operation
Materials and products, loading and hauling
Mineral properties care
Exploration and development work
Storage, shipping, maintenances, repair, and guard services
Auxiliary production for own use (i.e. power plant) record keeping
Regular maintenance and repair
Drilling and maintaining wells
Seismic testing or cementing walls
Exclude:
Supervisory employees above the first-line level (Report these in A2.)
Employees of contractors or subcontractors

Check
if
None

2022 Number

2. What was the number of other employees at this domestic reporting unit for the pay period including March 12
(Q1)?
Include:
Force-account construction employees and your payroll engaged in construction of major additions or
alterations to your facilities that are utilized as a separate work force
Nonproduction personnel engaged in supervision above the working supervisor level and employees
engaged in activities such as:
Sales, advertising, purchasing, finance
Highway trucking and other transportation
Credit, collection, executive, legal, clerical, and routine office functions
Personnel including cafeteria, medical, etc.
Professional (engineers, geologists, etc.) and technical workers
Exclude:
Proprietors and partners
Temporary staff and leased employees
Employees of contractors or subcontractors

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

20

TOTAL (Add lines A1 and A2.)

B. HOURS WORKED
What was the annual number of hours worked by the mining, production, development, and exploration workers
(direct labor including first-line supervisors) at this domestic reporting unit reported in A1?
Include:
All hours worked or paid (except hours paid for vacations, holidays, or sick leave)
Overtime hours (Report actual hours worked, not straight-time equivalent hours.)
Actual hours worked by an employee who elects to work during a vacation period
All hours worked for the entire year by a full and part-time mining, production, development, and
exploration workers of the type reported in A1
Exclude:
Hours of proprietors or partners
Hours worked by temporary staff or leased employees
Hours worked by employees of contractors or subcontractors

Check
if
None

2022 Hours
,000

C. PAYROLL
Report the gross earnings paid in calendar year 2022 to employees prior to such deductions as employee’s Social Security contributions, withholding taxes, group insurance
premiums, union dues, and savings bonds.
Payroll should equal the taxable Medicare wages and tips reported on the Internal Revenue Services (IRS) Form 941, Employer’s Quarterly Tax Return and definitions as described in
Circular E, Employer’s Tax Guide.
Include:
Commissions, dismissal pay and paid bonuses
Employee contributions to pension plans such as a 401(k) plan
Vacation and sick-leave pay
Salaries of officers
Spread on stock options that are taxable to employee as wages
Cash equivalent of compensation paid in kind such as:
Board and housing
Payments in the form of shared profits and special stock purchases that are subject to withholding tax
Exclude:
Payroll for temporary staff and leased employees
Payments to proprietor or partners
Payments to members of Armed Forces and pensioners carried on your active payroll
Royalty payments to unions
Payments to contract or subcontractors who performed work for you
Employer-paid annual cost for fringe benefits (Report these costs in D1 through D3.)
Check
if
None

2022

1. What was the annual payroll before deductions for mining, production, development, and exploration workers
(direct labor including first-line supervisors) of the type reported in A1 at this domestic reporting unit?

$

,000.00

2. What was the annual payroll before deductions for all other employees of the type reported in A2 at this domestic
reporting unit?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $,000.00 reported above, what was the first quarter payroll at this domestic reporting unit before
deductions (January - March 2022)?

$

,000.00

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21

Item 7: Employment and Payroll - Continued

ITEM 7: EMPLOYMENT AND PAYROLL

D. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS
This is the employer’s annual cost at this domestic reporting unit for legally required programs and programs not required by law.
1. What were the employer’s annual costs at this domestic reporting unit for health insurance? (insurance premiums on
hospitals, medical plans, and single service plans such as dental, vision, and prescription drug plans)
Include:
Premium equivalents for self-insured plans and fees paid to third-party administrators (TPAs)
Exclude:
Employee contributions
Disbursements from trusts or funds to satisfy health insurance claims

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Retirement plans:
a. What were the employer’s annual costs at this domestic reporting unit for defined benefit pension plans? (Costs
include both qualified and nonqualified defined pension plans, as well as plans that specify the benefit to be
paid to employee upon retirement, generally either as a specified amount or a percentage of compensation.
Employer contributions are based on actuarial computations that include the employee's compensation and years
of service and are not allocated to specific accounts maintained for employees.)

b. What were the employer’s annual costs at this domestic reporting unit for defined contribution plans? (These
are plans that define the employer contributions to a separate account provided for each employee. The
employee "benefit" at retirement depends on the amount contributed and the results of the account's activity.)
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

3. What were the employer’s annual costs at this domestic reporting unit for employer-paid payroll taxes, insurance
premiums, and all other employer-paid benefits?
Include:
Life insurance benefits
“Quality of life” benefits (e.g., childcare assistance, subsidized commuting, etc.)
Education assistance
Legally-required fringe benefits
Social Security
Workers' compensation insurance
Unemployment tax
State disability insurance programs (long- and short-term disability – LTD and STD)
Medicare
Exclude:
Disbursements from trusts or funds to satisfy health insurance claims

TOTAL (Add lines D1 through D3.)

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

22

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

23

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES

Report inventories at cost or market using generally accepted accounting practices. Report the value of all inventories that are attributable to the domestic reporting unit’s operations
regardless of where the inventories are held or stored.

What was the value of inventories for mined products and supplies owned by this domestic reporting unit as of December 31 before Last-In, First-Out (LIFO) adjustment (if any)
for:
A. Mined or quarried products?
Include:
Stocks of raw products awaiting treatment or
preparation
Stockpiles of products (raw, prepared minerals, or
quarried products) ready for shipment

Check
if
None

Check
if
None

2022

2021

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

B. Materials, parts, supplies, fuels, etc.?
Include:
Stockpiles of minerals received from other reporting
units for further processing
Cost of items to be used for extracting and
beneficiating

TOTAL (Add lines A and B.)

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

24

Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this domestic reporting unit as of December 31, 2022 and the $,000.00 reported in Item 9 as the total
value of inventories owned by this domestic reporting unit as of December 31, 2021:
Check
if
None

Check
if
None

2022

2021

A. What was the amount subject to Last-In, First-Out (LIFO)
gross (gross LIFO amount)?

$

,000.00

$

,000.00

B. What was the amount not subject to LIFO valuation
method?

$

,000.00

$

,000.00

TOTAL (Sum of lines A and B should equal TOTAL in Item
9.)

$

,000.00

$

,000.00

C. What was the amount of LIFO reserve (if any)? [LIFO
reserve represents the excess of current period cost over
the LIFO carrying value. LIFO reserve is the difference
between the current cost (i.e., FIFO) of inventories (gross
value) and the LIFO carrying value (net value).]

$

,000.00

$

,000.00

Describe

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25

Item 13: Capital Expenditures

ITEM 13: CAPITAL EXPENDITURES

Report the actual outlays during 2022, not the final value of buildings or other structures completed or equipment put in place during the year. These expenditures are of the type for which
depreciation or amortization accounts are ordinarily maintained.
Capital expenditures during 2022 may be determined by the following computation:
(a) Cost of additions completed during the year, plus
(b) Work-in-progress at the end of the year, minus
(c) Work-in-progress at the beginning of the year.
Include labor and installation costs whether on contract or by your own forces
Exclude the cost of maintenance and repairs charged as current operating expense
A. What were the capital expenditures for new and used buildings, structures, machinery, and equipment for this domestic
reporting unit?
Include:
Buildings and structures directly related to mineral exploration, development, and production
Machinery, such as hoists, cranes, crushers, separators, and power plants
Exploration, development, production, and processing plant machinery
Value of the equipment produced and used
All mining loading, transportation, and similar equipment for use at mines
Equipment such as excavators, loaders, locomotives, tractors, hoists, drills, compressors, pumps
Transportation equipment, such as automobiles, trucks, and similar equipment
Office equipment, such as computers and peripheral data processing equipment, as well as furniture and fixtures
for offices, cafeterias, and change rooms
Replacements as well as additions to new capacity
Values from construction by your own employees, where capitalized
Value of improvements and capitalized repairs to machinery and equipment including those done to assets
transferred from other domestic reporting units of this company
Expenditures for old or existing plants and for second-hand equipment acquired from others (including U.S.
Government)
Gross book value of machinery or equipment transferred from other domestic reporting units of your company
Exclude:
Company houses and general recreational facilities
Value of land
Cost of maintenance and repairs charged as current operating expense

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. What were the capital expenditures for mineral exploration and development for this domestic reporting unit?
Include:
All intangible development and exploration outlays that were charged to a capital or Office of Minerals Exploration
account
Capitalized expenditures for entries, shafts, rail and other road construction, test boring, surveying, etc.

C. What were the capital expenditures for mineral land and rights for this domestic reporting unit?
Include:
All capital expenditures for acquiring either undeveloped or developed acreage
Capitalized lease bonuses and any other outlays necessary to acquire leases, mineral rights, and fee lands
incident to mineral exploration, development, or production

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

26

$

TOTAL (Add lines A through C.)

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

,000.00

27

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS
Report rental payments made to other companies for use of depreciable assets such as buildings, other structures, machinery, and equipment. Include rental payments for land.
Domestic reporting units involved with leasing arrangements for equipment and/or buildings, report lease equipment according to the type of lease negotiated with the producer or the
lessor.
Include:
Operating leases (Report the periodic payments made to the producer or lessor.)
Exclude:
Capital leases (leases with a contract to own at the end of the lease) (Report cost, at market value, of acquisitions of building and equipment during the year as a capital
expenditure, Item 13.)
At this domestic reporting unit, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production machinery and equipment
Loading machinery and equipment
Transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles

TOTAL (Add lines A and B.)

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

28

Item 15: Mineral Property Expenses

ITEM 15: MINERAL PROPERTY EXPENSES

Report mineral property expenses charged to current accounts.

Check
if
None
A. What were the lease rents for mineral properties for this domestic reporting unit?

2022
$

,000.00

B. Current Operation Expenses
Include:
Acquisition costs for mineral land and rights that were not capitalized
Cost of royalty payments related to mineral production
Labor costs whether on a contract basis or by your own forces associated with exploration and development or the acquisition of mineral properties
Intangible development and exploration outlays charged to a current account
Expenses for mineral properties charged to current accounts, such as:
all supplies, machinery, equipment, parts, fuel, power, etc., used for development or exploration (whether purchased or received from other domestic reporting units of
your company) and charged as current operating expenses
cost of maintenance and repairs associated with development or exploration activity that is charged to current accounts
Exclude:
Lease rents (Report separately in A.)
1. What were the current operating expenses for exploration, development, and mineral land and rights for this
domestic reporting unit?

$

,000.00

2. What were the current operating expenses for royalty payments for this domestic reporting unit?

$

,000.00

TOTAL (Add lines B1 and B2.)

$

,000.00

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29

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

SELECTED EXTRACTION/MINING/QUARRYING COSTS AND ELECTRICITY
Include costs incurred in mining processes such as supplies, resales, contract work, fuels, and electricity.

A. What were the extraction/mining/quarrying-related costs in 2022 for this domestic reporting unit for:

1. Materials, parts, and supplies used; and minerals received for preparation? (Report detail in Item 18.)
Include:
Cost of extraction/mining/quarrying-related materials purchased for other companies (contractors)
Cost of materials purchased or received from other domestic reporting units of your company
Exclude:
Non-extraction/mining/quarrying-related expenses that were paid to other companies (Report these
expense details in C.)

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Products bought and sold without further processing (products bought and resold in the same condition as when
purchased)? (Report these sales in Wholesaling Services product codes in Item 22.)
Exclude:
oil, gas or natural gas liquids (if applicable)

3. Work done for you by others on your materials (work contracted to others)? [Report in A1 the materials, parts, and
supplies purchased for other companies (contractors).]
4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report detail in Item 19.)
Report the total amount actually paid or payable for all purchased fuels consumed.
Include:
Fuels or coal consumed at this domestic reporting unit, but produced at another domestic reporting unit of
your company (Assign commercial values to them.)
Fuel used to power on-site trucks, forklifts, or motor vehicles
Anthracite, lignite, bituminous, and subbituminous coal, coke, natural and manufactured gas, gasoline,
wood, purchased steam, and all other fuels
Exclude:
Gas purchased for gas lift
Crude petroleum, natural gas, and coal produced at the domestic reporting unit and used for heat, power,
or the generation of electricity

5. Purchased electricity? (Report comparable quantity in B1.)
Report total amount actually paid or payable for electric energy purchased during 2022 from other companies or
received from other domestic reporting units of your company.
Exclude value of electricity generated and used at this domestic reporting unit

TOTAL (Add lines A1 through A5.)

B. For this domestic reporting unit, what was the quantity of:

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30

Check
if
None
1. Purchased electricity? (quantity comparable to cost reported in A5)

2022 Kilowatt Hours
,000

2. Generated electricity? (gross less generating station use)
When a figure is reported on this line, include data relating to the activity of the power stations in other sections of
this questionnaire. For example, include the number of employees assigned to the power station, their wages, and
hours worked in the figures reported in Item 7 and the cost of fuels used to generate electricity, in Item 16, line A4
and Item 18.
Include energy generated at the drilling site that was used for lighting or other purposes.

3. Electricity sold or transferred to other domestic reporting units? (Also include quantity in B1 and/or B2.)

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

,000

,000

31

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

OTHER OPERATING EXPENSES
C. What were the other operating expenses paid by this domestic reporting unit in 2022 for:
Include:
Costs for each of these services purchased from other companies that are paid directly by this domestic reporting unit
Expenses normally considered nonproduction related costs
Exclude:
Salaries paid to employees of this domestic reporting unit for any of the specified services (Report in Item 7.)
Cost of mining activities contracted or subcontracted to others (Report on A3.)
1. Temporary staff and leased employees? [total costs paid to Professional Employer Organizations (PEOs) and
staffing agencies for personnel]
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report in 3.)
Leased and rented equipment (Report in Item 14, line B.)

3. Expensed purchases of software? (purchases of prepackaged, custom-coded or vendor-customized software)
Include:
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Credit card transaction fees
Other wired and wireless communication services

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32

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other domestic reporting units of this company (such as a separate central data
processing unit)
Expensed integrated systems (Report in 4.)
Repair and maintenance of computer equipment (Report in 6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in 9 and credit card
transaction fees in 4.)
Expenses for telecommunication services, e.g., Internet, connectivity, telephone, etc. (Report in 4.)

$

,000.00

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof, replacing parts, over-hauling of equipment, and other repairs chargeable as
current operating costs
Cost of repair and maintenance of any leased property if the domestic reporting unit assumes the cost
Exclude:
Materials, parts, and supplies used for repairs and maintenance performed by this domestic reporting unit’s
employees (Report in A1.)
Extensive “repairs” or reconstruction that is capitalized (Report these as a capital expenditure in Item 13.)
Costs incurred directly by this domestic reporting unit in using its own work force to perform repairs and
maintenance work
Repairs and maintenance provided by the building or machinery owner as part of the rental contract

7. Water, sewer, refuse removal, and other non-electric utility payments? (Report electric utility payments on line
A5. If the cost of these utilities is included in a lease or rental payment, report in Item 14 line A.)
Include:
Cost of hazardous waste removal

8. Purchased advertising and promotional services?
Include:
Printed materials
Media coverage
Marketing and public relations services
Exclude:
All salaries paid to employees of the domestic reporting unit for advertising work

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33

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other professional services
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

$

,000.00

10. Governmental taxes and licensing fees? (payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

11. All other operating expenses not reported elsewhere?
Exclude:
Purchases of merchandise for resale (Report on line A2.)
Non-operating expenses

Describe

TOTAL (Add lines C1 through C11.)

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34

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
Report:
Delivered cost of individual items listed below. Delivered cost is the amount paid or payable after discounts and including freight and other direct charges incurred by the
domestic reporting unit in acquiring the materials. The figures reported should represent the total purchase cost of supplies, minerals received for preparation, etc., actually used
or processed during 2022. Include purchases, interplant transfers, and withdrawals from inventories. Do not combine material lines. If the information is not directly available
from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Estimated quantity and cost of minerals received for processing on a custom or toll basis, as if purchased.
Minerals mined and also processed at this domestic reporting unit.
Include:
Minerals received from other domestic reporting units for preparation which were used or processed during 2022
Cost of materials and supplies not covered in the pre-listed material codes (Report these in material code 00970098 - "All other supplies".)
Supplies purchased by this domestic reporting unit for use by companies performing contract work at this domestic reporting unit
Exclude:
Associated labor costs of the kind reported in Item 7 and Item 16, line A3
Payments made for contract services performed, including payments for supplies and equipment furnished by the contractor incidental to this work

Unit of
Measure

Description

Quantity

Census
Material
Code

Value

1. Parts and attachments for mining, mineral preparation, construction, and
conveying machinery and equipment

$

,000.00

33300009

2. Explosive materials, including ammonium nitrate, and blasting accessories

$

,000.00

32592000

3. Miscellaneous iron, steel, and ferroalloy ingot, shapes, and forms (excluding
castings, forgings, bars, structural shapes, wire, sheet, strip, and semifinished
shapes)

$

,000.00

33110090

4. All basic organic and inorganic chemicals, excluding petrochemicals

$

,000.00

32518000

$

,000.00

21239003

$

,000.00

00970098

short tons
(dry basis)

5. Crude minerals received for preparation
6. All other supplies
Describe

7. Crude minerals mined and prepared at same domestic reporting unit

short tons
(dry basis)

21239005

$

TOTAL

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

,000.00

77100000

35

Item 19: Fuels Used

ITEM 19: FUELS USED
Of the $,000.00 of purchased fuels in 2022, reported on Item 16, line A4, how much was for the following specified fuels?
Report:
Delivered cost of fuels received, not cost per unit. Delivered cost is the amount paid or payable after discounts, including freight and other direct charges incurred by the
domestic reporting unit in acquiring the fuels. Do not combine fuel lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Include:
Fuels purchased from other companies or transferred from other domestic reporting units of your company and used at this domestic reporting unit for the production of heat,
power, or generated electricity. The fuels transferred from other domestic reporting units of your company should be estimated at market value.
Cost of fuels not covered in the pre-listed fuel codes (Report these in fuel code 00960018 - "Other fuels".)

Unit of
Measure

Description

1. Diesel fuel

2. Gasoline used as a fuel

3. Gas (natural, manufactured, and mixed) used as a fuel
4. Other fuels (liquefied petroleum gas, coke, wood, etc.)

Quantity
Consumed

Cost, including delivery cost
(freight-in)

Census
Fuel Code

barrels

$

,000.00

32411021

1000 gal

$

,000.00

32411015

mil ft3

$

,000.00

21111015

$

,000.00

00960018

$

,000.00

00772000

Describe

TOTAL

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36

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The mined products and services listed below are generally produced in your industry. They include products shipped and services performed by this domestic reporting unit. Select
the items that apply to your domestic reporting unit. If you mine products or have revenue from other sources not listed, you will report them in the next section.

Description

Select

Product Code

1000375000

1. Mining of potassium salts and boron compounds

1000400000

2. Mining of sodium carbonate and sulfate, natural
3. Mining of crude and prepared phosphate rock, including crude ore or matrix, washed, concentrated, dried, calcined, sintered or
nodulized

1000875000

1001150000

4. Mining of barite

1000900000

5. Mining of rock salt
6. Mining of other chemical and fertilizer materials (ores, fines, and concentrates, including fluorspar, pyrites, spodumene, mineral
pigments, native sulfur, etc.)

1001125000

1000925000

7. Mining and/or benefication of diatomite

1000950000

8. Mining and/or benefication of gypsum

9. Mining and/or benefication of talc, soapstone, and pyrophyllite

1000975000

1001000000

10. Mining and/or benefication of mica

1001025000

11. Mining and/or benefication of pumice and pumicite

1001375000

12. Mining and/or benefication of peat

1001050000

13. Mining and/or benefication of perlite

14. Mining and/or benefication of all other nonmetallic minerals, including natural abrasives, shell and native asphalt and bitumens

15. Open-pit or quarry nonmetallic minerals mining not for your own account

16. Nonmetallic mineral prospect services and test drilling services

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

1001075000

1002150000

1002175000

37

17. Other nonmetallic mineral services, including overburden stripping, drilling services, blasting, and repair and maintenance services

1002200000

All other sales, shipments, receipts, or revenue from this domestic reporting unit

18. Manufacturing of treated lightweight aggregate and crushed slag, minerals and earths
19. Manufacturing of other minerals or earths, treated, including exfoliated vermiculite, refractory magnesia, refined or blended
graphite, feldspar, mica, and roofing granules

20. Wholesale sales of nonmetallic minerals, except crude petroleum and minerals used in construction and fertilizer

2026225000

2026275000

4003525000

Add product/service not listed

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

38

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Report:
The value of the products shipped and services performed at the net selling value, free on board (FOB) quarry or plant to customer, after discounts or allowances.
Quantities in the unit of measure specified. Note: Short tons equal to 2,000 pounds.
Include:
All products mined, quarried, extracted, or leached from this domestic reporting unit
Material withdrawn from stockpiles, i.e. for leaching, sale, etc.
Products shipped on consignment
Prepared minerals from crude materials mined at this domestic reporting unit, purchased, or received from other domestic reporting units of your company
Concentrated ores, metals, and agglomerates from ores mined at this domestic reporting unit, or purchased or received from other domestic reporting units of your company
Estimated value of products treated on a custom or toll basis
Products transferred to other domestic reporting units of your company for treatment, preparation, milling, or other use
Bonuses or other credits for minerals contained, as well as royalties
Quantity of production of crude ore mined for treatment at this domestic reporting unit
Exclude:
Penalties for impurities
Wholesaling products (previously Resales), which include products that are bought from other domestic reporting units or transferred from other domestic reporting units of your
company and then sold without further treatment, processing, preparation, or milling by this domestic reporting unit. Report these products in the appropriate wholesaling
product line(s) you selected or else "Add product/service not listed" at the end of this item.
Freight charged
Excise taxes

Description

Quantity
Shipped

Unit of
Measure

Quantity
Produced

Unit of
Measure

Product
Code

Value

1. Mining of potassium salts and boron
compounds

short tons

2. Mining of sodium carbonate and sulfate,
natural

short tons

3. Mining of crude and prepared phosphate
rock, including crude ore or matrix,
washed, concentrated, dried, calcined,
sintered or nodulized

short tons
(dry basis)

short tons
(dry basis)

$

,000.00

1000875000

short tons

short tons

$

,000.00

1001150000

4. Mining of barite

5. Mining of rock salt

short tons

$

short tons

,000.00

$

short tons

short tons

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

,000.00

,000.00

$

6. Mining of other chemical and fertilizer
materials (ores, fines, and concentrates,
including fluorspar, pyrites, spodumene,
mineral pigments, native sulfur, etc.)

7. Mining and/or benefication of diatomite

$

,000.00

$

,000.00

1000375000

1000400000

1000900000

1001125000

1000925000

39

8. Mining and/or benefication of gypsum
9. Mining and/or benefication of talc,
soapstone, and pyrophyllite

10. Mining and/or benefication of mica
11. Mining and/or benefication of pumice
and pumicite

12. Mining and/or benefication of peat

13. Mining and/or benefication of perlite
14. Mining and/or benefication of all other
nonmetallic minerals, including natural
abrasives, shell and native asphalt and
bitumens

short tons

short tons

$

,000.00

1000950000

short tons

short tons

$

,000.00

1000975000

short tons

short tons

$

,000.00

1001000000

short tons

short tons

$

,000.00

1001025000

short tons

short tons

$

,000.00

1001375000

short tons

short tons

$

,000.00

1001050000

short tons

short tons

$

,000.00

1001075000

15. Open-pit or quarry nonmetallic minerals
mining not for your own account

$

,000.00

1002150000

16. Nonmetallic mineral prospect services
and test drilling services

$

,000.00

1002175000

$

,000.00

1002200000

18. Manufacturing of treated lightweight
aggregate and crushed slag, minerals
and earths

$

,000.00

2026225000

19. Manufacturing of other minerals or
earths, treated, including exfoliated
vermiculite, refractory magnesia, refined
or blended graphite, feldspar, mica, and
roofing granules

$

,000.00

2026275000

20. Wholesale sales of nonmetallic minerals,
except crude petroleum and minerals
used in construction and fertilizer

$

,000.00

4003525000

17. Other nonmetallic mineral services,
including overburden stripping, drilling
services, blasting, and repair and
maintenance services
All other sales, shipments, receipts, or revenue from this domestic reporting unit

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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40

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this domestic reporting unit a cooperative?
Yes
No

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41

Item 28: Special Items - Water Use

ITEM 28: SPECIAL ITEMS - WATER USE
1. What was this domestic reporting unit’s water intake in 2022, that is, the quantity of new water introduced into the domestic reporting unit for the first time, regardless of source or
quality?
Include water used in the production process and auxiliary operations (such as cooling and condensing, boiler feed, sanitary and domestic use). Report to the nearest thousand.
,000 gallons

2. Did this domestic reporting unit recirculate or reuse any water during 2022?
Yes
No

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42

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s gross water use in 2022, that is, the quantity of water that would have been required if no water had been recirculated or reused?
For example, if total water intake was 500 million gallons and, of these 500 million gallons, 100 million gallons were used twice for cooling purposes and once for washing products or
materials, the total water required would be 300 million gallons, plus the 400 million gallons not recirculated, for a total of 700 million gallons of gross water use (less consumption and
evaporation loss). Report to the nearest thousand.
,000 gallons

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43

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
What was this domestic reporting unit’s main source of new water in 2022? Select only ONE.
Public water system includes water supplied by a water utility (whether municipally- or privately-owned) whose primary purpose is the supply of water to the general public and/or
industrial users. Self-supplied water systems include water obtained by this domestic reporting unit through its own system of pumps, pipes, hoses, etc. Also include here water obtained
from another company that is not primarily a water utility.
Public water system (municipally- or privately-owned utility)
Self-supplied surface water system (rivers, streams, lakes)
Self-supplied ground water system (wells, deep springs)
Self-supplied tide water system (estuaries, bays, oceans)
Self-supplied mine water (underground mines, quarries, open pits, water produced with oil)
Other sources (e.g., rainwater, truck deliveries)

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44

Item 28: Special Items - Water Use - Continued

ITEM 28: SPECIAL ITEMS - WATER USE
Which of the following types of water was mainly supplied by the public water system? Select only ONE.
Potable
Reclaimed wastewater

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45

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this domestic reporting unit sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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46

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this domestic reporting unit purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?

Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

47

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this domestic reporting unit use touchscreens/kiosks for customer interface in its own operations?

Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as
registering for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this domestic reporting unit use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this domestic reporting unit use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this domestic reporting unit use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into standalone stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this domestic reporting unit use service robots in its own operations?

Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots

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48

Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots
Yes
No
Do not know
6. In 2022, did this domestic reporting unit use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?

Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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49

Item 29: Business Technologies - Touchscreens/Kiosks for customer interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this domestic reporting unit acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

50

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this domestic reporting unit acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

51

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)

How did this domestic reporting unit acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

52

Item 29: Business Technologies - Industrial Robots

ITEM 29 BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS

How did this domestic reporting unit acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

53

Item 29: Business Technologies - Service Robots

ITEM 29 BUSINESS TECHNOLOGIES - SERVICE ROBOTS

How did this domestic reporting unit acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

54

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)

How did this domestic reporting unit acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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55

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

1000

characters remaining

56

Item 32: Number of Domestic Reporting Units - Domestic Reporting Unit Information

ITEM 32: NUMBER OF DOMESTIC REPORTING UNITS - DOMESTIC REPORTING UNIT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MI-21238_su.pdf Generated 2022-02-23 16:26:28

,000.00

57

Location Information

DEFINITION OF DOMESTIC REPORTING UNIT
The reporting unit for this questionnaire is a mineral service domestic reporting unit. A mineral service domestic reporting unit represents all nationwide mineral support activities
performed for operators of mineral properties specified in the "Industry" field below on a fee or contract basis.
Mineral service activities include exploration and other mining and quarrying support services.
Please update the pre-identified locations for this industry in Item 33A, Pre-identified Locations of Operation.

Name 1

Name 2

NAICS

Industry

For Census Bureau Use Only
CFN

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

1

Item 4A: Primary Business or Activity

CFN:

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this domestic reporting unit's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the domestic reporting unit's
primary business or activity.
Select only ONE.

Support activities for coal mining, e.g., sinking mine shafts and driving mine tunnels services, overburden stripping, recovering culm bank,
etc.

213113 001

Support activities for metal mining, e.g., sinking mine shafts and driving mine tunnels services, overburden stripping, etc.

213114 001

Support activities for nonmetallic minerals (excluding fuel) mining, e.g., sinking mine shafts and driving mine tunnels services, overburden
stripping, etc.

213115 001

Drilling oil and gas wells, on a contract basis

213111 001

Support activities for oil and gas operations on a contract basis (excluding drilling wells), e.g., cementing wells, exploration services,
hydraulic fracturing, gathering services, etc.

213112 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

2

Item 4B: Type of Operation

ITEM 4B: TYPE OF OPERATION

For which ONE activity did this domestic reporting unit receive the largest receipts?
(Include production, development, and exploration operations.)
Principal mineral activity of domestic reporting units served
452

Metal mining

454

Coal mining

456

Mining of nonmetallic minerals, except fuels

458

Crude petroleum, natural gas, and natural gas liquids

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

3

General Reporting Guidelines

CFN:

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

2036

,000.00

4

Item 5: Sales, Shipments, Receipts, or Revenue

CFN:

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What was the total value of products shipped and other receipts for this domestic reporting unit?
(Report details in Item 22.)
Include:
All products physically shipped during 2022
Receipts for services
Value of resales
Interplant transfers
Exports
Other miscellaneous receipts
Exclude:
Non-operating income such as royalties, interest, dividends, or the sale of fixed assets
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

$

,000.00

B. What was the value of products shipped for export for this domestic reporting unit?
(This is a breakout of the $,000.00 reported in A.)
Include:
Shipments going directly for export including shipments to foreign subsidiaries or foreign divisions of your
company and their affiliates:
Shipments to customers in the Panama Canal Zone, the Commonwealth of Puerto Rico, and U.S.
possessions
Shipments of your products to export firms and to other customers who export these items
Sales to the U.S. government to be shipped to foreign nations under military and economic assistance
programs
Exclude:
Sales to the U.S. Government overseas

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5

Item 7: Employment and Payroll

CFN:

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941, Employer's Quarterly Federal
Tax Return, and filed under the Employer Identification Number (EIN)
Persons on paid sick leave, paid holidays, and paid vacations during the year
Officers, if a corporation
Exclude:
Members of the Armed Forces and pensioners carried on your active payrolls
Proprietor or partners, if an unincorporated concern
Workers at manufacturing plants, company stores, boardinghouses, bunkhouses, recreational centers, and auxiliary offices
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report these values in Item 16, line D1.)
Temporary staffing obtained from a staffing service (Report these values in Item 16, line D1.)
Purchased professional and technical services (Report these values in Item 16, line D9.)
Contractors and subcontractors and their employees (Report the cost of contract work in Item 16, line A3.)
A. EMPLOYMENT
1. What was the number of mining, production, development, and exploration workers (direct labor including
first-line supervisors) at this domestic reporting unit for the pay period including March 12 (Q1)?
Include:
Workers engaged in services closely associated with production and development operations such as:
Manual work
Tool use and machine operation
Materials and products, loading and hauling
Mineral properties care
Exploration and development work
Storage, shipping, maintenances, repair, and guard services
Auxiliary production for own use (i.e. power plant) record keeping
Regular maintenance and repair
Drilling and maintaining wells
Seismic testing or cementing walls
Exclude:
Supervisory employees above the first-line level (Report these in A2.)
Employees of contractors or subcontractors

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

Check
if
None

2022 Number

6

2. What was the number of other employees at this domestic reporting unit for the pay period including March 12
(Q1)?
Include:
Force-account construction employees and your payroll engaged in construction of major additions or
alterations to your facilities that are utilized as a separate work force
Nonproduction personnel engaged in supervision above the working supervisor level and employees
engaged in activities such as:
Sales, advertising, purchasing, finance
Highway trucking and other transportation
Credit, collection, executive, legal, clerical, and routine office functions
Personnel including cafeteria, medical, etc.
Professional (engineers, geologists, etc.) and technical workers
Exclude:
Proprietors and partners
Temporary staff and leased employees
Employees of contractors or subcontractors

TOTAL (Add lines A1 and A2.)

B. HOURS WORKED
What was the annual number of hours worked by the mining, production, development, and exploration workers
(direct labor including first-line supervisors) at this domestic reporting unit reported in A1?
Include:
All hours worked or paid (except hours paid for vacations, holidays, or sick leave)
Overtime hours (Report actual hours worked, not straight-time equivalent hours.)
Actual hours worked by an employee who elects to work during a vacation period
All hours worked for the entire year by a full and part-time mining, production, development, and
exploration workers of the type reported in A1
Exclude:
Hours of proprietors or partners
Hours worked by temporary staff or leased employees
Hours worked by employees of contractors or subcontractors

Check
if
None

2022 Hours
,000

C. PAYROLL
Report the gross earnings paid in calendar year 2022 to employees prior to such deductions as employee’s Social Security contributions, withholding taxes, group insurance
premiums, union dues, and savings bonds.
Payroll should equal the taxable Medicare wages and tips reported on the Internal Revenue Services (IRS) Form 941, Employer’s Quarterly Tax Return and definitions as described in
Circular E, Employer’s Tax Guide.
Include:
Commissions, dismissal pay and paid bonuses
Employee contributions to pension plans such as a 401(k) plan
Vacation and sick-leave pay
Salaries of officers
Spread on stock options that are taxable to employee as wages
Cash equivalent of compensation paid in kind such as:
Board and housing
Payments in the form of shared profits and special stock purchases that are subject to withholding tax
Exclude:
Payroll for temporary staff and leased employees
Payments to proprietor or partners
Payments to members of Armed Forces and pensioners carried on your active payroll
Royalty payments to unions
Payments to contract or subcontractors who performed work for you

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

7

Employer-paid annual cost for fringe benefits (Report these costs in D1 through D3.)
Check
if
None

2022

1. What was the annual payroll before deductions for mining, production, development, and exploration workers
(direct labor including first-line supervisors) of the type reported in A1 at this domestic reporting unit?

$

,000.00

2. What was the annual payroll before deductions for all other employees of the type reported in A2 at this domestic
reporting unit?

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines C1 and C2.)
3. Of the $,000.00 reported above, what was the first quarter payroll at this domestic reporting unit before
deductions (January - March 2022)?

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8

Item 7: Employment and Payroll - Continued

CFN:

ITEM 7: EMPLOYMENT AND PAYROLL

D. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS
This is the employer’s annual cost at this domestic reporting unit for legally required programs and programs not required by law.
1. What were the employer’s annual costs at this domestic reporting unit for health insurance? (insurance premiums on
hospitals, medical plans, and single service plans such as dental, vision, and prescription drug plans)
Include:
Premium equivalents for self-insured plans and fees paid to third-party administrators (TPAs)
Exclude:
Employee contributions
Disbursements from trusts or funds to satisfy health insurance claims

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

2. Retirement plans:
a. What were the employer’s annual costs at this domestic reporting unit for defined benefit pension plans? (Costs
include both qualified and nonqualified defined pension plans, as well as plans that specify the benefit to be
paid to employee upon retirement, generally either as a specified amount or a percentage of compensation.
Employer contributions are based on actuarial computations that include the employee's compensation and years
of service and are not allocated to specific accounts maintained for employees.)

b. What were the employer’s annual costs at this domestic reporting unit for defined contribution plans? (These
are plans that define the employer contributions to a separate account provided for each employee. The
employee "benefit" at retirement depends on the amount contributed and the results of the account's activity.)
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

9

3. What were the employer’s annual costs at this domestic reporting unit for employer-paid payroll taxes, insurance
premiums, and all other employer-paid benefits?
Include:
Life insurance benefits
“Quality of life” benefits (e.g., childcare assistance, subsidized commuting, etc.)
Education assistance
Legally-required fringe benefits
Social Security
Workers' compensation insurance
Unemployment tax
State disability insurance programs (long- and short-term disability – LTD and STD)
Medicare
Exclude:
Disbursements from trusts or funds to satisfy health insurance claims

TOTAL (Add lines D1 through D3.)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

$

,000.00

$

,000.00

10

Item 9: Value of Inventories

CFN:

ITEM 9: VALUE OF INVENTORIES

Report inventories at cost or market using generally accepted accounting practices. Report the value of all inventories that are attributable to the domestic reporting unit’s operations
regardless of where the inventories are held or stored.

What was the value of inventories owned by this domestic reporting unit as of December 31 before Last-In, First-Out (LIFO) adjustment (if any)?

Include:
Stocks of items to be used for mineral service work
Stocks of materials, parts, supplies, fuels, etc.

Check
if
None

Check
if
None

2022
$

,000.00

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

2021
$

,000.00

11

Item 10: Inventories by Valuation Method

CFN:

ITEM 10: INVENTORIES BY VALUATION METHOD
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this domestic reporting unit as of December 31, 2022 and the $,000.00 reported in Item 9 as the total
value of inventories owned by this domestic reporting unit as of December 31, 2021:
Check
if
None

Check
if
None

2022

2021

A. What was the amount subject to Last-In, First-Out (LIFO)
gross (gross LIFO amount)?

$

,000.00

$

,000.00

B. What was the amount not subject to LIFO valuation
method?

$

,000.00

$

,000.00

TOTAL (Sum of lines A and B should equal TOTAL in Item
9.)

$

,000.00

$

,000.00

C. What was the amount of LIFO reserve (if any)? [LIFO
reserve represents the excess of current period cost over
the LIFO carrying value. LIFO reserve is the difference
between the current cost (i.e., FIFO) of inventories (gross
value) and the LIFO carrying value (net value).]

$

,000.00

$

,000.00

Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

12

Item 13: Capital Expenditures

CFN:

ITEM 13: CAPITAL EXPENDITURES

Report the actual outlays during 2022, not the final value of buildings or other structures completed or equipment put in place during the year. These expenditures are of the type for which
depreciation or amortization accounts are ordinarily maintained.
Capital expenditures during 2022 may be determined by the following computation:
(a) Cost of additions completed during the year, plus
(b) Work-in-progress at the end of the year, minus
(c) Work-in-progress at the beginning of the year.
Include labor and installation costs whether on contract or by your own forces
Exclude the cost of maintenance and repairs charged as current operating expense
A. What were the capital expenditures for new and used buildings, structures, machinery, and equipment for this domestic
reporting unit?
Include:
Buildings and structures directly related to mineral exploration, development, and production
Machinery, such as hoists, cranes, crushers, separators, and power plants
Exploration, development, production, and processing plant machinery
Value of the equipment produced and used
Equipment such as excavators, loaders, locomotives, tractors, hoists, drills, compressors, pumps
Transportation equipment, such as automobiles, trucks, and similar equipment
Office equipment, such as computers and peripheral data processing equipment, as well as furniture and fixtures
for offices, cafeterias, and change rooms
Replacements as well as additions to new capacity
Values from construction by your own employees, where capitalized
Value of improvements and capitalized repairs to machinery and equipment including those done to assets
transferred from other domestic reporting units of this company
Expenditures for old or existing plants and for second-hand equipment acquired from others (including U.S.
Government)
Gross book value of machinery or equipment transferred from other domestic reporting units of your company
Exclude:
Company houses and general recreational facilities
Value of land
Cost of maintenance and repairs charged as current operating expense

Check
if
None

2022
$

,000.00

$

,000.00

B. What were the capital expenditures for mineral exploration and development for this domestic reporting unit?
Include:
All intangible development and exploration outlays that were charged to a capital or Office of Minerals Exploration
account
Capitalized expenditures for entries, shafts, rail and other road construction, test boring, surveying, etc.
Capitalized expenditures for oil and gas field exploration and for drilling oil, gas, dry, and service wells through
completion of the well

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

13

$

TOTAL (Add lines A and B.)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

,000.00

14

Item 14: Rental Payments

CFN:

ITEM 14: RENTAL PAYMENTS
Report rental payments made to other companies for use of depreciable assets such as buildings, other structures, machinery, and equipment. Include rental payments for land.
Domestic reporting units involved with leasing arrangements for equipment and/or buildings, report lease equipment according to the type of lease negotiated with the producer or the
lessor.
Include:
Operating leases (Report the periodic payments made to the producer or lessor.)
Exclude:
Capital leases (leases with a contract to own at the end of the lease) (Report cost, at market value, of acquisitions of building and equipment during the year as a capital
expenditure, Item 13.)
At this domestic reporting unit, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production machinery and equipment
Loading machinery and equipment
Transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles

TOTAL (Add lines A and B.)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

15

Item 15: Mineral Property Expenses

CFN:

ITEM 15: MINERAL PROPERTY EXPENSES

Report mineral property expenses charged to current accounts.

Check
if
None
A. What were the lease rents for mineral properties for this domestic reporting unit?

2022
$

,000.00

B. Current Operation Expenses
Include:
Acquisition costs for mineral land and rights that were not capitalized
Cost of royalty payments related to mineral production
Labor costs whether on a contract basis or by your own forces associated with exploration and development or the acquisition of mineral properties
Intangible development and exploration outlays charged to a current account
Expenses for mineral properties charged to current accounts, such as:
all supplies, machinery, equipment, parts, fuel, power, etc., used for development or exploration (whether purchased or received from other domestic reporting units of
your company) and charged as current operating expenses
cost of maintenance and repairs associated with development or exploration activity that is charged to current accounts
Exclude:
Lease rents (Report separately in A.)
1. What were the current operating expenses for exploration, development, and mineral land and rights for this
domestic reporting unit?

$

,000.00

2. What were the current operating expenses for royalty payments for this domestic reporting unit?

$

,000.00

TOTAL (Add lines B1 and B2.)

$

,000.00

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

16

Item 16: Selected Expenses Additional Information

CFN:

ITEM 16: SELECTED EXPENSES

SELECTED EXTRACTION/MINING/QUARRYING COSTS AND ELECTRICITY
Include costs incurred in mining processes such as supplies, resales, contract work, fuels, and electricity.

A. What were the extraction/mining/quarrying-related costs in 2022 for this domestic reporting unit for:

1. Materials, parts, and supplies used; and minerals received for preparation? (Report detail in Item 18.)
Include:
Cost of extraction/mining/quarrying-related materials purchased for other companies (contractors)
Cost of materials purchased or received from other domestic reporting units of your company
Exclude:
Non-extraction/mining/quarrying-related expenses that were paid to other companies (Report these
expense details in C.)

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Products bought and sold without further processing (products bought and resold in the same condition as when
purchased)? (Report these sales in Wholesaling Services product codes in Item 22.)
Exclude:
oil, gas or natural gas liquids (if applicable)

3. Work done for you by others on your materials (work contracted to others)? [Report in A1 the materials, parts, and
supplies purchased for other companies (contractors).]
4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report detail in Item 19.)
Report the total amount actually paid or payable for all purchased fuels consumed.
Include:
Fuels or coal consumed at this domestic reporting unit, but produced at another domestic reporting unit of
your company (Assign commercial values to them.)
Fuel used to power on-site trucks, forklifts, or motor vehicles
Anthracite, lignite, bituminous, and subbituminous coal, coke, natural and manufactured gas, gasoline,
wood, purchased steam, and all other fuels
Exclude:
Gas purchased for gas lift
Crude petroleum, natural gas, and coal produced at the domestic reporting unit and used for heat, power,
or the generation of electricity

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

17

5. Purchased electricity? (Report comparable quantity in B1.)
Report total amount actually paid or payable for electric energy purchased during 2022 from other companies or
received from other domestic reporting units of your company.
Exclude value of electricity generated and used at this domestic reporting unit

TOTAL (Add lines A1 through A5.)

$

,000.00

$

,000.00

B. For this domestic reporting unit, what was the quantity of:
Check
if
None
1. Purchased electricity? (quantity comparable to cost reported in A5)

2022 Kilowatt Hours
,000

2. Generated electricity? (gross less generating station use)
When a figure is reported on this line, include data relating to the activity of the power stations in other sections of
this questionnaire. For example, include the number of employees assigned to the power station, their wages, and
hours worked in the figures reported in Item 7 and the cost of fuels used to generate electricity, in Item 16, line A4
and Item 18.
Include energy generated at the drilling site that was used for lighting or other purposes.

3. Electricity sold or transferred to other domestic reporting units? (Also include quantity in B1 and/or B2.)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

,000

,000

18

Item 16: Selected Expenses - Continued

CFN:

ITEM 16: SELECTED EXPENSES

OTHER OPERATING EXPENSES
C. What were the other operating expenses paid by this domestic reporting unit in 2022 for:
Include:
Costs for each of these services purchased from other companies that are paid directly by this domestic reporting unit
Expenses normally considered nonproduction related costs
Exclude:
Salaries paid to employees of this domestic reporting unit for any of the specified services (Report in Item 7.)
Cost of mining activities contracted or subcontracted to others (Report on A3.)
1. Temporary staff and leased employees? [total costs paid to Professional Employer Organizations (PEOs) and
staffing agencies for personnel]
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report in 3.)
Leased and rented equipment (Report in Item 14, line B.)

3. Expensed purchases of software? (purchases of prepackaged, custom-coded or vendor-customized software)
Include:
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

19

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Credit card transaction fees
Other wired and wireless communication services

$

,000.00

$

,000.00

$

,000.00

$

,000.00

$

,000.00

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other domestic reporting units of this company (such as a separate central data
processing unit)
Expensed integrated systems (Report in 4.)
Repair and maintenance of computer equipment (Report in 6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in 9 and credit card
transaction fees in 4.)
Expenses for telecommunication services, e.g., Internet, connectivity, telephone, etc. (Report in 4.)

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof, replacing parts, over-hauling of equipment, and other repairs chargeable as
current operating costs
Cost of repair and maintenance of any leased property if the domestic reporting unit assumes the cost
Exclude:
Materials, parts, and supplies used for repairs and maintenance performed by this domestic reporting unit’s
employees (Report in A1.)
Extensive “repairs” or reconstruction that is capitalized (Report these as a capital expenditure in Item 13.)
Costs incurred directly by this domestic reporting unit in using its own work force to perform repairs and
maintenance work
Repairs and maintenance provided by the building or machinery owner as part of the rental contract

7. Water, sewer, refuse removal, and other non-electric utility payments? (Report electric utility payments on line
A5. If the cost of these utilities is included in a lease or rental payment, report in Item 14 line A.)
Include:
Cost of hazardous waste removal

8. Purchased advertising and promotional services?
Include:
Printed materials
Media coverage
Marketing and public relations services
Exclude:
All salaries paid to employees of the domestic reporting unit for advertising work

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

20

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other professional services
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

$

,000.00

10. Governmental taxes and licensing fees? (payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

11. All other operating expenses not reported elsewhere?
Exclude:
Purchases of merchandise for resale (Report on line A2.)
Non-operating expenses

Describe

TOTAL (Add lines C1 through C11.)

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

21

Item 18: Detailed Cost of Materials, Parts, and Supplies

CFN:

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
Report:
Delivered cost of individual items listed below. Delivered cost is the amount paid or payable after discounts and including freight and other direct charges incurred by the
domestic reporting unit in acquiring the materials. The figures reported should represent the total purchase cost of supplies, minerals received for preparation, etc., actually used
or processed during 2022. Include purchases, interplant transfers, and withdrawals from inventories. Do not combine material lines. If the information is not directly available
from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Estimated quantity and cost of minerals received for processing on a custom or toll basis, as if purchased.
Minerals mined and also processed at this domestic reporting unit.
Include:
Minerals received from other domestic reporting units for preparation which were used or processed during 2022
Cost of materials and supplies not covered in the pre-listed material codes (Report these in material code 00970098 - "All other supplies".)
Supplies purchased by this domestic reporting unit for use by companies performing contract work at this domestic reporting unit
Exclude:
Associated labor costs of the kind reported in Item 7 and Item 16, line A3
Payments made for contract services performed, including payments for supplies and equipment furnished by the contractor incidental to this work

Description

Census
Material
Code

Value

1. Parts and attachments for mining, mineral preparation, construction, and conveying machinery and equipment

$

,000.00

33300009

2. Explosive materials, including ammonium nitrate, and blasting accessories

$

,000.00

32592000

3. Miscellaneous iron, steel, and ferroalloy ingot, shapes, and forms (excluding castings, forgings, bars, structural
shapes, wire, sheet, strip, and semifinished shapes)

$

,000.00

33110090

4. All other supplies

$

,000.00

00970098

$

,000.00

77100000

Describe

TOTAL

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

22

Item 19: Fuels Used

CFN:

ITEM 19: FUELS USED
Of the $,000.00 of purchased fuels in 2022, reported on Item 16, line A4, how much was for the following specified fuels?
Report:
Delivered cost of fuels received, not cost per unit. Delivered cost is the amount paid or payable after discounts, including freight and other direct charges incurred by the
domestic reporting unit in acquiring the fuels. Do not combine fuel lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Quantities in the unit of measure specified.
Include:
Fuels purchased from other companies or transferred from other domestic reporting units of your company and used at this domestic reporting unit for the production of heat,
power, or generated electricity. The fuels transferred from other domestic reporting units of your company should be estimated at market value.
Cost of fuels not covered in the pre-listed fuel codes (Report these in fuel code 00960018 - "Other fuels".)

Unit of
Measure

Description

1. Diesel fuel

2. Gasoline used as a fuel

3. Gas (natural, manufactured, and mixed) used as a fuel
4. Other fuels (liquefied petroleum gas, coke, wood, etc.)

Quantity
Consumed

Cost, including delivery cost
(freight-in)

Census
Fuel Code

barrels

$

,000.00

32411021

1000 gal

$

,000.00

32411015

mil ft3

$

,000.00

21111015

$

,000.00

00960018

$

,000.00

00772000

Describe

TOTAL

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

23

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

CFN:

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The mined products and services listed below are generally produced in your industry. They include products shipped and services performed by this domestic reporting unit. Select
the items that apply to your domestic reporting unit. If you mine products or have revenue from other sources not listed, you will report them in the next section.

Description

Select

Product Code

1001950000

1. Coal mining prospect and test drilling services

2. Sinking coal mine shafts and driving coal mine tunnels services
3. Other coal mining services, including strip, auger or underground mining, drilling, overburden stripping, recovering culm bank, and
repair and maintenance services not for your own account

4. Metal mining exploration work, excluding prospect services, test drilling, and geophysical surveying services

1001975000

1002000000

1002025000

1002050000

5. Open-pit metal ores mining not for your own account

1002075000

6. Metal mining prospect services and test drilling services

7. Sinking metal mine shafts and driving metal mine tunnels services

8. Other metal mining services, including overburden stripping and repair and maintenance services

9. Open-pit or quarry nonmetallic minerals mining not for your own account

10. Nonmetallic mineral prospect services and test drilling services

11. Other nonmetallic mineral services, including overburden stripping, drilling services, blasting, and repair and maintenance services

1002100000

1002125000

1002150000

1002175000

1002200000

All other sales, shipments, receipts, or revenue from this domestic reporting unit

12. Wholesale sales of construction, forestry, and mining machinery and equipment, including attachments

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

4002100000

24

6000625000

13. Site remediation cleanup services

6000750000

14. Decommissioning services

15. Integrated surveying and mapping services, except geophysical

16. Integrated geophysical services, excluding oil and gas well logging

17. Rental services for agricultural, construction, forestry, mining, and oil and gas field machinery and equipment

18. Maintenance and repair services for agricultural, construction, forestry, mining, and oil and gas field machinery and equipment

19. Transportation of dry bulks, except in intermodal containers, by road

7008100000

7012260000

7009025000

7009050000

7011325000

Add product/service not listed

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

25

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

CFN:

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Report:
The value of the products shipped and services performed at the net selling value, free on board (FOB) quarry or plant to customer, after discounts or allowances.
Quantities in the unit of measure specified. Note: Short tons equal to 2,000 pounds.
Include:
All products mined, quarried, extracted, or leached from this domestic reporting unit
Material withdrawn from stockpiles, i.e. for leaching, sale, etc.
Products shipped on consignment
Prepared minerals from crude materials mined at this domestic reporting unit, purchased, or received from other domestic reporting units of your company
Concentrated ores, metals, and agglomerates from ores mined at this domestic reporting unit, or purchased or received from other domestic reporting units of your company
Estimated value of products treated on a custom or toll basis
Products transferred to other domestic reporting units of your company for treatment, preparation, milling, or other use
Bonuses or other credits for minerals contained, as well as royalties
Quantity of production of crude ore mined for treatment at this domestic reporting unit
Exclude:
Penalties for impurities
Wholesaling products (previously Resales), which include products that are bought from other domestic reporting units or transferred from other domestic reporting units of your
company and then sold without further treatment, processing, preparation, or milling by this domestic reporting unit. Report these products in the appropriate wholesaling
product line(s) you selected or else "Add product/service not listed" at the end of this item.
Freight charged
Excise taxes

Description

Value

Product Code

1. Coal mining prospect and test drilling services

$

,000.00

1001950000

2. Sinking coal mine shafts and driving coal mine tunnels services

$

,000.00

1001975000

3. Other coal mining services, including strip, auger or underground mining, drilling, overburden stripping, recovering
culm bank, and repair and maintenance services not for your own account

$

,000.00

1002000000

4. Metal mining exploration work, excluding prospect services, test drilling, and geophysical surveying services

$

,000.00

1002025000

5. Open-pit metal ores mining not for your own account

$

,000.00

1002050000

6. Metal mining prospect services and test drilling services

$

,000.00

1002075000

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

26

7. Sinking metal mine shafts and driving metal mine tunnels services

$

,000.00

1002100000

8. Other metal mining services, including overburden stripping and repair and maintenance services

$

,000.00

1002125000

9. Open-pit or quarry nonmetallic minerals mining not for your own account

$

,000.00

1002150000

10. Nonmetallic mineral prospect services and test drilling services

$

,000.00

1002175000

11. Other nonmetallic mineral services, including overburden stripping, drilling services, blasting, and repair and
maintenance services

$

,000.00

1002200000

$

,000.00

4002100000

13. Site remediation cleanup services

$

,000.00

6000625000

14. Decommissioning services

$

,000.00

6000750000

15. Integrated surveying and mapping services, except geophysical

$

,000.00

7008100000

16. Integrated geophysical services, excluding oil and gas well logging

$

,000.00

7012260000

17. Rental services for agricultural, construction, forestry, mining, and oil and gas field machinery and equipment

$

,000.00

7009025000

18. Maintenance and repair services for agricultural, construction, forestry, mining, and oil and gas field machinery and
equipment

$

,000.00

7009050000

19. Transportation of dry bulks, except in intermodal containers, by road

$

,000.00

7011325000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

All other sales, shipments, receipts, or revenue from this domestic reporting unit

12. Wholesale sales of construction, forestry, and mining machinery and equipment, including attachments

Add product/service not listed

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

27

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this domestic reporting unit use touchscreens/kiosks for customer interface in its own operations?

Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as
registering for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this domestic reporting unit use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this domestic reporting unit use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this domestic reporting unit use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into standalone stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this domestic reporting unit use service robots in its own operations?

Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

28

Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots
Yes
No
Do not know
6. In 2022, did this domestic reporting unit use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?

Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

29

Item 29: Business Technologies - Touchscreens/Kiosks for customer interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this domestic reporting unit acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

30

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this domestic reporting unit acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

31

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)

How did this domestic reporting unit acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

32

Item 29: Business Technologies - Industrial Robots

ITEM 29 BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS

How did this domestic reporting unit acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

33

Item 29: Business Technologies - Service Robots

ITEM 29 BUSINESS TECHNOLOGIES - SERVICE ROBOTS

How did this domestic reporting unit acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

34

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)

How did this domestic reporting unit acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

35

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

1000

characters remaining

36

Item 33: Locations of Operation

CFN:

ITEM 33: LOCATIONS OF OPERATION
A. Complete Item 33A: Pre-Identified Locations of Operation (On the Location List that follows, Type will be 'Pre-listed (Item
33A)')
B. Complete Item 33B: Additional Locations of Operation (On the Location List that follows, Type will be 'Added (Item 33B)')
Number of locations
Include:
All locations in operation or temporarily inactive in Item 33A
All locations added in Item 33B
Exclude:
All locations that have ceased operation or were sold
Check
if
None

2022

What was the total number of locations in operation in 2022?

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

37

Item 33A: Pre-identified Locations of Operation

ITEM 33A: PRE-IDENTIFIED LOCATIONS OF OPERATION
LOCATION INFORMATION
We have listed domestic reporting units of your company based on Census records. Correct any errors or omissions below.
(P.O. Box and rural route addresses are not physical locations)
Line No.

EIN

NAICS
99-9999999

Major Activity

Name

Secondary Name

Store/Plant Number

Physical Location (Number and Street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

CFN

EMPLOYMENT, PAYROLL, AND RECEIPTS
Include the number of employees and payroll for full- and part-time employees working at this domestic reporting unit 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 domestic reporting units
If book figures are not available for employment and payroll for each domestic reporting unit, please provide your best estimates.

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January-March 2022)?

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

,000.00

38

2022
$

What were the sales, shipments, receipts, or revenue?

,000.00

OPERATIONAL STATUS
Which of the following best describes this domestic reporting unit's operational status at the end of 2022?
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
CEASED OPERATION OR SOLD OR LEASED INFORMATION

If this domestic reporting unit ceased operation or was sold or leased to another operator, what was the date?
MMDDYYYY
MMDDYYYY



If this domestic reporting unit was sold or leased to another operator, what is the name and address of this domestic reporting unit's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

99999-9999

39

Item 33B: Additional Locations of Operation

ITEM 33B: ADDITIONAL LOCATIONS OF OPERATION
LOCATION INFORMATION
What is this domestic reporting unit's physical location?
(P.O. Box and rural route addresses are not physical locations)
EIN
99-9999999

Name

Secondary Name

Store/Plant

Physical Location (Number and Street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Date domestic reporting unit
opened or is expected to open
MMDDYYYY



CFN

EMPLOYMENT AND PAYROLL
Include the number of employees and payroll for full- and part-time employees working at this domestic reporting unit 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 domestic reporting units
If book figures are not available for employment and payroll for each domestic reporting unit, please provide your best estimates.

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January-March 2022)?

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

,000.00

40

2022
$

What were the sales, shipments, receipts, or revenue?

,000.00

MAJOR ACTIVITY CODE
Select the ACTIVITY CODE that best describes the activity of this domestic reporting unit and what were the primary products or services?
Primary products or services

Activity Code

Describe

FORMER OWNER OR OPERATOR INFORMATION
If this domestic reporting unit was acquired, who was the former owner or operator, and when was this domestic reporting unit acquired?
Name of former owner or operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

Month
Acquired

99999-9999

Year
Acquired

2022_MI-2132A_mu.pdf Generated 2022-02-23 16:31:09

41

Attachment D-3
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 22

Attachment Sector

D-3

22

Instrument
Path
Instrument Path Title

2211A
22110
22120
22130

Hydroelectric Power Generation
Electric Power Generation, Transmission and Distribution
Natural Gas Distribution
Water, Sewage and Other Systems

Location Information

DEFINITION OF REPORTING UNIT
The reporting unit for this questionnaire is a consolidation of all your company's domestic establishments for the industry specified in the "Industry" field below. Establishments are
generally single physical locations. Please update the pre-identified establishments for this industry in Item 33A, Pre-identified Locations of Operation.

Name 1

Name 2

NAICS

Industry

For Census Bureau Use Only
CFN

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

1

Item 4: Primary Business or Activity

CFN:

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this consolidated reporting unit's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the consolidated reporting unit's
primary business or activity.
Select only ONE.
Electric services
Hydroelectric power generation

221111 001

Fossil fuel electric power generation

221112 001

Nuclear electric power generation

221113 001

Solar electric power generation

221114 001

Wind electric power generation

221115 001

Geothermal electric power generation

221116 001

Biomass electric power generation, except at landfill

221117 001

Other electric power generation (Excludes hydroelectric, fossil fuel, nuclear, solar, wind, geothermal, and biomass.) - Describe

221118 001

Describe
Electric bulk power transmission and control

221121 001

Electric power distribution

221122 001

Electric power marketers and brokers

221122 002

Natural gas distribution and/or natural gas marketing

221210 005

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2

General Reporting Guidelines

CFN:

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

%

3

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

CFN:

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue of this consolidated reporting unit?
For further clarification, click the "Additional Information" link above.

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2022
$

,000.00

4

Item 7: Employment and Payroll Additional Information

CFN:

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees for this consolidated reporting unit (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2022
$

,000.00

$

,000.00

5

Item 20: Class of Customer

CFN:

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this consolidated reporting unit's total operating revenue (reported in Item 5) by class of customer?
2022 Whole
percent of
revenue
%

1. Residential (Include apartment buildings.)

%

2. Commercial (Include farms.)

%

3. Industrial

%

4. Institutional

%

5. Government (Exclude utilities.)

%

6. Government-owned utilities

7. Private utilities (Include co-ops, etc.)

%

8. Other

%

Describe

9. TOTAL - Sum of lines 1 through 8 should equal 100%. (Exclude utilities.)

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

%

6

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

CFN:

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

6000075000

1. Electricity generation

a. Electricity generation (except waste energy generation - incineration at landfill)

b. Non-hazardous waste energy generation services (by incineration at landfill)

6000075003

6000075006

6000075009

c. Hazardous waste energy generation services

2. Electricity distribution and support services (except marketing and brokering)

6000125000

6000150000

3. Electricity (power) marketing and brokering

4. Natural gas distribution and support services (except marketing and brokering)

6000030000

6000035000

5. Natural gas (power) marketing and brokering

6000100000

6. Electricity transmission services

Add product/service not listed

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

7

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

CFN:

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Electricity generation

$

,000.00

6000075003

b. Non-hazardous waste energy generation services (by incineration at landfill)

$

,000.00

6000075006

c. Hazardous waste energy generation services

$

,000.00

6000075009

$

,000.00

6000075000

2. Electricity distribution and support services (except marketing and brokering)

$

,000.00

6000125000

3. Electricity (power) marketing and brokering

$

,000.00

6000150000

$

,000.00

6000030000

5. Natural gas (power) marketing and brokering

$

,000.00

6000035000

6. Electricity transmission services

$

,000.00

6000100000

$

,000.00

9900000000

a. Electricity generation (except waste energy generation - incineration at landfill)

Subtotal

4. Natural gas distribution and support services (except marketing and brokering)

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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8

Item 28: Special Items - Exported Energy

CFN:

ITEM 28: SPECIAL ITEMS - EXPORTED ENERGY

Check
if
None
What was the percentage of revenue (reported in Item 5) from exports to customers in Canada and Mexico?

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2022 Whole
percent of
revenue
%

9

Item 28: Special Items - Cost of Electricity

CFN:

ITEM 28: SPECIAL ITEMS - COST OF ELECTRICITY
Check
if
None
1. What was the cost of electricity purchased for resale?
2. What was the revenue from the sale of electricity purchased for resale?
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2022
$

,000.00

$

,000.00

10

Item 28: Special Items - Cost of Natural Gas

CFN:

ITEM 28: SPECIAL ITEMS - COST OF NATURAL GAS
Check
if
None
1. Cost of natural gas purchased for resale
2. Revenue from the sale of natural gas purchased for resale
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

2022
$

,000.00

$

,000.00

11

Item 28: Special Items - New Construction, Including Renovation

CFN:

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION
Was this consolidated reporting unit involved in new construction or renovation of buildings, structures, or communication lines during 2022?
Yes
No

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

12

Item 28: Special Items - New Construction, Including Renovation - Continued

CFN:

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION

2022
1. What were the capital expenditures for new construction, including renovation?
(Include labor and materials. Exclude land and the value of production machinery and equipment not an integral part of a structure.)

Check
if
None
2. What percentage of the capital expenditures reported above represented work done by your own employees as
opposed to work done by contractors or other hired labor?

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

$

,000.00

2022
%

13

Item 28: Special Items - Maintenance and Repair

CFN:

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR
Was this consolidated reporting unit involved in maintenance and repair of buildings, structures, or communication lines owned by your enterprise during 2022?
(Report "No" if expenses were limited to activities such as janitorial services, cleaning, lawn maintenance, etc.)
Yes
No

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

14

Item 28: Special Items - Maintenance and Repair - Continued

CFN:

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR

2022
1. What were your expenses for maintenance and repairs?
(Exclude expenses for such activities as janitorial services, cleaning, lawn maintenance, etc.)

$

Check
if
None
2. What percentage of the expenses for maintenance and repairs reported above represented work done by your own
employees as opposed to work done by contractors or other hired labor?

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

,000.00

2022
%

15

Item 29: Business Technologies

CFN:

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this consolidated reporting unit use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this consolidated reporting unit use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this consolidated reporting unit use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this consolidated reporting unit use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

16

5. In 2022, did this consolidated reporting unit use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots
Yes
No
Do not know
6. In 2022, did this consolidated reporting unit use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

17

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this consolidated reporting unit acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

18

Item 29: Business Technologies - Additive Manufacturing

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this consolidated reporting unit acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

19

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this consolidated reporting unit acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

20

Item 29: Business Technologies - Industrial Robots

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this consolidated reporting unit acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

21

Item 29: Business Technologies - Service Robots

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this consolidated reporting unit acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

22

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

CFN:

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this consolidated reporting unit acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

23

Item 31: Remarks

CFN:

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

1000

characters remaining

24

Item 33: Locations of Operation Additional Information

CFN:

ITEM 33: LOCATIONS OF OPERATION
A. Complete Item 33A: Pre-Identified Locations of Operation (On the Location List that follows, Type will be 'Pre-listed (Item
33A)')
B. Complete Item 33B: Additional Locations of Operation (On the Location List that follows, Type will be 'Added (Item 33B)')
Number of locations
Include:
All locations in operation or temporarily inactive in Item 33A
All locations added in Item 33B
Exclude:
All locations that have ceased operation or were sold
For further clarification, click the "Additional Information" link above.
Check
if
None

2022

What was the total number of locations in operation in 2022?

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

25

Item 33A: Pre-identified Locations of Operation Additional Information

ITEM 33A: PRE-IDENTIFIED LOCATIONS OF OPERATION
LOCATION INFORMATION
We have listed establishments of your company based on Census records. Correct any errors or omissions below.
(P.O. Box and rural route addresses are not physical locations)
Line No.

EIN

NAICS
99-9999999

Major Activity

Name

Secondary Name

Store/Plant Number

Physical Location (Number and Street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

CFN

EMPLOYMENT AND PAYROLL
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.

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January-March 2022)?

,000.00

OPERATIONAL STATUS

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

26

Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

CEASED OPERATION OR SOLD OR LEASED INFORMATION

If this establishment ceased operation or was sold or leased to another operator, what was the date?
MMDDYYYY
MMDDYYYY



If this establishment was sold or leased to another operator, what is the name and address of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

2022_UT-2211A_mu.pdf Generated 2022-02-23 17:13:27

99999-9999

27

Item 33B: Additional Locations of Operation Additional Information

ITEM 33B: ADDITIONAL LOCATIONS OF OPERATION
LOCATION INFORMATION
What is this establishment's physical location?
(P.O. Box and rural route addresses are not physical locations)
EIN
99-9999999

Name

Secondary Name

Store/Plant

Physical Location (Number and Street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Date establishment opened or
is expected to open
MMDDYYYY



CFN

EMPLOYMENT AND PAYROLL
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.

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January-March 2022)?

,000.00

MAJOR ACTIVITY CODE

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28

Select the ACTIVITY CODE that best describes the activity of this establishment and what were the primary products or services?
Activity
Code

Primary products or services
Describe

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

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

Month
Acquired

99999-9999

Year
Acquired

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29

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Electric services
Hydroelectric power generation

221111 001

Fossil fuel electric power generation

221112 001

Nuclear electric power generation

221113 001

Solar electric power generation

221114 001

Wind electric power generation

221115 001

Geothermal electric power generation

221116 001

Biomass electric power generation, except at landfill

221117 001

Other electric power generation (Excludes hydroelectric, fossil fuel, nuclear, solar, wind, geothermal, and biomass.) - Describe

221118 001

Describe
Nonhazardous solid waste combustors and incinerators producing electricity at landfill

562213 002

Hazardous solid waste combustors and incinerators producing electricity at landfill

562211 004

Electric bulk power transmission and control

221121 001

Electric power distribution

221122 001

Electric power marketers and brokers

221122 002

Natural gas distribution and/or natural gas marketing

221210 005

Finance services
523130 002

Commodity trading company
Other primary business or activity

779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating revenue (reported in Item 5) by class of customer?
2022 Whole
percent of
revenue
%

1. Residential (Include apartment buildings.)

2. Commercial (Include farms.)

%

3. Industrial

%

4. Institutional

%

%

5. Government (Exclude utilities.)

6. Government-owned utilities

%

7. Private utilities (Include co-ops, etc.)

%

8. Other

%

Describe

9. TOTAL - Sum of lines 1 through 8 should equal 100%. (Exclude utilities.)

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

%

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

6000075000

1. Electricity generation

a. Electricity generation (except waste energy generation - incineration at landfill)

b. Non-hazardous waste energy generation services (by incineration at landfill)

6000075003

6000075006

6000075009

c. Hazardous waste energy generation services

2. Electricity distribution and support services (except marketing and brokering)

6000125000

6000150000

3. Electricity (power) marketing and brokering

4. Natural gas distribution and support services (except marketing and brokering)

6000030000

6000035000

5. Natural gas (power) marketing and brokering

6000100000

6. Electricity transmission services

7. Transportation of natural gas by pipeline, excluding gas field gathering services

7011150000

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Electricity generation

a. Electricity generation (except waste energy generation - incineration at landfill)

$

,000.00

6000075003

b. Non-hazardous waste energy generation services (by incineration at landfill)

$

,000.00

6000075006

c. Hazardous waste energy generation services

$

,000.00

6000075009

Subtotal

$

,000.00

6000075000

$

,000.00

6000125000

$

,000.00

6000150000

4. Natural gas distribution and support services (except marketing and brokering)

$

,000.00

6000030000

5. Natural gas (power) marketing and brokering

$

,000.00

6000035000

6. Electricity transmission services

$

,000.00

6000100000

7. Transportation of natural gas by pipeline, excluding gas field gathering services

$

,000.00

7011150000

$

,000.00

9900000000

2. Electricity distribution and support services (except marketing and brokering)

3. Electricity (power) marketing and brokering

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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22

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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23

Item 28: Special Items - Exported Energy

ITEM 28: SPECIAL ITEMS - EXPORTED ENERGY

Check
if
None
What was the percentage of revenue (reported in Item 5) from exports to customers in Canada and Mexico?

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

2022 Whole
percent of
revenue
%

24

Item 28: Special Items - Cost of Electricity

ITEM 28: SPECIAL ITEMS - COST OF ELECTRICITY
Check
if
None
1. What was the cost of electricity purchased for resale?
2. What was the revenue from the sale of electricity purchased for resale?
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

2022
$

,000.00

$

,000.00

25

Item 28: Special Items - Cost of Natural Gas

ITEM 28: SPECIAL ITEMS - COST OF NATURAL GAS
Check
if
None
1. Cost of natural gas purchased for resale
2. Revenue from the sale of natural gas purchased for resale
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

2022
$

,000.00

$

,000.00

26

Item 28: Special Items - New Construction, Including Renovation

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION
Was this establishment involved in new construction or renovation of buildings, structures, or communication lines during 2022?
Yes
No

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Item 28: Special Items - New Construction, Including Renovation - Continued

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION

2022
1. What were the capital expenditures for new construction, including renovation?
(Include labor and materials. Exclude land and the value of production machinery and equipment not an integral part of a structure.)

Check
if
None
2. What percentage of the capital expenditures reported above represented work done by your own employees as
opposed to work done by contractors or other hired labor?

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

$

,000.00

2022
%

28

Item 28: Special Items - Maintenance and Repair

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR
Was this establishment involved in maintenance and repair of buildings, structures, or communication lines owned by your enterprise during 2022?
(Report "No" if expenses were limited to activities such as janitorial services, cleaning, lawn maintenance, etc.)
Yes
No

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29

Item 28: Special Items - Maintenance and Repair - Continued

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR

2022
1. What were your expenses for maintenance and repairs?
(Exclude expenses for such activities as janitorial services, cleaning, lawn maintenance, etc.)

$

Check
if
None
2. What percentage of the expenses for maintenance and repairs reported above represented work done by your own
employees as opposed to work done by contractors or other hired labor?

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

,000.00

2022
%

30

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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32

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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33

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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34

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

41

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_UT-22110_su.pdf Generated 2022-02-23 17:08:29

,000.00

42

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Gas production and distribution
Natural gas distribution

221210 003

Natural gas power marketers and brokers

221210 004

Pipeline transportation of natural gas and storage of natural gas

486210 001

Mixed, manufactured, or liquefied petroleum gas production and distribution

221210 002

Electric power distribution and/or electric power marketing

221122 003

Finance services
523130 002

Commodity trading company
Other utility-related activities
Heating/fuel oil dealer

454310 101

Liquefied petroleum (LP) gas dealer

454310 401

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue?
For further clarification, click the "Additional Information" link above.

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating revenue (reported in Item 5) by class of customer?
2022 Whole
percent of
revenue
%

1. Residential (Include apartment buildings.)

2. Commercial (Include farms.)

%

3. Industrial

%

4. Institutional

%

%

5. Government (Exclude utilities.)

6. Government-owned utilities

%

7. Private utilities (Include co-ops, etc.)

%

8. Other

%

Describe

9. TOTAL - Sum of lines 1 through 8 should equal 100%. (Exclude utilities.)

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

%

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Natural gas distribution and support services (except marketing and brokering)

Product Code

6000030000

6000035000

2. Natural gas (power) marketing and brokering

6000075000

3. Electricity generation

a. Electricity generation (except waste energy generation - incineration at landfill)

b. Non-hazardous waste energy generation services (by incineration at landfill)

6000075003

6000075006

6000075009

c. Hazardous waste energy generation services

4. Electricity distribution and support services (except marketing and brokering)

6000125000

6000150000

5. Electricity (power) marketing and brokering

6000100000

6. Electricity transmission services

7. Transportation of natural gas by pipeline, excluding gas field gathering services

7011150000

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Natural gas distribution and support services (except marketing and brokering)

$

,000.00

6000030000

2. Natural gas (power) marketing and brokering

$

,000.00

6000035000

a. Electricity generation (except waste energy generation - incineration at landfill)

$

,000.00

6000075003

b. Non-hazardous waste energy generation services (by incineration at landfill)

$

,000.00

6000075006

c. Hazardous waste energy generation services

$

,000.00

6000075009

$

,000.00

6000075000

4. Electricity distribution and support services (except marketing and brokering)

$

,000.00

6000125000

5. Electricity (power) marketing and brokering

$

,000.00

6000150000

6. Electricity transmission services

$

,000.00

6000100000

7. Transportation of natural gas by pipeline, excluding gas field gathering services

$

,000.00

7011150000

$

,000.00

9900000000

3. Electricity generation

Subtotal

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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22

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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23

Item 28: Special Items - Exported Energy

ITEM 28: SPECIAL ITEMS - EXPORTED ENERGY

Check
if
None
What was the percentage of revenue (reported in Item 5) from exports to customers in Canada and Mexico?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

2022 Whole
percent of
revenue
%

24

Item 28: Special Items - Cost of Electricity

ITEM 28: SPECIAL ITEMS - COST OF ELECTRICITY
Check
if
None
1. What was the cost of electricity purchased for resale?
2. What was the revenue from the sale of electricity purchased for resale?
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

2022
$

,000.00

$

,000.00

25

Item 28: Special Items - Cost of Natural Gas

ITEM 28: SPECIAL ITEMS - COST OF NATURAL GAS
Check
if
None
1. Cost of natural gas purchased for resale
2. Revenue from the sale of natural gas purchased for resale
(Revenue reported here should be less than or equal to the revenue reported in Item 5.)

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

2022
$

,000.00

$

,000.00

26

Item 28: Special Items - New Construction, Including Renovation

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION
Was this establishment involved in new construction or renovation of buildings, structures, or communication lines during 2022?
Yes
No

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27

Item 28: Special Items - New Construction, Including Renovation - Continued

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION

2022
1. What were the capital expenditures for new construction, including renovation?
(Include labor and materials. Exclude land and the value of production machinery and equipment not an integral part of a structure.)

Check
if
None
2. What percentage of the capital expenditures reported above represented work done by your own employees as
opposed to work done by contractors or other hired labor?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

$

,000.00

2022
%

28

Item 28: Special Items - Maintenance and Repair

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR
Was this establishment involved in maintenance and repair of buildings, structures, or communication lines owned by your enterprise during 2022?
(Report "No" if expenses were limited to activities such as janitorial services, cleaning, lawn maintenance, etc.)
Yes
No

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29

Item 28: Special Items - Maintenance and Repair - Continued

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR

2022
1. What were your expenses for maintenance and repairs?
(Exclude expenses for such activities as janitorial services, cleaning, lawn maintenance, etc.)

$

Check
if
None
2. What percentage of the expenses for maintenance and repairs reported above represented work done by your own
employees as opposed to work done by contractors or other hired labor?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

,000.00

2022
%

30

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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31

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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32

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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33

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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34

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

41

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_UT-22120_su.pdf Generated 2022-02-23 17:10:04

,000.00

42

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Water, sewerage, and other systems
Water supply and water treatment, except irrigation

221310 003

Irrigation system

221310 001

Sewerage system, including sewage treatment plant

221320 001

Steam or air-conditioning supply, including geothermal

221330 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue?
For further clarification, click the "Additional Information" link above.

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating revenue (reported in Item 5) by class of customer?
2022 Whole
percent of
revenue
%

1. Residential (Include apartment buildings.)

2. Commercial (Include farms.)

%

3. Industrial

%

4. Institutional

%

%

5. Government (Exclude utilities.)

6. Government-owned utilities

%

7. Private utilities (Include co-ops, etc.)

%

8. Other

%

Describe

9. TOTAL - Sum of lines 1 through 8 should equal 100%. (Exclude utilities.)

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%

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Water supply and sewage treatment services (including waste water treatment)

a. Water supply, transmission, treatment, and distribution, including water supply through irrigation systems

Product Code

6000175000

6000175003

6000175006

b. Sewage treatment

6000050000

2. Steam distribution services, including air-conditioning

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Water supply and sewage treatment services (including waste water treatment)

a. Water supply, transmission, treatment, and distribution, including water supply through irrigation systems

$

,000.00

6000175003

b. Sewage treatment

$

,000.00

6000175006

Subtotal

$

,000.00

6000175000

2. Steam distribution services, including air-conditioning

$

,000.00

6000050000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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22

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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23

Item 28: Special Items - New Construction, Including Renovation

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION
Was this establishment involved in new construction or renovation of buildings, structures, or communication lines during 2022?
Yes
No

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24

Item 28: Special Items - New Construction, Including Renovation - Continued

ITEM 28: SPECIAL ITEMS - NEW CONSTRUCTION, INCLUDING RENOVATION

2022
1. What were the capital expenditures for new construction, including renovation?
(Include labor and materials. Exclude land and the value of production machinery and equipment not an integral part of a structure.)

Check
if
None
2. What percentage of the capital expenditures reported above represented work done by your own employees as
opposed to work done by contractors or other hired labor?

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

$

,000.00

2022
%

25

Item 28: Special Items - Maintenance and Repair

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR
Was this establishment involved in maintenance and repair of buildings, structures, or communication lines owned by your enterprise during 2022?
(Report "No" if expenses were limited to activities such as janitorial services, cleaning, lawn maintenance, etc.)
Yes
No

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26

Item 28: Special Items - Maintenance and Repair - Continued

ITEM 28: SPECIAL ITEMS - MAINTENANCE AND REPAIR

2022
1. What were your expenses for maintenance and repairs?
(Exclude expenses for such activities as janitorial services, cleaning, lawn maintenance, etc.)

$

Check
if
None
2. What percentage of the expenses for maintenance and repairs reported above represented work done by your own
employees as opposed to work done by contractors or other hired labor?

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

,000.00

2022
%

27

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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28

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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29

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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30

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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31

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

38

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_UT-22130_su.pdf Generated 2022-02-23 17:11:49

,000.00

39

Attachment D-4
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 23

Attachment Sector

D-4

23

Instrument
Path
Instrument Path Title

23610
23810
23830
23890

Residential and Nonresidential Building Construction
Foundation, Structure, and Building Exterior Contractors
Building Finishing Contractors
Other Specialty Trade Contractors

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is a construction establishment which is generally a permanent office, payroll office, or other place where business activities related to
construction are conducted. A construction establishment manages one or more projects or jobs and is usually maintained on a continuing basis.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Temporary construction site

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

New single-family housing construction (excluding for-sale builders), including attached and detached housing

236115 001

New multifamily housing construction (excluding for-sale builders), including apartments and condominiums

236116 001

New housing for-sale builder of single-family housing and multifamily housing

236117 001

Residential remodeler for home improvement (e.g., adding on, renovating, maintenance, and repair), including remodeling homes for resale

236118 001

Industrial building construction (e.g., processing and assembly plants, factories, refineries, waste disposal facilities), excluding warehouses
and sewage disposal plants

236210 001

Commercial and institutional building construction (e.g., office and school buildings, hospitals, health and data facilities, stores, and
warehouses)

236220 001

Water and sewer line and related structures construction (e.g., mains, sewage disposal plants, pumping stations, and water well drilling)

237110 001

Oil and gas pipeline and related structures construction (e.g., mains, petrochemical plants, pumping stations, and oil refineries)

237120 001

Power and communication line and related structures construction (e.g., alternative energy structures, power plants, transformer stations,
high voltage transmission cable connections, and cellular phone towers)

237130 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Highway, street, and bridge construction, including curbs, airport runway construction, and line painting of streets and parking lots

237310 001

Other heavy and civil engineering construction (e.g., tunnels, railways, outside recreation areas, dams, flood and drainage control projects,
dredging, trenching, and marine facilities)

237990 001

Poured concrete foundation and structure contractor (e.g., shotcrete, mud-jacking, gunning, gunite, pumping, and placement footing)

238110 001

Structural steel and precast concrete contractor, including structural iron work

238120 001

Framing contractor, including wood and steel (excluding structural steel or precast concrete)

238130 001

Masonry contractor (e.g., brick, stone, slate, glass block, cement, cinder blocking, stucco setting and other stone work)

238140 001

Glass and glazing contractor (e.g., glass coating and tinting (excluding automotive), window pane, glass sheet, glass curtain wall, and mirror
installation)

238150 001

Roofing contractor, including treating roofs (i.e., spraying, painting or coating) and skylight installation

238160 001

Siding contractor (e.g., gutters, downspouts, fascia, soffit, eavestrough, flashing, and ice apron)

238170 001

Other foundation, structure, and building exterior contractor (e.g., awning, metal balcony and stairway, and falsework construction), including
decorative steel and wrought iron work; poured concrete form installation and dismantling; and welding at site

238190 001

Electrical and other wiring installation contractor (e.g., electronic and environmental controls, telecommunications and fiber optic equipment
(excluding transmission line), solar panel installation, traffic signals, and fire and security systems)

238210 001

Plumbing, heating, and air-conditioning (HVAC) contractor, including installation, maintenance, and repair of refrigeration systems, sprinkler
systems, water systems, gas and oil line individual hookups, and steam and pipe fittings

238220 001

Other building equipment contractor (e.g., millwrights, machine rigging), including installation, maintenance, and repair of ATM equipment,
elevators, escalators, service station gasoline pumps, commercial and industrial doors)

238290 001

Drywall and insulation contractor, including acoustical, plastering, and fireproofing contractors

238310 001

Painting and wall covering contractor, including on-site electrostatic painting, whitewashing, and rustproofing of buildings, ships, bridges,
tanks, and towers (excluding automotive)

238320 001

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15

Flooring contractor (e.g., laying carpet, linoleum, hardwood, laminate, and vinyl flooring), excluding fireproof, stone, concrete, and ceramic
tile flooring

238330 001

Tile and terrazzo contractor (e.g., marble, granite, slate, ceramic, stone, and mosaic work for floors, walls, and ceilings), excluding exterior
marble, granite, and slate work

238340 001

Finish carpentry contractor (e.g., door, window, cabinetry, countertop, stairway, deck, molding, trim, and paneling work, residential-type,
installation), excluding framing

238350 001

Other building finishing contractor (e.g., waterproofing, spectator seating, modular furniture system attachments, closet organizer systems,
concrete coating, window shades and blinds, and trade show exhibit installation and dismantling)

238390 001

Site preparation contractor, without land subdivision (e.g., land clearing, drilling, demolition, trenching, and earthmoving), and rental of
construction equipment with operators (excluding cranes))

238910 001

All other specialty trade contractor (e.g., driveway paving; constructions of residential and commercial parking lots, sidewalks, patios, and
outdoor swimming pools; installation of fences (excluding electric) and playground equipment; and crane rental with operator)

238990 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Include:
Receipts (or billings) derived from contract construction work done for others
Sales of houses and other buildings you built and sold
Construction management and design-build contracts
Site preparation receipts, such as land clearing, laying roads, installing utilities, and subdividing land into lots (Exclude purchase cost of land or estimated value of raw land for
construction projects.)
Architectural services, except the design portion of integrated design-build contracts
Engineering services
Rental or lease of properties
Real estate commissions and property management fees
Rental of construction machinery or equipment to others, without an operator
Manufacturing, mining, and transportation activities
Retail and wholesale trades
Other business activities
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building structure)
Purchased cost of land or estimated value of raw land for construction projects (Include site preparation receipts.)
Non-operating income such as interest, dividends, or the sale of fixed assets.
What were the receipts for all business activities done by this establishment, including receipts, billings, or sales for
construction work? (Construction work includes new construction and remodeling as well as maintenance and repair
work. The activities of prime and trade contractors are considered to be construction. Some trades not traditionally
thought of as construction are included such as land subdivision, excavation, building demolition, painting, carpet-laying,
water well drilling, plumbing and electrical work.)

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

Check
if
None

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Number of employees at this establishment
Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
If the legal form of organization for this business is a corporation, the reporting of other employees and other payroll at this establishment is required. Enter "0" if the establishment
did not have payroll and employment for specific data for this EIN. If payroll and employment for this EIN are zero, please indicate if the EIN is a joint venture or reason why data
are zero in Item 31: Remarks at the end of the survey.
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Spread on stock options that are taxable to employees at this establishment as wages
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company’s EIN (Report values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line C1.)
Contractors, subcontractors, or independent contractors
Purchased or managed services, such as janitorial, security, or landscape services (Report values in Item 16, line C9.)
Purchased professional and technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services (Report
values in Item 16, line C9.)
Members of the Armed Forces and pensioners carried on your active rolls
Proprietors and partners, if an unincorporated concern
Number of construction workers at this establishment include:
Apprentices
Working foremen
Equipment operators and mechanics
Journeymen
Job-site record keepers
Craftsmen
Laborers
Truck drivers and helpers
Others engaged directly in construction
Number of other employees at this establishment include:
Supervisors above working foremen
Office staff
Executives
Architects
Purchasing Agents
Personnel staff
Engineers
Accounting staff
Others engaged in non-construction activities
A. Number of employees at this establishment for the pay period including the 12th of the month.
March 2022

June 2022

September 2022

December 2022

1. What was the number of construction workers
(direct labor including first-line supervisors)?

2. What was the number of other employees?

TOTAL (Add lines A1 and A2.)

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

20

B. HOURS WORKED
Check
if
None

2022 Hours

What was the annual number of hours worked by the construction workers at this establishment (direct labor
including first-line supervisors) reported in line A?

,000

C. PAYROLL
Include:
Payroll for officers at this establishment
Exclude:
Income or costs not recorded as payroll for IRS by establishment.
Employer-paid annual cost for fringe benefits reported in lines 7D1 and 7D2
Check
if
None

2022

1. What was the annual payroll at this establishment before deductions for construction workers (direct labor
including first-line supervisors)?

$

,000.00

2. What was the annual payroll before deductions for other employees?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $0,000.00 reported above, what was the first quarter payroll at this establishment before deductions
(January-March 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits
Check
if
None

2022

1. What were the legally required fringe benefits? (Include employer payments for Social Security, Medicare,
unemployment compensation, workmen's compensation, and State disability programs, if required.)

$

,000.00

2. What were the voluntarily provided fringe benefits? (Include such items as payments for life insurance, medical
insurance, pensions, welfare benefits, and union-negotiated benefits.)

$

,000.00

TOTAL (Add lines D1 and D2.)

$

,000.00

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21

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Include:
Inventories, regardless of where held, for materials and supplies owned by this establishment as of December 31
Exclude:
Work-in-progress and finished units

Using current cost, what was the value of inventories owned
by this establishment as of December 31? (If using LIFO
method of evaluation, adjust to obtain FIFO or current cost.)

Check
if
None

2022
$

2021
,000.00

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

$

,000.00

22

Item 13: Assets, Capital Expenditures, and Retirements Additional Information

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS
Exclude
Land (Report cost of land acquired during the year in Item 16A, line 5.)

Check
if
None

2022
$

,000.00

B. What were the capital expenditures for new and used depreciable assets?

$

,000.00

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc.?

$

,000.00

D. What was the value of depreciable assets at the end of the year? (Add lines A and B minus line C.)

$

,000.00

A. What was the gross value of depreciable assets (usually original cost) at the beginning of the year?

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

23

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production, loading, and transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles
Exclude:
Computer time-sharing charges for machinery and equipment rentals from computer service companies where
the computer is not on site at the establishment

TOTAL (Add lines A and B.)

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24

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
A. For this establishment, what were the cost of materials, subcontract work, fuels, electricity, and land acquired in 2022 for:
Include:
Current account expenses normally considered as cost of work performed or job-specific costs

1. Cost of materials, parts, and supplies?
Include:
All job-site, office, and construction materials and supplies
Cost of materials purchased by this establishment's subcontractors
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building
structure)
Non-construction-related expenses that were paid to subcontractors by this establishment (Report these
expense details on the next screen, Item 16: Selected Expenses - Continued, in line C.)

Check
if
None

2022
$

,000.00

$

,000.00

a. Natural gas and manufactured gas (propane)?

$

,000.00

b. Gasoline and diesel fuel - ON highway (not at site)?

$

,000.00

c. Gasoline and diesel fuel - OFF highway (at site)?

$

,000.00

$

,000.00

$

,000.00

2. Cost of construction-related work subcontracted out to others?
Exclude:
Cost of materials purchased by this establishment for subcontractors (These costs should be reported in line
A1.)

Check
if
None

3. Cost of fuels for heat, power, lubricants
Check
if
None

d. All other fuels and lubricants, including heating oils, lubricating oils, and greases?

Check
if
None
4. Cost of electricity?

5. When you answered Item 5, did you include the purchased cost of land or estimated value of raw land? Please check one, and answer the below question.
Yes
No

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

25

Check
if
None
6. What was the purchased cost of land or estimated value of raw land for reported construction projects during the
covered time?

$

,000.00

$

,000.00

Check
if
None
B. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

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26

Item 16: Selected Expenses - Continued Additional Information

ITEM 16: SELECTED EXPENSES

C. What were the other operating expenses paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services your establishment paid to the Professional Employer
Organizations for the temporary staff and leased employees

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report on line C3.)
Leased and rented equipment (Report on Item 14, line B.)

3. Expensed purchases of software? (Purchases of prepackaged, custom coded or vendor customized software)
Include
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Other wired and wireless communication services
Credit card transaction fees

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

27

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data Storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other establishments of this company (such as a separate central data processing
unit)
Expensed integrated systems (Report in line C4.)
Repair and maintenance of computer equipment (Report in line C6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in line C9 and credit
card transaction fees in line C4.)
Expenses for telecommunication services (e.g., Internet, connectivity, telephone) (Report in line C4.)

$

,000.00

Exclude
Materials, parts, and supplies used for repairs and maintenance performed by this firm's employees

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments in Item 16, line A4. If the cost of these utilities is included in a leased or rental
payment, report in Item 14, line A.)
Include:
Cost of hazardous waste removal

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?

8. Purchased advertising and promotional services?
Include:
Marketing and public relations services
Exclude:
Salaries paid to employees of this establishment for advertising work

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other Professional services (i.e. such as janitorial, security, or landscape services)
Exclude:
Salaries paid to your own employees for these services (Report in Item 7.)

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28

10. Governmental taxes and licensing fees?(Payments to government agencies for taxes and licenses)
Include:
Business and property tax fees for establishment to remain active legal operable business
Permits and licensing fees
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?

Include:
Expenses for paid temporary day labors not on your payroll or hired as construction subcontractors
Exclude:
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

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29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included? Select ALL that apply.
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
The construction project types listed below are general to your industry. Select the project types that apply to your establishment. On the next screen, you will report the specific
construction products and services related to the construction projects you select. If you have revenue from other sources not listed, you will have the opportunity to report them later.
At-risk construction project management revenue should be reported with the specific construction project associated with those management services. For example, if at-risk
construction project management is for office buildings, then include the management revenue with the project for office buildings. However, at-fee project management services
should be reported in the specific project for construction project management services.
Description

Select

Amusement, social, and recreational building construction

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

Commercial warehouses, such as distribution buildings and mini-storage

Project Code

334

322

359

327

319

Dormitories and barracks

329

Educational building construction

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

323

333

Farm building construction, nonresidential

331

Health care and institutional building construction

324

Hotel, motel, and inn construction

321

Industrial warehouse construction

Nonresidential mobile building construction, office and other commercial

335

325

Office building construction

332

Public safety building construction

328

Religious building construction

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

30

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

326

336

338

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

318

314

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

317

316

Single detached residential building construction

346

Bridge and elevated highway

Conservation and development construction, including dams, drainage canals, and flood control projects

368

378

Fencing

373

Harbor and port facilities

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

341

357

Hydroelectric power plants

Oil and gas pipelines, pumping stations, storage tanks, and mains

353

364

Petrochemical plant and petroleum refinery construction

Power and cogeneration plant construction, except hydroelectric construction

Power and communication transmission line, cable, tower, and related facilities

Private driveway and parking area construction, except garages

356

354

343

361

Sewage and water treatment plants

Sewers, sewer lines, septic systems, and related facilities

351

375

Swimming pools

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

31

347

Tunnels

352

Water mains, storage wells, and related facilities

395

Other nonresidential constructions, except buildings

Other specialized cleaning services, not elsewhere classified

399

376

Residential decks

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks

Project management services, except at-risk, for building and non-building projects

377

313

Add product/service not listed

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32

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services associated with the construction projects you previously selected. If you have revenue from sources not listed, describe and report them in the
"All other sales, shipments, receipts, or revenue from this establishment" section at the end of this question.
At-risk construction project management revenue should be reported with the specific constructions or construction services associated with those management services. For
example, if at-risk construction project management is for entire office building constructions, then include the management revenue with the new constructions for office buildings.
However, at-fee project management services should be reported in the specific product lines for construction project management services.
New Constructions and Construction Services – Report only the main activities including the type of buildings, structures, or facilities contracted to construct or work on by this
establishment in the reporting year in which this establishment received receipts only. If you worked on more than one type of building or structure in a multipurpose complex, report
separately for each building or type of structure. However, if you worked on a building that had more than one purpose, i.e. office, residential, or commercial, classify this building by
its major purpose.
New constructions include all components of the entire original building or structure. Land development work on the site and demolition of existing structures are included with
new constructions.
Construction services for new building or structures include separate components of the original building or structure, such as electric work, painting, plumbing, etc.
Construction services for additions, renovations, and alterations to buildings or structures include construction work which adds to the value of useful life of an existing
building or structure, or which adapts a building or structure to a new or different use. Included are “major replacements” of building systems such as the installation of a new
roof or heating system, and the resurfacing of streets or highways. Exclude activities such as the repair of a hole in a roof or the routine patching of highways and streets, which
are classified as “maintenance and repair work”.
Construction services for maintenance and repair of buildings or structures include incidental construction work that keeps a property in ordinary working condition.
Exclude trash and snow removal, lawn maintenance, and janitorial services.

Description

Value

Product Code

Amusement, social, and recreational building construction
1. Amusement, social, and recreational building new constructions (by builders and at-risk project managers)

$

,000.00

3000875000

2. Construction services for new amusement, social, and recreational buildings

$

,000.00

3001350000

3. Construction services for additions, renovations, and alterations to amusement, social, and recreational buildings

$

,000.00

3001750000

4. Construction services for maintenance and repair of amusement, social, and recreational buildings

$

,000.00

3002150000

5. Apartment building (two or more units) new constructions, excluding condominiums (by builders and at-risk project
managers)

$

,000.00

3000625000

6. Construction services for new apartment buildings (two or more units), excluding condominiums

$

,000.00

3001050000

7. Construction services for additions, renovations, and alterations to apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001075000

8. Construction services for maintenance and repair of apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001100000

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

33

9. Chemical (except petrochemical) complex/plant, blast furnace, and mining appurtenance new constructions (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002600000

10. Construction services for new chemical (except petrochemical) complexes/plants, blast furnaces, and mining
appurtenances

$

,000.00

3003250000

11. Construction services for additions, renovations, and alterations to chemical (except petrochemical)
complexes/plants, blast furnaces, and mining appurtenances

$

,000.00

3003900000

12. Construction services for maintenance and repair of chemical (except petrochemical) complexes/plants, blast
furnaces, and mining appurtenances

$

,000.00

3004550000

13. Commercial warehouse new constructions, such as distribution buildings and mini-storage (by builders and at-risk
project managers)

$

,000.00

3000750000

14. Construction services for new commercial warehouses, such as distribution buildings and mini-storage

$

,000.00

3001225000

15. Construction services for additions, renovations, and alterations to commercial warehouses, such as distribution
buildings and mini-storage

$

,000.00

3001625000

16. Construction services for maintenance and repair of commercial warehouses, such as distribution buildings and
mini-storage

$

,000.00

3002025000

17. Educational institution dormitories new constructions (by builders and at-risk project mangers)

$

,000.00

3001005000

18. Military and other public safety dormitories and barracks new constructions (by builders and at-risk project
managers)

$

,000.00

3001010000

$

,000.00

3001480000

20. Construction services for new military and other public safety dormitories and barracks

$

,000.00

3001485000

21. Construction services for additions, renovations, and alterations to educational institution dormitories

$

,000.00

3001880000

22. Construction services for additions, renovations, and alterations to military and other public safety dormitories and
barracks

$

,000.00

3001885000

$

,000.00

3002280000

$

,000.00

3002285000

25. Educational building new constructions (by builders and at-risk project managers)

$

,000.00

3000825000

26. Construction services for new educational buildings

$

,000.00

3001300000

Commercial warehouses, such as distribution buildings and mini-storage

Dormitories and barracks

19. Construction services for new educational institution dormitories

23. Construction services for maintenance and repair of educational institution dormitories

24. Construction services for maintenance and repair of military and other public safety dormitories and barracks

Educational building construction

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

34

27. Construction services for additions, renovations, and alterations to educational buildings

$

,000.00

3001700000

28. Construction services for maintenance and repair of educational buildings

$

,000.00

3002100000

29. Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building new
constructions (by builders and at-risk project managers)

$

,000.00

3000700000

30. Construction services for new factories, assembly plants, industrial research laboratories, and other new
manufacturing and industrial buildings

$

,000.00

3001175000

31. Construction services for additions, renovations, and alterations to factories, assembly plants, industrial research
laboratories, and other manufacturing and industrial buildings

$

,000.00

3001575000

32. Construction services for maintenance and repair of factories, assembly plants, industrial research laboratories, and
other manufacturing and industrial buildings

$

,000.00

3001975000

$

,000.00

3000975000

$

,000.00

3001450000

35. Construction services for additions, renovations, and alterations to farm buildings, nonresidential

$

,000.00

3001850000

36. Construction services for maintenance and repair of farm buildings, nonresidential

$

,000.00

3002250000

$

,000.00

3000850000

$

,000.00

3001325000

39. Construction services for additions, renovations, and alterations to health care and institutional buildings

$

,000.00

3001725000

40. Construction services for maintenance and repair of health care and institutional buildings

$

,000.00

3002125000

41. Hotel, motel, and inn new constructions (by builders and at-risk project managers)

$

,000.00

3000650000

42. Construction services for new hotels, motels, and inns

$

,000.00

3001125000

43. Construction services for additions, renovations, and alterations to hotels, motels, and inns

$

,000.00

3001525000

44. Construction services for maintenance and repair of hotels, motels, and inns

$

,000.00

3001925000

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

Farm building construction, nonresidential
33. Farm building new constructions, nonresidential (by builders and at-risk project managers)

34. Construction services for new farm buildings, nonresidential

Health care and institutional building construction
37. Health care and institutional buildings new constructions (by builders and at-risk project managers)

38. Construction services for new health care and institutional buildings

Hotel, motel, and inn construction

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

35

Industrial warehouse construction
45. Industrial warehouse new constructions at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000680000

46. Industrial warehouse new constructions not at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000685000

47. Construction services for new industrial warehouses at manufacturing sites

$

,000.00

3001155000

48. Construction services for new industrial warehouses not at manufacturing sites

$

,000.00

3001160000

49. Construction services for additions, renovations, and alterations to industrial warehouses at manufacturing sites

$

,000.00

3001555000

50. Construction services for additions, renovations, and alterations to industrial warehouses not at manufacturing sites

$

,000.00

3001560000

51. Construction services for maintenance and repair of industrial warehouses at manufacturing sites

$

,000.00

3001955000

$

,000.00

3001960000

53. Nonresidential mobile building new constructions, office (by builders and at-risk project managers)

$

,000.00

3000930000

54. Nonresidential mobile building new constructions, other commercial (by builders and at-risk project managers)

$

,000.00

3000935000

55. Construction services for new nonresidential mobile building constructions, office

$

,000.00

3001405000

56. Construction services for new nonresidential mobile building constructions, other commercial

$

,000.00

3001410000

57. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
office

$

,000.00

3001805000

58. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
other commercial

$

,000.00

3001810000

59. Construction services for maintenance and repair of nonresidential mobile building constructions, office

$

,000.00

3002205000

60. Construction services for maintenance and repair of nonresidential mobile building constructions, other commercial

$

,000.00

3002210000

61. Office building and data center new constructions (by builders and at-risk project managers)

$

,000.00

3000725000

62. Construction services for new office buildings and data centers

$

,000.00

3001200000

63. Construction services for additions, renovations, and alterations to office buildings and data centers

$

,000.00

3001600000

52. Construction services for maintenance and repair of industrial warehouses not at manufacturing sites

Nonresidential mobile building construction, office and other commercial

Office building construction

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

36

64. Construction services for maintenance and repair of office buildings and data centers

$

,000.00

3002000000

65. Public safety building new constructions (by builders and at-risk project managers)

$

,000.00

3000900000

66. Construction services for new public safety buildings

$

,000.00

3001375000

67. Construction services for additions, renovations, and alterations to public safety buildings

$

,000.00

3001775000

68. Construction services for maintenance and repair of public safety buildings

$

,000.00

3002175000

$

,000.00

3000800000

70. Construction services for new religious buildings

$

,000.00

3001275000

71. Construction services for additions, renovations, and alterations to religious buildings

$

,000.00

3001675000

72. Construction services for maintenance and repair of religious buildings

$

,000.00

3002075000

73. Store, restaurant, automobile service station, parking garage, and other commercial building new constructions
(excluding mobile buildings)(by builders and at-risk project managers)

$

,000.00

3000775000

74. Construction services for new stores, restaurants, automobile service stations, parking garages, and other
commercial buildings (excluding mobile buildings)

$

,000.00

3001250000

75. Construction services for additions, renovations, and alterations to stores, restaurants, automobile service stations,
parking garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3001650000

76. Construction services for maintenance and repair of stores, restaurants, automobile service stations, parking
garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3002050000

77. Nonresidential mobile building new constructions, classroom (by builders and at-risk project managers)

$

,000.00

3000955000

78. Nonresidential mobile building new constructions, industrial (by builders and at-risk project managers)

$

,000.00

3000960000

79. Construction services for new nonresidential mobile building constructions, classroom

$

,000.00

3001430000

80. Construction services for new nonresidential mobile building constructions, industrial

$

,000.00

3001435000

81. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, classrooms

$

,000.00

3001830000

Public safety building construction

Religious building construction
69. Religious building new constructions (by builders and at-risk project managers)

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

37

82. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, industrial

$

,000.00

3001835000

83. Construction services for maintenance and repair of other nonresidential mobile building constructions, classrooms

$

,000.00

3002230000

84. Construction services for maintenance and repair of other nonresidential mobile building constructions, industrial

$

,000.00

3002235000

85. All other nonresidential building new constructions (by builders and at-risk project managers)

$

,000.00

3001025000

86. Construction services for all other new nonresidential buildings

$

,000.00

3001500000

87. Construction services for additions, renovations, and alterations to all other nonresidential buildings

$

,000.00

3001900000

88. Construction services for maintenance and repair of all other nonresidential buildings

$

,000.00

3002300000

89. Constructions of new apartment type condominiums, excluding single family condominiums (by builders and at-risk
project managers)

$

,000.00

3000100000

90. Construction services for new apartment type condominiums, excluding single family condominiums

$

,000.00

3000200000

91. Construction services for additions, renovations, and alterations to apartment type condominiums, excluding single
family condominiums

$

,000.00

3000300000

92. Construction services for maintenance and repair of apartment type condominiums, excluding single family
condominiums

$

,000.00

3000400000

93. Constructions of new manufactured (mobile) homes, all width sizes (including multisection) (by builders and at-risk
project managers)

$

,000.00

3000075000

94. Construction services for new manufactured homes (mobile homes), all width sizes (including multisection)

$

,000.00

3000175000

95. Construction services for additions, renovations, and alterations to manufactured homes (mobile homes), all width
sizes (including multisection)

$

,000.00

3000275000

96. Construction services for maintenance and repair of manufactured homes (mobile homes), all width sizes (including
multisection)

$

,000.00

3000375000

97. Constructions of new single attached residential buildings, including row houses and town houses (by builders and
at-risk project managers)

$

,000.00

3000050000

98. Construction services for new single attached residential buildings, including row houses and town houses

$

,000.00

3000150000

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

38

99. Construction services for additions, renovations, and alterations to single attached residential buildings, including
row houses and town houses

$

,000.00

3000250000

100. Construction services for maintenance and repair of single attached residential buildings, including row houses and
town houses

$

,000.00

3000350000

101. Constructions of new single detached residential buildings (by builders and at-risk project managers)

$

,000.00

3000025000

102. Construction services for new single detached residential buildings

$

,000.00

3000125000

103. Construction services for additions, renovations, and alterations to single detached residential buildings

$

,000.00

3000225000

104. Construction services for maintenance and repair of single detached residential buildings

$

,000.00

3000325000

105. Bridge and elevated highway new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002375000

106. Construction services for new bridges and elevated highways

$

,000.00

3003025000

107. Construction services for additions, renovations, and alterations to bridges and elevated highways

$

,000.00

3003675000

108. Construction services for maintenance and repair of bridges and elevated highways

$

,000.00

3004325000

109. Conservation and development new constructions, including dams, drainage canals, and flood control projects (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002650000

110. Construction services for new conservation and development constructions, including dams, drainage canals, and
flood control projects

$

,000.00

3003300000

111. Construction services for additions, renovations, and alterations to conservation and development constructions,
including dams, drainage canals, and flood control projects

$

,000.00

3003950000

112. Construction services for maintenance and repair of conservation and development constructions, including dams,
drainage canals, and flood control projects

$

,000.00

3004600000

$

,000.00

3002825000

$

,000.00

3003475000

115. Construction services for additions, renovations, and alterations to fencing constructions

$

,000.00

3004125000

116. Construction services for maintenance and repair of fencing constructions

$

,000.00

3004750000

Single detached residential building construction

Bridge and elevated highway

Conservation and development construction, including dams, drainage canals, and flood control projects

Fencing
113. Fencing new constructions (by heavy construction contractors and at-risk project managers)

114. Construction services for new fencing constructions

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

39

Harbor and port facilities
117. Harbor and port facilities new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002725000

118. Construction services for new harbor and port facilities

$

,000.00

3003375000

119. Construction services for additions, renovations, and alterations to harbor and port facilities

$

,000.00

3004025000

120. Construction services for maintenance and repair of harbor and port facilities

$

,000.00

3004675000

121. Highway, street, and related work new constructions, including public sidewalks, curbs, guardrails and signs (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002325000

122. Construction services for new highways, streets, and related work, including public sidewalks, curbs, guardrails
and signs

$

,000.00

3002975000

123. Construction services for additions, renovations, and alterations to highways, streets, and related works, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3003625000

124. Construction services for maintenance and repair of highways, streets, and related work constructions, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3004275000

$

,000.00

3002575000

$

,000.00

3003225000

$

,000.00

3003875000

$

,000.00

3004525000

$

,000.00

3002500000

$

,000.00

3003150000

131. Construction services for additions, renovations, and alterations to oil and gas pipelines, pumping stations, storage
tanks, and mains

$

,000.00

3003800000

132. Construction services for maintenance and repair of oil and gas pipelines, pumping stations, storage tanks, and
mains

$

,000.00

3004450000

$

,000.00

3002625000

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

Hydroelectric power plants
125. Power plant new constructions, hydroelectric (by heavy construction contractors and at-risk project managers)

126. Construction services for new power plants, hydroelectric

127. Construction services for additions, renovations, and alterations to power plants, hydroelectric

128. Construction services for maintenance and repair of power plants, hydroelectric

Oil and gas pipelines, pumping stations, storage tanks, and mains
129. Oil and gas pipeline, pumping station, storage tank, and main new constructions (by heavy construction
contractors and at-risk project managers)
130. Construction services for new oil and gas pipelines, pumping stations, storage tanks, and mains

Petrochemical plant and petroleum refinery construction
133. Petrochemical plant and petroleum refinery new constructions (by heavy construction contractors and at-risk
project managers)

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

40

134. Construction services for new petrochemical plants and petroleum refineries

$

,000.00

3003275000

$

,000.00

3003925000

$

,000.00

3004575000

$

,000.00

3002550000

$

,000.00

3003200000

$

,000.00

3003850000

$

,000.00

3004500000

141. Power and communication transmission line, cable, tower, and related facilities new constructions (by heavy
construction contractors and at-risk project managers)

$

,000.00

3002525000

142. Construction services for new power and communication transmission lines, cables, towers, and related facilities

$

,000.00

3003175000

143. Construction services for additions, renovations, and alterations to power and communication transmission lines,
cables, towers, and related facilities

$

,000.00

3003825000

144. Construction services for maintenance and repair of power and communication transmission lines, cables, towers,
and related facilities

$

,000.00

3004475000

145. Private driveway and parking area new constructions, except garages (by heavy construction contractors and atrisk project managers)

$

,000.00

3002350000

146. Construction services for new private driveways and parking areas, excluding garages

$

,000.00

3003000000

147. Construction services for additions, renovations, and alterations to private driveways and parking areas, excluding
garages

$

,000.00

3003650000

148. Construction services for maintenance and repair of private driveways and parking areas, excluding garages

$

,000.00

3004300000

149. Sewage and water treatment plant new constructions(by heavy construction contractors and at-risk project
managers)

$

,000.00

3002475000

150. Construction services for new sewage and water treatment plants

$

,000.00

3003125000

135. Construction services for additions, renovations, and alterations to petrochemical plants and petroleum refineries

136. Construction services for maintenance and repair of petrochemical plants and petroleum refineries

Power and cogeneration plant construction, except hydroelectric construction
137. Power and cogeneration plant new constructions, except hydroelectric (by heavy construction contractors and atrisk project managers)
138. Construction services for new power and cogeneration plants, except hydroelectric

139. Construction services for additions, renovations, and alterations to power and cogeneration plants, except
hydroelectric
140. Construction services for maintenance and repair of power and cogeneration plants, except hydroelectric

Power and communication transmission line, cable, tower, and related facilities

Private driveway and parking area construction, except garages

Sewage and water treatment plants

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

41

151. Construction services for additions, renovations, and alterations to sewage and water treatment plants

$

,000.00

3003775000

152. Construction services for maintenance and repair of sewage and water treatment plants

$

,000.00

3004425000

153. Sewer, sewer line, septic system, and related facilities new constructions (by heavy construction contractors and
at-risk project managers)

$

,000.00

3002425000

154. Construction services for new sewers, sewer lines, septic systems, and related facilities

$

,000.00

3003075000

155. Construction services for additions, renovations, and alterations to sewers, sewer lines, septic systems, and
related facilities

$

,000.00

3003725000

156. Construction services for maintenance and repair of sewers, sewer lines, septic systems, and related facilities

$

,000.00

3004375000

$

,000.00

3002775000

$

,000.00

3003425000

$

,000.00

3004075000

$

,000.00

3002400000

$

,000.00

3003050000

$

,000.00

3003700000

$

,000.00

3004350000

$

,000.00

3002450000

$

,000.00

3003100000

$

,000.00

3003750000

$

,000.00

3004400000

Sewers, sewer lines, septic systems, and related facilities

Swimming pools
157. Swimming pool new constructions (by builders and at-risk project managers)

158. Construction services for new swimming pools

159. Construction services for additions, renovations, and alterations to swimming pools

Tunnels
160. Tunnel new constructions (by heavy construction contractors and at-risk project managers)

161. Construction services for new tunnels

162. Construction services for additions, renovations, and alterations to tunnels

163. Construction services for maintenance and repair of tunnels

Water mains, storage wells, and related facilities
164. Water main, storage, well, and related facilities new constructions (by heavy construction contractors and at-risk
project managers)
165. Construction services for new water mains, storage, wells, and related facilities

166. Construction services for additions, renovations, and alterations to water mains, storage, wells, and related
facilities
167. Construction services for maintenance and repair of water mains, storage, wells, and related facilities

Other nonresidential constructions, except buildings

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

42

168. Other nonresidential new constructions, except buildings (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002950000

169. Construction services for other new nonresidential constructions, excluding buildings

$

,000.00

3003600000

170. Construction services for additions, renovations, and alterations to other nonresidential constructions, excluding
buildings

$

,000.00

3004250000

171. Construction services for maintenance and repair of all other nonresidential constructions, excluding buildings

$

,000.00

3004775000

$

,000.00

7008725003

$

,000.00

7008725006

$

,000.00

7008725009

$

,000.00

7008725012

$

,000.00

7008725000

$

,000.00

3000425000

$

,000.00

3000450000

$

,000.00

3000475000

$

,000.00

3000500000

$

,000.00

3000525003

$

,000.00

3000525006

$

,000.00

3000525000

Other specialized cleaning services, not elsewhere classified
172. Other specialized cleaning services, not elsewhere classified
a. Drain and gutter cleaning services

b. Parking lot sweeping services

c. Swimming pool cleaning and maintenance services

d. All other specialized cleaning services, not elsewhere classified

Subtotal

Residential decks
173. Residential deck new constructions (by builders and at-risk project managers)

174. Construction services for new residential deck constructions

175. Construction services for additions, renovations, and alterations to residential deck constructions

176. Construction services for maintenance and repair of residential deck constructions

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks
177. Residential landscape new constructions, excluding decks (by builders and at-risk project managers)
a. Residential irrigation and sprinkler system new constructions (by builders and at-risk project managers)

b. Other residential landscape new constructions, excluding decks (by builders and at-risk project managers)

Subtotal

178. Construction services for new residential landscape constructions, excluding decks (by builders and at-risk project
managers)

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

43

a. Construction services for new residential irrigation and sprinkler system constructions

$

,000.00

3000550003

$

,000.00

3000550006

$

,000.00

3000550000

a. Construction services for additions, renovations, and alterations to residential irrigation and sprinkler system
constructions

$

,000.00

3000575003

b. Construction services for additions, renovations, and alterations to other residential landscape constructions,
excluding decks

$

,000.00

3000575006

Subtotal

$

,000.00

3000575000

$

,000.00

3000600003

$

,000.00

3000600006

$

,000.00

3000600000

$

,000.00

3004800003

$

,000.00

3004800006

c. Construction project management services for new constructions of apartment type condominiums, excluding
single family condominiums

$

,000.00

3004800009

d. Construction project management services for new constructions of apartment buildings (two or more units),
excluding condominiums

$

,000.00

3004800012

e. Construction project management services for additions, renovations, alterations, maintenance, and repair of
residential single family buildings and apartment buildings (two or more units), including condominiums

$

,000.00

3004800015

f. Construction project management services for constructions of industrial buildings

$

,000.00

3004800018

g. Construction project management services for constructions of commercial and institutional buildings

$

,000.00

3004800021

$

,000.00

3004800024

b. Construction services for other new residential landscape constructions, excluding decks

Subtotal

179. Construction services for additions, renovations, and alterations to residential landscape constructions, excluding
decks

180. Construction services for maintenance and repair of residential landscape constructions, excluding decks
a. Construction services for maintenance and repair of residential irrigation and sprinkler system constructions

b. Construction services for maintenance and repair of other residential landscape constructions, excluding decks

Subtotal

Project management services, except at-risk, for building and non-building projects
181. Construction project management services, excluding at-risk
a. Construction project management services for new constructions of single detached residential buildings

b. Construction project management services for new constructions of single attached residential buildings

h. Construction project management services for constructions of water and sewer line and related structures

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

44

i. Construction project management services for constructions of oil and gas pipeline and related structures

$

,000.00

3004800027

j. Construction project management services for constructions of power and communication line and related
structures

$

,000.00

3004800033

k. Construction project management services for land subdivision

$

,000.00

3004800036

l. Construction project management services for highway, street, and bridge constructions

$

,000.00

3004800039

$

,000.00

3004800042

$

,000.00

3004800000

$

,000.00

9900000000

m. Construction project management services for other heavy and civil engineering constructions

Subtotal

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

45

Item 23: Kind of Business Activities Additional Information

ITEM 23: KIND OF BUSINESS ACTIVITIES
For the $,000.00 of sales, shipments, receipts, or revenue in 2022, please report the percent of the total represented by the following construction and non-construction business
activities. The sum of these percentages should equal 100%.
CONSTRUCTION WORK ACTIVITIES
Report only the main activities for which you were contracted. Work which was incidental to the primary activities of jobs should not be reported separately. If the construction activity is
not listed below, please enter a description of the construction activity in the “Other construction activities” write-in box, along with a percentage of the value of total business for that
specified construction activity.
OTHER BUSINESS ACTIVITIES
Report any non-construction activities. If the activity is not listed below, please enter a description of the non-construction activity in the “Other business activities” write-in box, along
with a percentage of the value of total business for that specified activity.

Description

Code

Value

Construction work activities

1. Building construction on land you own or control, for sale

2. Building construction on land customer owns
3. Remodeling contractor (except those performing specialized work such as carpentry,
flooring, doors, or windows)

4. Construction management, at risk

5. Construction management, agency or fee only

6. Subdividing and servicing of raw land into lots, for sale by you to builders
7. Heavy construction contractor, such as bridges, tunnels, pipelines, utility lines, and anchored
earth retention

8. Concrete contractor (except paving or precast)

9. Framing contractor

10. Finish carpentry contractor

11. Excavation work, earthmoving, or land clearing contractor
12. Other kinds of construction

6001

%

6002

%

6003

%

6701

%

6702

%

7210

%

7001

%

8110

%

8130

%

8350

%

8911

%

9000

%

Describe

Other business activity

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

46

13. Architectural services

14. Engineering services

15. Real estate commissions and property management fees

16. Rental or lease of properties

17. Building construction on land owned by you, for rent or lease (investment builder)

18. Retail trade
19. Other business activities

9911

%

9914

%

9917

%

9918

%

9923

%

9925

%

9929

%

8005

%

Describe

TOTAL

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

47

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

48

Item 28: Special Items - Ownership of Projects Additional Information

ITEM 28: SPECIAL ITEMS - OWNERSHIP OF PROJECTS
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue) on projects owned by the following:
2022
%

1. Private businesses and individuals

%

2. State and local governments

%

3. Federal Government
TOTAL
(Percentages reported in lines 1 through 3 should equal 100%.)

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

%

49

Item 28: Special Items - Construction Subcontractors

ITEM 28: SPECIAL ITEMS - CONSTRUCTION SUBCONTRACTORS
What percent of the amount you reported in Item 5 (Sales, Shipments, Receipts, or Revenue) represents work you did for other contractors or builders?
(Enter "0" if you did not subcontract work from other contractors or builders.)
2022
%

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

50

Item 28: Special Items - Construction by State

ITEM 28: SPECIAL ITEMS - CONSTRUCTION BY STATE
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue), which occurred in each state
(The sum of the percentages reported should equal 100%.)
2022

2022
%

Montana

%

%

Nebraska

%

%

Nevada

%

%

New Hampshire

%

%

New Jersey

%

%

New Mexico

%

%

New York

%

Delaware

%

North Carolina

%

District of Columbia

%

North Dakota

%

Florida

%

Ohio

%

Georgia

%

Oklahoma

%

Hawaii

%

Oregon

%

Idaho

%

Pennsylvania

%

%

Rhode Island

%

%

South Carolina

%

%

South Dakota

%

%

Tennessee

%

%

Texas

%

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Illinois

Indiana

Iowa

Kansas

Kentucky

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

51

Louisiana

%

Utah

%

Maine

%

Vermont

%

%

Virginia

%

%

Washington

%

%

West Virginia

%

%

Wisconsin

%

%

Wyoming

%

%

United States

%

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

2022_CC-23610_su.pdf Generated 2022-02-23 15:53:16

52

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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53

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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54

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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55

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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57

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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58

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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60

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

63

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

64

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is a construction establishment which is generally a permanent office, payroll office, or other place where business activities related to
construction are conducted. A construction establishment manages one or more projects or jobs and is usually maintained on a continuing basis.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Temporary construction site

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

New single-family housing construction (excluding for-sale builders), including attached and detached housing

236115 001

New multifamily housing construction (excluding for-sale builders), including apartments and condominiums

236116 001

New housing for-sale builder of single-family housing and multifamily housing

236117 001

Residential remodeler for home improvement (e.g., adding on, renovating, maintenance, and repair), including remodeling homes for resale

236118 001

Industrial building construction (e.g., processing and assembly plants, factories, refineries, waste disposal facilities), excluding warehouses
and sewage disposal plants

236210 001

Commercial and institutional building construction (e.g., office and school buildings, hospitals, health and data facilities, stores, and
warehouses)

236220 001

Water and sewer line and related structures construction (e.g., mains, sewage disposal plants, pumping stations, and water well drilling)

237110 001

Oil and gas pipeline and related structures construction (e.g., mains, petrochemical plants, pumping stations, and oil refineries)

237120 001

Power and communication line and related structures construction (e.g., alternative energy structures, power plants, transformer stations,
high voltage transmission cable connections, and cellular phone towers)

237130 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Highway, street, and bridge construction, including curbs, airport runway construction, and line painting of streets and parking lots

237310 001

Other heavy and civil engineering construction (e.g., tunnels, railways, outside recreation areas, dams, flood and drainage control projects,
dredging, trenching, and marine facilities)

237990 001

Poured concrete foundation and structure contractor (e.g., shotcrete, mud-jacking, gunning, gunite, pumping, and placement footing)

238110 001

Structural steel and precast concrete contractor, including structural iron work

238120 001

Framing contractor, including wood and steel (excluding structural steel or precast concrete)

238130 001

Masonry contractor (e.g., brick, stone, slate, glass block, cement, cinder blocking, stucco setting and other stone work)

238140 001

Glass and glazing contractor (e.g., glass coating and tinting (excluding automotive), window pane, glass sheet, glass curtain wall, and mirror
installation)

238150 001

Roofing contractor, including treating roofs (i.e., spraying, painting or coating) and skylight installation

238160 001

Siding contractor (e.g., gutters, downspouts, fascia, soffit, eavestrough, flashing, and ice apron)

238170 001

Other foundation, structure, and building exterior contractor (e.g., awning, metal balcony and stairway, and falsework construction), including
decorative steel and wrought iron work; poured concrete form installation and dismantling; and welding at site

238190 001

Electrical and other wiring installation contractor (e.g., electronic and environmental controls, telecommunications and fiber optic equipment
(excluding transmission line), solar panel installation, traffic signals, and fire and security systems)

238210 001

Plumbing, heating, and air-conditioning (HVAC) contractor, including installation, maintenance, and repair of refrigeration systems, sprinkler
systems, water systems, gas and oil line individual hookups, and steam and pipe fittings

238220 001

Other building equipment contractor (e.g., millwrights, machine rigging), including installation, maintenance, and repair of ATM equipment,
elevators, escalators, service station gasoline pumps, commercial and industrial doors)

238290 001

Drywall and insulation contractor, including acoustical, plastering, and fireproofing contractors

238310 001

Painting and wall covering contractor, including on-site electrostatic painting, whitewashing, and rustproofing of buildings, ships, bridges,
tanks, and towers (excluding automotive)

238320 001

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Flooring contractor (e.g., laying carpet, linoleum, hardwood, laminate, and vinyl flooring), excluding fireproof, stone, concrete, and ceramic
tile flooring

238330 001

Tile and terrazzo contractor (e.g., marble, granite, slate, ceramic, stone, and mosaic work for floors, walls, and ceilings), excluding exterior
marble, granite, and slate work

238340 001

Finish carpentry contractor (e.g., door, window, cabinetry, countertop, stairway, deck, molding, trim, and paneling work, residential-type,
installation), excluding framing

238350 001

Other building finishing contractor (e.g., waterproofing, spectator seating, modular furniture system attachments, closet organizer systems,
concrete coating, window shades and blinds, and trade show exhibit installation and dismantling)

238390 001

Site preparation contractor, without land subdivision (e.g., land clearing, drilling, demolition, trenching, and earthmoving), and rental of
construction equipment with operators (excluding cranes))

238910 001

All other specialty trade contractor (e.g., driveway paving; constructions of residential and commercial parking lots, sidewalks, patios, and
outdoor swimming pools; installation of fences (excluding electric) and playground equipment; and crane rental with operator)

238990 001

Other primary business or activity

779000 001

Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Include:
Receipts (or billings) derived from contract construction work done for others
Sales of houses and other buildings you built and sold
Construction management and design-build contracts
Site preparation receipts, such as land clearing, laying roads, installing utilities, and subdividing land into lots (Exclude purchase cost of land or estimated value of raw land for
construction projects.)
Architectural services, except the design portion of integrated design-build contracts
Engineering services
Rental or lease of properties
Real estate commissions and property management fees
Rental of construction machinery or equipment to others, without an operator
Manufacturing, mining, and transportation activities
Retail and wholesale trades
Other business activities
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building structure)
Purchased cost of land or estimated value of raw land for construction projects (Include site preparation receipts.)
Non-operating income such as interest, dividends, or the sale of fixed assets.
What were the receipts for all business activities done by this establishment, including receipts, billings, or sales for
construction work? (Construction work includes new construction and remodeling as well as maintenance and repair
work. The activities of prime and trade contractors are considered to be construction. Some trades not traditionally
thought of as construction are included such as land subdivision, excavation, building demolition, painting, carpet-laying,
water well drilling, plumbing and electrical work.)

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Check
if
None

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Number of employees at this establishment
Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
If the legal form of organization for this business is a corporation, the reporting of other employees and other payroll at this establishment is required. Enter "0" if the establishment
did not have payroll and employment for specific data for this EIN. If payroll and employment for this EIN are zero, please indicate if the EIN is a joint venture or reason why data
are zero in Item 31: Remarks at the end of the survey.
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Spread on stock options that are taxable to employees at this establishment as wages
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company’s EIN (Report values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line C1.)
Contractors, subcontractors, or independent contractors
Purchased or managed services, such as janitorial, security, or landscape services (Report values in Item 16, line C9.)
Purchased professional and technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services (Report
values in Item 16, line C9.)
Members of the Armed Forces and pensioners carried on your active rolls
Proprietors and partners, if an unincorporated concern
Number of construction workers at this establishment include:
Apprentices
Working foremen
Equipment operators and mechanics
Journeymen
Job-site record keepers
Craftsmen
Laborers
Truck drivers and helpers
Others engaged directly in construction
Number of other employees at this establishment include:
Supervisors above working foremen
Office staff
Executives
Architects
Purchasing Agents
Personnel staff
Engineers
Accounting staff
Others engaged in non-construction activities
A. Number of employees at this establishment for the pay period including the 12th of the month.
March 2022

June 2022

September 2022

December 2022

1. What was the number of construction workers
(direct labor including first-line supervisors)?

2. What was the number of other employees?

TOTAL (Add lines A1 and A2.)

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B. HOURS WORKED
Check
if
None

2022 Hours

What was the annual number of hours worked by the construction workers at this establishment (direct labor
including first-line supervisors) reported in line A?

,000

C. PAYROLL
Include:
Payroll for officers at this establishment
Exclude:
Income or costs not recorded as payroll for IRS by establishment.
Employer-paid annual cost for fringe benefits reported in lines 7D1 and 7D2
Check
if
None

2022

1. What was the annual payroll at this establishment before deductions for construction workers (direct labor
including first-line supervisors)?

$

,000.00

2. What was the annual payroll before deductions for other employees?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $0,000.00 reported above, what was the first quarter payroll at this establishment before deductions
(January-March 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits
Check
if
None

2022

1. What were the legally required fringe benefits? (Include employer payments for Social Security, Medicare,
unemployment compensation, workmen's compensation, and State disability programs, if required.)

$

,000.00

2. What were the voluntarily provided fringe benefits? (Include such items as payments for life insurance, medical
insurance, pensions, welfare benefits, and union-negotiated benefits.)

$

,000.00

TOTAL (Add lines D1 and D2.)

$

,000.00

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Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Include:
Inventories, regardless of where held, for materials and supplies owned by this establishment as of December 31
Exclude:
Work-in-progress and finished units

Using current cost, what was the value of inventories owned
by this establishment as of December 31? (If using LIFO
method of evaluation, adjust to obtain FIFO or current cost.)

Check
if
None

2022
$

2021
,000.00

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$

,000.00

22

Item 13: Assets, Capital Expenditures, and Retirements Additional Information

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS
Exclude
Land (Report cost of land acquired during the year in Item 16A, line 5.)

Check
if
None

2022
$

,000.00

B. What were the capital expenditures for new and used depreciable assets?

$

,000.00

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc.?

$

,000.00

D. What was the value of depreciable assets at the end of the year? (Add lines A and B minus line C.)

$

,000.00

A. What was the gross value of depreciable assets (usually original cost) at the beginning of the year?

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Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production, loading, and transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles
Exclude:
Computer time-sharing charges for machinery and equipment rentals from computer service companies where
the computer is not on site at the establishment

TOTAL (Add lines A and B.)

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Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
A. For this establishment, what were the cost of materials, subcontract work, fuels, electricity, and land acquired in 2022 for:
Include:
Current account expenses normally considered as cost of work performed or job-specific costs

1. Cost of materials, parts, and supplies?
Include:
All job-site, office, and construction materials and supplies
Cost of materials purchased by this establishment's subcontractors
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building
structure)
Non-construction-related expenses that were paid to subcontractors by this establishment (Report these
expense details on the next screen, Item 16: Selected Expenses - Continued, in line C.)

Check
if
None

2022
$

,000.00

$

,000.00

a. Natural gas and manufactured gas (propane)?

$

,000.00

b. Gasoline and diesel fuel - ON highway (not at site)?

$

,000.00

c. Gasoline and diesel fuel - OFF highway (at site)?

$

,000.00

$

,000.00

$

,000.00

2. Cost of construction-related work subcontracted out to others?
Exclude:
Cost of materials purchased by this establishment for subcontractors (These costs should be reported in line
A1.)

Check
if
None

3. Cost of fuels for heat, power, lubricants
Check
if
None

d. All other fuels and lubricants, including heating oils, lubricating oils, and greases?

Check
if
None
4. Cost of electricity?

5. When you answered Item 5, did you include the purchased cost of land or estimated value of raw land? Please check one, and answer the below question.
Yes
No

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

25

Check
if
None
6. What was the purchased cost of land or estimated value of raw land for reported construction projects during the
covered time?

$

,000.00

$

,000.00

Check
if
None
B. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

26

Item 16: Selected Expenses - Continued Additional Information

ITEM 16: SELECTED EXPENSES

C. What were the other operating expenses paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services your establishment paid to the Professional Employer
Organizations for the temporary staff and leased employees

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report on line C3.)
Leased and rented equipment (Report on Item 14, line B.)

3. Expensed purchases of software? (Purchases of prepackaged, custom coded or vendor customized software)
Include
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Other wired and wireless communication services
Credit card transaction fees

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

27

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data Storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other establishments of this company (such as a separate central data processing
unit)
Expensed integrated systems (Report in line C4.)
Repair and maintenance of computer equipment (Report in line C6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in line C9 and credit
card transaction fees in line C4.)
Expenses for telecommunication services (e.g., Internet, connectivity, telephone) (Report in line C4.)

$

,000.00

Exclude
Materials, parts, and supplies used for repairs and maintenance performed by this firm's employees

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments in Item 16, line A4. If the cost of these utilities is included in a leased or rental
payment, report in Item 14, line A.)
Include:
Cost of hazardous waste removal

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?

8. Purchased advertising and promotional services?
Include:
Marketing and public relations services
Exclude:
Salaries paid to employees of this establishment for advertising work

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other Professional services (i.e. such as janitorial, security, or landscape services)
Exclude:
Salaries paid to your own employees for these services (Report in Item 7.)

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

28

10. Governmental taxes and licensing fees?(Payments to government agencies for taxes and licenses)
Include:
Business and property tax fees for establishment to remain active legal operable business
Permits and licensing fees
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?

Include:
Expenses for paid temporary day labors not on your payroll or hired as construction subcontractors
Exclude:
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
The construction project types listed below are general to your industry. Select the project types that apply to your establishment. On the next screen, you will report the specific
construction products and services related to the construction projects you select. If you have revenue from other sources not listed, you will have the opportunity to report them later.
At-risk construction project management revenue should be reported with the specific construction project associated with those management services. For example, if at-risk
construction project management is for office buildings, then include the management revenue with the project for office buildings. However, at-fee project management services
should be reported in the specific project for construction project management services.
Description

Select

Amusement, social, and recreational building construction

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

Commercial warehouses, such as distribution buildings and mini-storage

Project Code

334

322

359

327

319

Dormitories and barracks

329

Educational building construction

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

323

333

Farm building construction, nonresidential

331

Health care and institutional building construction

324

Hotel, motel, and inn construction

321

Industrial warehouse construction

Nonresidential mobile building construction, office and other commercial

335

325

Office building construction

332

Public safety building construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

30

328

Religious building construction

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

326

336

338

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

318

314

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

317

316

Single detached residential building construction

342

Airport runways and landing fields

346

Bridge and elevated highway

Conservation and development construction, including dams, drainage canals, and flood control projects

368

378

Fencing

373

Harbor and port facilities

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

341

357

Hydroelectric power plants

Marine construction, such as dredging, navigational channels, and locks

374

366

Mass transit, including railroads

Oil and gas pipelines, pumping stations, storage tanks, and mains

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

353

381

364

Petrochemical plant and petroleum refinery construction

Power and cogeneration plant construction, except hydroelectric construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

356

31

Power and communication transmission line, cable, tower, and related facilities

Private driveway and parking area construction, except garages

354

343

361

Sewage and water treatment plants

Sewers, sewer lines, septic systems, and related facilities

351

384

Ship maintenance and repair services

375

Swimming pools

347

Tunnels

352

Water mains, storage wells, and related facilities

395

Other nonresidential constructions, except buildings

Other specialized cleaning services, not elsewhere classified

399

376

Residential decks

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks

377

Add product/service not listed

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

32

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services associated with the construction projects you previously selected. If you have revenue from sources not listed, describe and report them in the
"All other sales, shipments, receipts, or revenue from this establishment" section at the end of this question.
At-risk construction project management revenue should be reported with the specific constructions or construction services associated with those management services. For
example, if at-risk construction project management is for entire office building constructions, then include the management revenue with the new constructions for office buildings.
However, at-fee project management services should be reported in the specific product lines for construction project management services.
New Constructions and Construction Services – Report only the main activities including the type of buildings, structures, or facilities contracted to construct or work on by this
establishment in the reporting year in which this establishment received receipts only. If you worked on more than one type of building or structure in a multipurpose complex, report
separately for each building or type of structure. However, if you worked on a building that had more than one purpose, i.e. office, residential, or commercial, classify this building by
its major purpose.
New constructions include all components of the entire original building or structure. Land development work on the site and demolition of existing structures are included with
new constructions.
Construction services for new building or structures include separate components of the original building or structure, such as electric work, painting, plumbing, etc.
Construction services for additions, renovations, and alterations to buildings or structures include construction work which adds to the value of useful life of an existing
building or structure, or which adapts a building or structure to a new or different use. Included are “major replacements” of building systems such as the installation of a new
roof or heating system, and the resurfacing of streets or highways. Exclude activities such as the repair of a hole in a roof or the routine patching of highways and streets, which
are classified as “maintenance and repair work”.
Construction services for maintenance and repair of buildings or structures include incidental construction work that keeps a property in ordinary working condition.
Exclude trash and snow removal, lawn maintenance, and janitorial services.

Description

Value

Product Code

Amusement, social, and recreational building construction
1. Amusement, social, and recreational building new constructions (by builders and at-risk project managers)

$

,000.00

3000875000

2. Construction services for new amusement, social, and recreational buildings

$

,000.00

3001350000

3. Construction services for additions, renovations, and alterations to amusement, social, and recreational buildings

$

,000.00

3001750000

4. Construction services for maintenance and repair of amusement, social, and recreational buildings

$

,000.00

3002150000

5. Apartment building (two or more units) new constructions, excluding condominiums (by builders and at-risk project
managers)

$

,000.00

3000625000

6. Construction services for new apartment buildings (two or more units), excluding condominiums

$

,000.00

3001050000

7. Construction services for additions, renovations, and alterations to apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001075000

8. Construction services for maintenance and repair of apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001100000

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

33

9. Chemical (except petrochemical) complex/plant, blast furnace, and mining appurtenance new constructions (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002600000

10. Construction services for new chemical (except petrochemical) complexes/plants, blast furnaces, and mining
appurtenances

$

,000.00

3003250000

11. Construction services for additions, renovations, and alterations to chemical (except petrochemical)
complexes/plants, blast furnaces, and mining appurtenances

$

,000.00

3003900000

12. Construction services for maintenance and repair of chemical (except petrochemical) complexes/plants, blast
furnaces, and mining appurtenances

$

,000.00

3004550000

13. Commercial warehouse new constructions, such as distribution buildings and mini-storage (by builders and at-risk
project managers)

$

,000.00

3000750000

14. Construction services for new commercial warehouses, such as distribution buildings and mini-storage

$

,000.00

3001225000

15. Construction services for additions, renovations, and alterations to commercial warehouses, such as distribution
buildings and mini-storage

$

,000.00

3001625000

16. Construction services for maintenance and repair of commercial warehouses, such as distribution buildings and
mini-storage

$

,000.00

3002025000

17. Educational institution dormitories new constructions (by builders and at-risk project mangers)

$

,000.00

3001005000

18. Military and other public safety dormitories and barracks new constructions (by builders and at-risk project
managers)

$

,000.00

3001010000

$

,000.00

3001480000

20. Construction services for new military and other public safety dormitories and barracks

$

,000.00

3001485000

21. Construction services for additions, renovations, and alterations to educational institution dormitories

$

,000.00

3001880000

22. Construction services for additions, renovations, and alterations to military and other public safety dormitories and
barracks

$

,000.00

3001885000

$

,000.00

3002280000

$

,000.00

3002285000

25. Educational building new constructions (by builders and at-risk project managers)

$

,000.00

3000825000

26. Construction services for new educational buildings

$

,000.00

3001300000

Commercial warehouses, such as distribution buildings and mini-storage

Dormitories and barracks

19. Construction services for new educational institution dormitories

23. Construction services for maintenance and repair of educational institution dormitories

24. Construction services for maintenance and repair of military and other public safety dormitories and barracks

Educational building construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

34

27. Construction services for additions, renovations, and alterations to educational buildings

$

,000.00

3001700000

28. Construction services for maintenance and repair of educational buildings

$

,000.00

3002100000

29. Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building new
constructions (by builders and at-risk project managers)

$

,000.00

3000700000

30. Construction services for new factories, assembly plants, industrial research laboratories, and other new
manufacturing and industrial buildings

$

,000.00

3001175000

31. Construction services for additions, renovations, and alterations to factories, assembly plants, industrial research
laboratories, and other manufacturing and industrial buildings

$

,000.00

3001575000

32. Construction services for maintenance and repair of factories, assembly plants, industrial research laboratories, and
other manufacturing and industrial buildings

$

,000.00

3001975000

$

,000.00

3000975000

$

,000.00

3001450000

35. Construction services for additions, renovations, and alterations to farm buildings, nonresidential

$

,000.00

3001850000

36. Construction services for maintenance and repair of farm buildings, nonresidential

$

,000.00

3002250000

$

,000.00

3000850000

$

,000.00

3001325000

39. Construction services for additions, renovations, and alterations to health care and institutional buildings

$

,000.00

3001725000

40. Construction services for maintenance and repair of health care and institutional buildings

$

,000.00

3002125000

41. Hotel, motel, and inn new constructions (by builders and at-risk project managers)

$

,000.00

3000650000

42. Construction services for new hotels, motels, and inns

$

,000.00

3001125000

43. Construction services for additions, renovations, and alterations to hotels, motels, and inns

$

,000.00

3001525000

44. Construction services for maintenance and repair of hotels, motels, and inns

$

,000.00

3001925000

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

Farm building construction, nonresidential
33. Farm building new constructions, nonresidential (by builders and at-risk project managers)

34. Construction services for new farm buildings, nonresidential

Health care and institutional building construction
37. Health care and institutional buildings new constructions (by builders and at-risk project managers)

38. Construction services for new health care and institutional buildings

Hotel, motel, and inn construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

35

Industrial warehouse construction
45. Industrial warehouse new constructions at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000680000

46. Industrial warehouse new constructions not at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000685000

47. Construction services for new industrial warehouses at manufacturing sites

$

,000.00

3001155000

48. Construction services for new industrial warehouses not at manufacturing sites

$

,000.00

3001160000

49. Construction services for additions, renovations, and alterations to industrial warehouses at manufacturing sites

$

,000.00

3001555000

50. Construction services for additions, renovations, and alterations to industrial warehouses not at manufacturing sites

$

,000.00

3001560000

51. Construction services for maintenance and repair of industrial warehouses at manufacturing sites

$

,000.00

3001955000

$

,000.00

3001960000

53. Nonresidential mobile building new constructions, office (by builders and at-risk project managers)

$

,000.00

3000930000

54. Nonresidential mobile building new constructions, other commercial (by builders and at-risk project managers)

$

,000.00

3000935000

55. Construction services for new nonresidential mobile building constructions, office

$

,000.00

3001405000

56. Construction services for new nonresidential mobile building constructions, other commercial

$

,000.00

3001410000

57. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
office

$

,000.00

3001805000

58. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
other commercial

$

,000.00

3001810000

59. Construction services for maintenance and repair of nonresidential mobile building constructions, office

$

,000.00

3002205000

60. Construction services for maintenance and repair of nonresidential mobile building constructions, other commercial

$

,000.00

3002210000

61. Office building and data center new constructions (by builders and at-risk project managers)

$

,000.00

3000725000

62. Construction services for new office buildings and data centers

$

,000.00

3001200000

63. Construction services for additions, renovations, and alterations to office buildings and data centers

$

,000.00

3001600000

52. Construction services for maintenance and repair of industrial warehouses not at manufacturing sites

Nonresidential mobile building construction, office and other commercial

Office building construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

36

64. Construction services for maintenance and repair of office buildings and data centers

$

,000.00

3002000000

65. Public safety building new constructions (by builders and at-risk project managers)

$

,000.00

3000900000

66. Construction services for new public safety buildings

$

,000.00

3001375000

67. Construction services for additions, renovations, and alterations to public safety buildings

$

,000.00

3001775000

68. Construction services for maintenance and repair of public safety buildings

$

,000.00

3002175000

$

,000.00

3000800000

70. Construction services for new religious buildings

$

,000.00

3001275000

71. Construction services for additions, renovations, and alterations to religious buildings

$

,000.00

3001675000

72. Construction services for maintenance and repair of religious buildings

$

,000.00

3002075000

73. Store, restaurant, automobile service station, parking garage, and other commercial building new constructions
(excluding mobile buildings)(by builders and at-risk project managers)

$

,000.00

3000775000

74. Construction services for new stores, restaurants, automobile service stations, parking garages, and other
commercial buildings (excluding mobile buildings)

$

,000.00

3001250000

75. Construction services for additions, renovations, and alterations to stores, restaurants, automobile service stations,
parking garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3001650000

76. Construction services for maintenance and repair of stores, restaurants, automobile service stations, parking
garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3002050000

77. Nonresidential mobile building new constructions, classroom (by builders and at-risk project managers)

$

,000.00

3000955000

78. Nonresidential mobile building new constructions, industrial (by builders and at-risk project managers)

$

,000.00

3000960000

79. Construction services for new nonresidential mobile building constructions, classroom

$

,000.00

3001430000

80. Construction services for new nonresidential mobile building constructions, industrial

$

,000.00

3001435000

81. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, classrooms

$

,000.00

3001830000

Public safety building construction

Religious building construction
69. Religious building new constructions (by builders and at-risk project managers)

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

37

82. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, industrial

$

,000.00

3001835000

83. Construction services for maintenance and repair of other nonresidential mobile building constructions, classrooms

$

,000.00

3002230000

84. Construction services for maintenance and repair of other nonresidential mobile building constructions, industrial

$

,000.00

3002235000

85. All other nonresidential building new constructions (by builders and at-risk project managers)

$

,000.00

3001025000

86. Construction services for all other new nonresidential buildings

$

,000.00

3001500000

87. Construction services for additions, renovations, and alterations to all other nonresidential buildings

$

,000.00

3001900000

88. Construction services for maintenance and repair of all other nonresidential buildings

$

,000.00

3002300000

89. Constructions of new apartment type condominiums, excluding single family condominiums (by builders and at-risk
project managers)

$

,000.00

3000100000

90. Construction services for new apartment type condominiums, excluding single family condominiums

$

,000.00

3000200000

91. Construction services for additions, renovations, and alterations to apartment type condominiums, excluding single
family condominiums

$

,000.00

3000300000

92. Construction services for maintenance and repair of apartment type condominiums, excluding single family
condominiums

$

,000.00

3000400000

93. Constructions of new manufactured (mobile) homes, all width sizes (including multisection) (by builders and at-risk
project managers)

$

,000.00

3000075000

94. Construction services for new manufactured homes (mobile homes), all width sizes (including multisection)

$

,000.00

3000175000

95. Construction services for additions, renovations, and alterations to manufactured homes (mobile homes), all width
sizes (including multisection)

$

,000.00

3000275000

96. Construction services for maintenance and repair of manufactured homes (mobile homes), all width sizes (including
multisection)

$

,000.00

3000375000

97. Constructions of new single attached residential buildings, including row houses and town houses (by builders and
at-risk project managers)

$

,000.00

3000050000

98. Construction services for new single attached residential buildings, including row houses and town houses

$

,000.00

3000150000

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

38

99. Construction services for additions, renovations, and alterations to single attached residential buildings, including
row houses and town houses

$

,000.00

3000250000

100. Construction services for maintenance and repair of single attached residential buildings, including row houses and
town houses

$

,000.00

3000350000

101. Constructions of new single detached residential buildings (by builders and at-risk project managers)

$

,000.00

3000025000

102. Construction services for new single detached residential buildings

$

,000.00

3000125000

103. Construction services for additions, renovations, and alterations to single detached residential buildings

$

,000.00

3000225000

104. Construction services for maintenance and repair of single detached residential buildings

$

,000.00

3000325000

105. Airport runway and landing field new constructions (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002675000

106. Construction services for new airport runways and landing fields

$

,000.00

3003325000

107. Construction services for additions, renovations, and alterations to airport runways and landing fields

$

,000.00

3003975000

108. Construction services for maintenance and repair of airport runways and landing fields

$

,000.00

3004625000

$

,000.00

3002375000

$

,000.00

3003025000

111. Construction services for additions, renovations, and alterations to bridges and elevated highways

$

,000.00

3003675000

112. Construction services for maintenance and repair of bridges and elevated highways

$

,000.00

3004325000

113. Conservation and development new constructions, including dams, drainage canals, and flood control projects (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002650000

114. Construction services for new conservation and development constructions, including dams, drainage canals, and
flood control projects

$

,000.00

3003300000

115. Construction services for additions, renovations, and alterations to conservation and development constructions,
including dams, drainage canals, and flood control projects

$

,000.00

3003950000

116. Construction services for maintenance and repair of conservation and development constructions, including dams,
drainage canals, and flood control projects

$

,000.00

3004600000

Single detached residential building construction

Airport runways and landing fields

Bridge and elevated highway
109. Bridge and elevated highway new constructions (by heavy construction contractors and at-risk project managers)

110. Construction services for new bridges and elevated highways

Conservation and development construction, including dams, drainage canals, and flood control projects

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

39

Fencing
117. Fencing new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002825000

118. Construction services for new fencing constructions

$

,000.00

3003475000

119. Construction services for additions, renovations, and alterations to fencing constructions

$

,000.00

3004125000

120. Construction services for maintenance and repair of fencing constructions

$

,000.00

3004750000

121. Harbor and port facilities new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002725000

122. Construction services for new harbor and port facilities

$

,000.00

3003375000

123. Construction services for additions, renovations, and alterations to harbor and port facilities

$

,000.00

3004025000

$

,000.00

3004675000

125. Highway, street, and related work new constructions, including public sidewalks, curbs, guardrails and signs (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002325000

126. Construction services for new highways, streets, and related work, including public sidewalks, curbs, guardrails
and signs

$

,000.00

3002975000

127. Construction services for additions, renovations, and alterations to highways, streets, and related works, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3003625000

128. Construction services for maintenance and repair of highways, streets, and related work constructions, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3004275000

$

,000.00

3002575000

$

,000.00

3003225000

$

,000.00

3003875000

$

,000.00

3004525000

$

,000.00

3002750000

Harbor and port facilities

124. Construction services for maintenance and repair of harbor and port facilities

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

Hydroelectric power plants
129. Power plant new constructions, hydroelectric (by heavy construction contractors and at-risk project managers)

130. Construction services for new power plants, hydroelectric

131. Construction services for additions, renovations, and alterations to power plants, hydroelectric

132. Construction services for maintenance and repair of power plants, hydroelectric

Marine construction, such as dredging, navigational channels, and locks
133. Marine new constructions, including dredging, navigational channels, and locks (by heavy construction contractors
and at-risk project managers)

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

40

134. Construction services for new marine constructions, including dredging, navigational channels, and locks

$

,000.00

3003400000

135. Construction services for additions, renovations, and alterations to marine constructions, including dredging,
navigational channels, and locks

$

,000.00

3004050000

136. Construction services for maintenance and repair of marine constructions, including dredging, navigational
channels, and locks

$

,000.00

3004700000

137. Mass transit new constructions, including railroads (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002700000

138. Construction services for new mass transit constructions, including railroads

$

,000.00

3003350000

139. Construction services contractors for additions, renovations, and alterations to mass transit constructions, including
railroads

$

,000.00

3004000000

140. Construction services for maintenance and repair of mass transit constructions, including railroads

$

,000.00

3004650000

141. Oil and gas pipeline, pumping station, storage tank, and main new constructions (by heavy construction
contractors and at-risk project managers)

$

,000.00

3002500000

142. Construction services for new oil and gas pipelines, pumping stations, storage tanks, and mains

$

,000.00

3003150000

143. Construction services for additions, renovations, and alterations to oil and gas pipelines, pumping stations, storage
tanks, and mains

$

,000.00

3003800000

144. Construction services for maintenance and repair of oil and gas pipelines, pumping stations, storage tanks, and
mains

$

,000.00

3004450000

145. Outdoor recreational area new constructions, including athletic fields, courts, golf courses, and campgrounds (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002800000

146. Construction services for new outdoor recreational areas, including athletic fields, courts, golf courses, and
campgrounds

$

,000.00

3003450000

147. Construction services for additions, renovations, and alterations to outdoor recreational area constructions,
including athletic fields, courts, golf courses, and campgrounds

$

,000.00

3004100000

148. Construction services for maintenance and repair of outdoor recreational area constructions, including athletic
fields, courts, golf courses, and campgrounds

$

,000.00

3004725000

149. Petrochemical plant and petroleum refinery new constructions (by heavy construction contractors and at-risk
project managers)

$

,000.00

3002625000

150. Construction services for new petrochemical plants and petroleum refineries

$

,000.00

3003275000

Mass transit, including railroads

Oil and gas pipelines, pumping stations, storage tanks, and mains

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

Petrochemical plant and petroleum refinery construction

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

41

151. Construction services for additions, renovations, and alterations to petrochemical plants and petroleum refineries

$

,000.00

3003925000

152. Construction services for maintenance and repair of petrochemical plants and petroleum refineries

$

,000.00

3004575000

153. Power and cogeneration plant new constructions, except hydroelectric (by heavy construction contractors and atrisk project managers)

$

,000.00

3002550000

154. Construction services for new power and cogeneration plants, except hydroelectric

$

,000.00

3003200000

155. Construction services for additions, renovations, and alterations to power and cogeneration plants, except
hydroelectric

$

,000.00

3003850000

156. Construction services for maintenance and repair of power and cogeneration plants, except hydroelectric

$

,000.00

3004500000

$

,000.00

3002525000

$

,000.00

3003175000

159. Construction services for additions, renovations, and alterations to power and communication transmission lines,
cables, towers, and related facilities

$

,000.00

3003825000

160. Construction services for maintenance and repair of power and communication transmission lines, cables, towers,
and related facilities

$

,000.00

3004475000

$

,000.00

3002350000

$

,000.00

3003000000

$

,000.00

3003650000

$

,000.00

3004300000

$

,000.00

3002475000

$

,000.00

3003125000

$

,000.00

3003775000

Power and cogeneration plant construction, except hydroelectric construction

Power and communication transmission line, cable, tower, and related facilities
157. Power and communication transmission line, cable, tower, and related facilities new constructions (by heavy
construction contractors and at-risk project managers)
158. Construction services for new power and communication transmission lines, cables, towers, and related facilities

Private driveway and parking area construction, except garages
161. Private driveway and parking area new constructions, except garages (by heavy construction contractors and atrisk project managers)
162. Construction services for new private driveways and parking areas, excluding garages

163. Construction services for additions, renovations, and alterations to private driveways and parking areas, excluding
garages
164. Construction services for maintenance and repair of private driveways and parking areas, excluding garages

Sewage and water treatment plants
165. Sewage and water treatment plant new constructions(by heavy construction contractors and at-risk project
managers)
166. Construction services for new sewage and water treatment plants

167. Construction services for additions, renovations, and alterations to sewage and water treatment plants

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

42

168. Construction services for maintenance and repair of sewage and water treatment plants

$

,000.00

3004425000

$

,000.00

3002425000

$

,000.00

3003075000

171. Construction services for additions, renovations, and alterations to sewers, sewer lines, septic systems, and
related facilities

$

,000.00

3003725000

172. Construction services for maintenance and repair of sewers, sewer lines, septic systems, and related facilities

$

,000.00

3004375000

$

,000.00

2053950000

$

,000.00

2053975000

175. Swimming pool new constructions (by builders and at-risk project managers)

$

,000.00

3002775000

176. Construction services for new swimming pools

$

,000.00

3003425000

$

,000.00

3004075000

$

,000.00

3002400000

179. Construction services for new tunnels

$

,000.00

3003050000

180. Construction services for additions, renovations, and alterations to tunnels

$

,000.00

3003700000

$

,000.00

3004350000

182. Water main, storage, well, and related facilities new constructions (by heavy construction contractors and at-risk
project managers)

$

,000.00

3002450000

183. Construction services for new water mains, storage, wells, and related facilities

$

,000.00

3003100000

184. Construction services for additions, renovations, and alterations to water mains, storage, wells, and related
facilities

$

,000.00

3003750000

Sewers, sewer lines, septic systems, and related facilities
169. Sewer, sewer line, septic system, and related facilities new constructions (by heavy construction contractors and
at-risk project managers)
170. Construction services for new sewers, sewer lines, septic systems, and related facilities

Ship maintenance and repair services
173. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, military

174. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, nonmilitary

Swimming pools

177. Construction services for additions, renovations, and alterations to swimming pools

Tunnels
178. Tunnel new constructions (by heavy construction contractors and at-risk project managers)

181. Construction services for maintenance and repair of tunnels

Water mains, storage wells, and related facilities

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43

185. Construction services for maintenance and repair of water mains, storage, wells, and related facilities

$

,000.00

3004400000

186. Other nonresidential new constructions, except buildings (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002950000

187. Construction services for other new nonresidential constructions, excluding buildings

$

,000.00

3003600000

188. Construction services for additions, renovations, and alterations to other nonresidential constructions, excluding
buildings

$

,000.00

3004250000

189. Construction services for maintenance and repair of all other nonresidential constructions, excluding buildings

$

,000.00

3004775000

$

,000.00

7008725003

$

,000.00

7008725006

c. Swimming pool cleaning and maintenance services

$

,000.00

7008725009

d. All other specialized cleaning services, not elsewhere classified

$

,000.00

7008725012

$

,000.00

7008725000

$

,000.00

3000425000

192. Construction services for new residential deck constructions

$

,000.00

3000450000

193. Construction services for additions, renovations, and alterations to residential deck constructions

$

,000.00

3000475000

$

,000.00

3000500000

a. Residential irrigation and sprinkler system new constructions (by builders and at-risk project managers)

$

,000.00

3000525003

b. Other residential landscape new constructions, excluding decks (by builders and at-risk project managers)

$

,000.00

3000525006

$

,000.00

3000525000

Other nonresidential constructions, except buildings

Other specialized cleaning services, not elsewhere classified
190. Other specialized cleaning services, not elsewhere classified
a. Drain and gutter cleaning services

b. Parking lot sweeping services

Subtotal

Residential decks
191. Residential deck new constructions (by builders and at-risk project managers)

194. Construction services for maintenance and repair of residential deck constructions

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks
195. Residential landscape new constructions, excluding decks (by builders and at-risk project managers)

Subtotal

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

44

196. Construction services for new residential landscape constructions, excluding decks (by builders and at-risk project
managers)
a. Construction services for new residential irrigation and sprinkler system constructions

$

,000.00

3000550003

b. Construction services for other new residential landscape constructions, excluding decks

$

,000.00

3000550006

Subtotal

$

,000.00

3000550000

a. Construction services for additions, renovations, and alterations to residential irrigation and sprinkler system
constructions

$

,000.00

3000575003

b. Construction services for additions, renovations, and alterations to other residential landscape constructions,
excluding decks

$

,000.00

3000575006

$

,000.00

3000575000

$

,000.00

3000600003

$

,000.00

3000600006

$

,000.00

3000600000

$

,000.00

9900000000

197. Construction services for additions, renovations, and alterations to residential landscape constructions, excluding
decks

Subtotal

198. Construction services for maintenance and repair of residential landscape constructions, excluding decks
a. Construction services for maintenance and repair of residential irrigation and sprinkler system constructions

b. Construction services for maintenance and repair of other residential landscape constructions, excluding decks

Subtotal

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

45

Item 23: Kind of Business Activities Additional Information

ITEM 23: KIND OF BUSINESS ACTIVITIES
For the $,000.00 of sales, shipments, receipts, or revenue in 2022, please report the percent of the total represented by the following construction and non-construction business
activities. The sum of these percentages should equal 100%.
CONSTRUCTION WORK ACTIVITIES
Report only the main activities for which you were contracted. Work which was incidental to the primary activities of jobs should not be reported separately. If the construction activity is
not listed below, please enter a description of the construction activity in the “Other construction activities” write-in box, along with a percentage of the value of total business for that
specified construction activity.
OTHER BUSINESS ACTIVITIES
Report any non-construction activities. If the activity is not listed below, please enter a description of the non-construction activity in the “Other business activities” write-in box, along
with a percentage of the value of total business for that specified activity.

Description

Code

Value

Construction work activities

1. Concrete contractor (except paving or precast)

2. Reinforcing steel contractor

3. Structural steel erection contractor

4. Precast concrete installation contractor

5. Framing contractor

6. Marble, granite, or slate contractor, exterior

7. Masonry contractor: brick, block, or stone (except brick paving)

8. Masonry: pointing, cleaning, or caulking contractor

9. Stucco contractor

10. Glass, glazing, and tinting contractor

11. Roofing contractor

12. Gutter, gutter guard, and downspout installation contractor

13. Siding contractor, including fascia and soffit

8110

%

8120

%

8121

%

8122

%

8130

%

8140

%

8141

%

8142

%

8143

%

8150

%

8160

%

8170

%

8171

%

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46

14. Metal curtain wall installation contractor
15. Ornamental metal contractor, including metal stairway, balcony, and wrought iron
installation

16. Wrecking, demolition, or blasting contractor

17. Welding contractor, operating at the site of construction

18. Paving contractor -- asphalt/concrete for highways, streets, bridges, airport runways

19. Plastering, lathing, or fresco contractor

20. Marble, granite, or slate contractor, interior

21. Finish carpentry contractor

22. Waterproofing and weather stripping contractor

23. Fireproofing for other foundation, structure, and building exterior contractor

24. Fireproof flooring contractor

25. Rental of construction machinery or equipment (except cranes) with operator

26. Rental of cranes with operator
27. Asphalt, concrete, and brick paving contractor, residential or commercial driveways and
parking areas

28. Excavation work, earthmoving, or land clearing contractor
29. Other kinds of construction

8190

%

8191

%

8914

%

8192

%

7311

%

8313

%

8340

%

8350

%

8391

%

8314

%

8315

%

8916

%

8991

%

8990

%

8911

%

9000

%

9915

%

9919

%

9921

%

9922

%

Describe

Other business activity

30. Manufacturing -- products manufactured and sold to others

31. Rental of construction machinery or equipment to others, without an operator

32. Transportation of goods for others

33. Wholesale trade

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34. Retail trade
35. Other business activities

9925

%

9929

%

8005

%

Describe

TOTAL

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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49

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Ownership of Projects Additional Information

ITEM 28: SPECIAL ITEMS - OWNERSHIP OF PROJECTS
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue) on projects owned by the following:
2022
%

1. Private businesses and individuals

2. State and local governments

%

3. Federal Government

%

TOTAL
(Percentages reported in lines 1 through 3 should equal 100%.)

%

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Item 28: Special Items - Construction Subcontractors

ITEM 28: SPECIAL ITEMS - CONSTRUCTION SUBCONTRACTORS
What percent of the amount you reported in Item 5 (Sales, Shipments, Receipts, or Revenue) represents work you did for other contractors or builders?
(Enter "0" if you did not subcontract work from other contractors or builders.)
2022
%

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Item 28: Special Items - Construction by State

ITEM 28: SPECIAL ITEMS - CONSTRUCTION BY STATE
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue), which occurred in each state
(The sum of the percentages reported should equal 100%.)
2022

2022
%

Montana

%

Alaska

%

Nebraska

%

Arizona

%

Nevada

%

Arkansas

%

New Hampshire

%

California

%

New Jersey

%

Colorado

%

New Mexico

%

Connecticut

%

New York

%

Delaware

%

North Carolina

%

%

North Dakota

%

%

Ohio

%

%

Oklahoma

%

%

Oregon

%

%

Pennsylvania

%

%

Rhode Island

%

%

South Carolina

%

Iowa

%

South Dakota

%

Kansas

%

Tennessee

%

Kentucky

%

Texas

%

Alabama

District of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

53

%

Utah

%

%

Vermont

%

%

Virginia

%

%

Washington

%

Michigan

%

West Virginia

%

Minnesota

%

Wisconsin

%

Mississippi

%

Wyoming

%

Missouri

%

United States

%

Louisiana

Maine

Maryland

Massachusetts

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54

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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56

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

57

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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58

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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59

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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60

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

61

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

62

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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63

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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64

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

65

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_CC-23810_su.pdf Generated 2022-02-23 15:44:50

,000.00

66

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is a construction establishment which is generally a permanent office, payroll office, or other place where business activities related to
construction are conducted. A construction establishment manages one or more projects or jobs and is usually maintained on a continuing basis.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Temporary construction site

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

New single-family housing construction (excluding for-sale builders), including attached and detached housing

236115 001

New multifamily housing construction (excluding for-sale builders), including apartments and condominiums

236116 001

New housing for-sale builder of single-family housing and multifamily housing

236117 001

Residential remodeler for home improvement (e.g., adding on, renovating, maintenance, and repair), including remodeling homes for resale

236118 001

Industrial building construction (e.g., processing and assembly plants, factories, refineries, waste disposal facilities), excluding warehouses
and sewage disposal plants

236210 001

Commercial and institutional building construction (e.g., office and school buildings, hospitals, health and data facilities, stores, and
warehouses)

236220 001

Water and sewer line and related structures construction (e.g., mains, sewage disposal plants, pumping stations, and water well drilling)

237110 001

Oil and gas pipeline and related structures construction (e.g., mains, petrochemical plants, pumping stations, and oil refineries)

237120 001

Power and communication line and related structures construction (e.g., alternative energy structures, power plants, transformer stations,
high voltage transmission cable connections, and cellular phone towers)

237130 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Highway, street, and bridge construction, including curbs, airport runway construction, and line painting of streets and parking lots

237310 001

Other heavy and civil engineering construction (e.g., tunnels, railways, outside recreation areas, dams, flood and drainage control projects,
dredging, trenching, and marine facilities)

237990 001

Poured concrete foundation and structure contractor (e.g., shotcrete, mud-jacking, gunning, gunite, pumping, and placement footing)

238110 001

Structural steel and precast concrete contractor, including structural iron work

238120 001

Framing contractor, including wood and steel (excluding structural steel or precast concrete)

238130 001

Masonry contractor (e.g., brick, stone, slate, glass block, cement, cinder blocking, stucco setting and other stone work)

238140 001

Glass and glazing contractor (e.g., glass coating and tinting (excluding automotive), window pane, glass sheet, glass curtain wall, and mirror
installation)

238150 001

Roofing contractor, including treating roofs (i.e., spraying, painting or coating) and skylight installation

238160 001

Siding contractor (e.g., gutters, downspouts, fascia, soffit, eavestrough, flashing, and ice apron)

238170 001

Other foundation, structure, and building exterior contractor (e.g., awning, metal balcony and stairway, and falsework construction), including
decorative steel and wrought iron work; poured concrete form installation and dismantling; and welding at site

238190 001

Electrical and other wiring installation contractor (e.g., electronic and environmental controls, telecommunications and fiber optic equipment
(excluding transmission line), solar panel installation, traffic signals, and fire and security systems)

238210 001

Plumbing, heating, and air-conditioning (HVAC) contractor, including installation, maintenance, and repair of refrigeration systems, sprinkler
systems, water systems, gas and oil line individual hookups, and steam and pipe fittings

238220 001

Other building equipment contractor (e.g., millwrights, machine rigging), including installation, maintenance, and repair of ATM equipment,
elevators, escalators, service station gasoline pumps, commercial and industrial doors)

238290 001

Drywall and insulation contractor, including acoustical, plastering, and fireproofing contractors

238310 001

Painting and wall covering contractor, including on-site electrostatic painting, whitewashing, and rustproofing of buildings, ships, bridges,
tanks, and towers (excluding automotive)

238320 001

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Flooring contractor (e.g., laying carpet, linoleum, hardwood, laminate, and vinyl flooring), excluding fireproof, stone, concrete, and ceramic
tile flooring

238330 001

Tile and terrazzo contractor (e.g., marble, granite, slate, ceramic, stone, and mosaic work for floors, walls, and ceilings), excluding exterior
marble, granite, and slate work

238340 001

Finish carpentry contractor (e.g., door, window, cabinetry, countertop, stairway, deck, molding, trim, and paneling work, residential-type,
installation), excluding framing

238350 001

Other building finishing contractor (e.g., waterproofing, spectator seating, modular furniture system attachments, closet organizer systems,
concrete coating, window shades and blinds, and trade show exhibit installation and dismantling)

238390 001

Site preparation contractor, without land subdivision (e.g., land clearing, drilling, demolition, trenching, and earthmoving), and rental of
construction equipment with operators (excluding cranes))

238910 001

All other specialty trade contractor (e.g., driveway paving; constructions of residential and commercial parking lots, sidewalks, patios, and
outdoor swimming pools; installation of fences (excluding electric) and playground equipment; and crane rental with operator)

238990 001

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Include:
Receipts (or billings) derived from contract construction work done for others
Sales of houses and other buildings you built and sold
Construction management and design-build contracts
Site preparation receipts, such as land clearing, laying roads, installing utilities, and subdividing land into lots (Exclude purchase cost of land or estimated value of raw land for
construction projects.)
Architectural services, except the design portion of integrated design-build contracts
Engineering services
Rental or lease of properties
Real estate commissions and property management fees
Rental of construction machinery or equipment to others, without an operator
Manufacturing, mining, and transportation activities
Retail and wholesale trades
Other business activities
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building structure)
Purchased cost of land or estimated value of raw land for construction projects (Include site preparation receipts.)
Non-operating income such as interest, dividends, or the sale of fixed assets.
What were the receipts for all business activities done by this establishment, including receipts, billings, or sales for
construction work? (Construction work includes new construction and remodeling as well as maintenance and repair
work. The activities of prime and trade contractors are considered to be construction. Some trades not traditionally
thought of as construction are included such as land subdivision, excavation, building demolition, painting, carpet-laying,
water well drilling, plumbing and electrical work.)

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Check
if
None

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Number of employees at this establishment
Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
If the legal form of organization for this business is a corporation, the reporting of other employees and other payroll at this establishment is required. Enter "0" if the establishment
did not have payroll and employment for specific data for this EIN. If payroll and employment for this EIN are zero, please indicate if the EIN is a joint venture or reason why data
are zero in Item 31: Remarks at the end of the survey.
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Spread on stock options that are taxable to employees at this establishment as wages
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company’s EIN (Report values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line C1.)
Contractors, subcontractors, or independent contractors
Purchased or managed services, such as janitorial, security, or landscape services (Report values in Item 16, line C9.)
Purchased professional and technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services (Report
values in Item 16, line C9.)
Members of the Armed Forces and pensioners carried on your active rolls
Proprietors and partners, if an unincorporated concern
Number of construction workers at this establishment include:
Apprentices
Working foremen
Equipment operators and mechanics
Journeymen
Job-site record keepers
Craftsmen
Laborers
Truck drivers and helpers
Others engaged directly in construction
Number of other employees at this establishment include:
Supervisors above working foremen
Office staff
Executives
Architects
Purchasing Agents
Personnel staff
Engineers
Accounting staff
Others engaged in non-construction activities
A. Number of employees at this establishment for the pay period including the 12th of the month.
March 2022

June 2022

September 2022

December 2022

1. What was the number of construction workers
(direct labor including first-line supervisors)?

2. What was the number of other employees?

TOTAL (Add lines A1 and A2.)

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B. HOURS WORKED
Check
if
None

2022 Hours

What was the annual number of hours worked by the construction workers at this establishment (direct labor
including first-line supervisors) reported in line A?

,000

C. PAYROLL
Include:
Payroll for officers at this establishment
Exclude:
Income or costs not recorded as payroll for IRS by establishment.
Employer-paid annual cost for fringe benefits reported in lines 7D1 and 7D2
Check
if
None

2022

1. What was the annual payroll at this establishment before deductions for construction workers (direct labor
including first-line supervisors)?

$

,000.00

2. What was the annual payroll before deductions for other employees?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $0,000.00 reported above, what was the first quarter payroll at this establishment before deductions
(January-March 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits
Check
if
None

2022

1. What were the legally required fringe benefits? (Include employer payments for Social Security, Medicare,
unemployment compensation, workmen's compensation, and State disability programs, if required.)

$

,000.00

2. What were the voluntarily provided fringe benefits? (Include such items as payments for life insurance, medical
insurance, pensions, welfare benefits, and union-negotiated benefits.)

$

,000.00

TOTAL (Add lines D1 and D2.)

$

,000.00

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Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Include:
Inventories, regardless of where held, for materials and supplies owned by this establishment as of December 31
Exclude:
Work-in-progress and finished units

Using current cost, what was the value of inventories owned
by this establishment as of December 31? (If using LIFO
method of evaluation, adjust to obtain FIFO or current cost.)

Check
if
None

2022
$

2021
,000.00

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$

,000.00

22

Item 13: Assets, Capital Expenditures, and Retirements Additional Information

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS
Exclude
Land (Report cost of land acquired during the year in Item 16A, line 5.)

Check
if
None

2022
$

,000.00

B. What were the capital expenditures for new and used depreciable assets?

$

,000.00

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc.?

$

,000.00

D. What was the value of depreciable assets at the end of the year? (Add lines A and B minus line C.)

$

,000.00

A. What was the gross value of depreciable assets (usually original cost) at the beginning of the year?

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Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production, loading, and transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles
Exclude:
Computer time-sharing charges for machinery and equipment rentals from computer service companies where
the computer is not on site at the establishment

TOTAL (Add lines A and B.)

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Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
A. For this establishment, what were the cost of materials, subcontract work, fuels, electricity, and land acquired in 2022 for:
Include:
Current account expenses normally considered as cost of work performed or job-specific costs

1. Cost of materials, parts, and supplies?
Include:
All job-site, office, and construction materials and supplies
Cost of materials purchased by this establishment's subcontractors
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building
structure)
Non-construction-related expenses that were paid to subcontractors by this establishment (Report these
expense details on the next screen, Item 16: Selected Expenses - Continued, in line C.)

Check
if
None

2022
$

,000.00

$

,000.00

a. Natural gas and manufactured gas (propane)?

$

,000.00

b. Gasoline and diesel fuel - ON highway (not at site)?

$

,000.00

c. Gasoline and diesel fuel - OFF highway (at site)?

$

,000.00

$

,000.00

$

,000.00

2. Cost of construction-related work subcontracted out to others?
Exclude:
Cost of materials purchased by this establishment for subcontractors (These costs should be reported in line
A1.)

Check
if
None

3. Cost of fuels for heat, power, lubricants
Check
if
None

d. All other fuels and lubricants, including heating oils, lubricating oils, and greases?

Check
if
None
4. Cost of electricity?

5. When you answered Item 5, did you include the purchased cost of land or estimated value of raw land? Please check one, and answer the below question.
Yes
No

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Check
if
None
6. What was the purchased cost of land or estimated value of raw land for reported construction projects during the
covered time?

$

,000.00

$

,000.00

Check
if
None
B. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

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Item 16: Selected Expenses - Continued Additional Information

ITEM 16: SELECTED EXPENSES

C. What were the other operating expenses paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services your establishment paid to the Professional Employer
Organizations for the temporary staff and leased employees

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report on line C3.)
Leased and rented equipment (Report on Item 14, line B.)

3. Expensed purchases of software? (Purchases of prepackaged, custom coded or vendor customized software)
Include
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Other wired and wireless communication services
Credit card transaction fees

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5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data Storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other establishments of this company (such as a separate central data processing
unit)
Expensed integrated systems (Report in line C4.)
Repair and maintenance of computer equipment (Report in line C6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in line C9 and credit
card transaction fees in line C4.)
Expenses for telecommunication services (e.g., Internet, connectivity, telephone) (Report in line C4.)

$

,000.00

Exclude
Materials, parts, and supplies used for repairs and maintenance performed by this firm's employees

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments in Item 16, line A4. If the cost of these utilities is included in a leased or rental
payment, report in Item 14, line A.)
Include:
Cost of hazardous waste removal

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?

8. Purchased advertising and promotional services?
Include:
Marketing and public relations services
Exclude:
Salaries paid to employees of this establishment for advertising work

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other Professional services (i.e. such as janitorial, security, or landscape services)
Exclude:
Salaries paid to your own employees for these services (Report in Item 7.)

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10. Governmental taxes and licensing fees?(Payments to government agencies for taxes and licenses)
Include:
Business and property tax fees for establishment to remain active legal operable business
Permits and licensing fees
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?

Include:
Expenses for paid temporary day labors not on your payroll or hired as construction subcontractors
Exclude:
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
The construction project types listed below are general to your industry. Select the project types that apply to your establishment. On the next screen, you will report the specific
construction products and services related to the construction projects you select. If you have revenue from other sources not listed, you will have the opportunity to report them later.
At-risk construction project management revenue should be reported with the specific construction project associated with those management services. For example, if at-risk
construction project management is for office buildings, then include the management revenue with the project for office buildings. However, at-fee project management services
should be reported in the specific project for construction project management services.
Description

Select

Amusement, social, and recreational building construction

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

Commercial warehouses, such as distribution buildings and mini-storage

Project Code

334

322

359

327

319

Dormitories and barracks

329

Educational building construction

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

323

333

Farm building construction, nonresidential

331

Health care and institutional building construction

324

Hotel, motel, and inn construction

321

Industrial warehouse construction

Nonresidential mobile building construction, office and other commercial

335

325

Office building construction

332

Public safety building construction

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30

328

Religious building construction

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

326

336

338

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

318

314

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

317

316

Single detached residential building construction

346

Bridge and elevated highway

Conservation and development construction, including dams, drainage canals, and flood control projects

368

378

Fencing

373

Harbor and port facilities

357

Hydroelectric power plants

Marine construction, such as dredging, navigational channels, and locks

374

366

Mass transit, including railroads

Oil and gas pipelines, pumping stations, storage tanks, and mains

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

353

381

364

Petrochemical plant and petroleum refinery construction

Power and cogeneration plant construction, except hydroelectric construction

Power and communication transmission line, cable, tower, and related facilities

356

354

361

Sewage and water treatment plants

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

31

Sewers, sewer lines, septic systems, and related facilities

351

384

Ship maintenance and repair services

375

Swimming pools

347

Tunnels

352

Water mains, storage wells, and related facilities

395

Other nonresidential constructions, except buildings

Other specialized cleaning services, not elsewhere classified

399

376

Residential decks

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks

377

Add product/service not listed

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services associated with the construction projects you previously selected. If you have revenue from sources not listed, describe and report them in the
"All other sales, shipments, receipts, or revenue from this establishment" section at the end of this question.
At-risk construction project management revenue should be reported with the specific constructions or construction services associated with those management services. For
example, if at-risk construction project management is for entire office building constructions, then include the management revenue with the new constructions for office buildings.
However, at-fee project management services should be reported in the specific product lines for construction project management services.
New Constructions and Construction Services – Report only the main activities including the type of buildings, structures, or facilities contracted to construct or work on by this
establishment in the reporting year in which this establishment received receipts only. If you worked on more than one type of building or structure in a multipurpose complex, report
separately for each building or type of structure. However, if you worked on a building that had more than one purpose, i.e. office, residential, or commercial, classify this building by
its major purpose.
New constructions include all components of the entire original building or structure. Land development work on the site and demolition of existing structures are included with
new constructions.
Construction services for new building or structures include separate components of the original building or structure, such as electric work, painting, plumbing, etc.
Construction services for additions, renovations, and alterations to buildings or structures include construction work which adds to the value of useful life of an existing
building or structure, or which adapts a building or structure to a new or different use. Included are “major replacements” of building systems such as the installation of a new
roof or heating system, and the resurfacing of streets or highways. Exclude activities such as the repair of a hole in a roof or the routine patching of highways and streets, which
are classified as “maintenance and repair work”.
Construction services for maintenance and repair of buildings or structures include incidental construction work that keeps a property in ordinary working condition.
Exclude trash and snow removal, lawn maintenance, and janitorial services.

Description

Value

Product Code

Amusement, social, and recreational building construction
1. Amusement, social, and recreational building new constructions (by builders and at-risk project managers)

$

,000.00

3000875000

2. Construction services for new amusement, social, and recreational buildings

$

,000.00

3001350000

3. Construction services for additions, renovations, and alterations to amusement, social, and recreational buildings

$

,000.00

3001750000

4. Construction services for maintenance and repair of amusement, social, and recreational buildings

$

,000.00

3002150000

5. Apartment building (two or more units) new constructions, excluding condominiums (by builders and at-risk project
managers)

$

,000.00

3000625000

6. Construction services for new apartment buildings (two or more units), excluding condominiums

$

,000.00

3001050000

7. Construction services for additions, renovations, and alterations to apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001075000

8. Construction services for maintenance and repair of apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001100000

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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9. Chemical (except petrochemical) complex/plant, blast furnace, and mining appurtenance new constructions (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002600000

10. Construction services for new chemical (except petrochemical) complexes/plants, blast furnaces, and mining
appurtenances

$

,000.00

3003250000

11. Construction services for additions, renovations, and alterations to chemical (except petrochemical)
complexes/plants, blast furnaces, and mining appurtenances

$

,000.00

3003900000

12. Construction services for maintenance and repair of chemical (except petrochemical) complexes/plants, blast
furnaces, and mining appurtenances

$

,000.00

3004550000

13. Commercial warehouse new constructions, such as distribution buildings and mini-storage (by builders and at-risk
project managers)

$

,000.00

3000750000

14. Construction services for new commercial warehouses, such as distribution buildings and mini-storage

$

,000.00

3001225000

15. Construction services for additions, renovations, and alterations to commercial warehouses, such as distribution
buildings and mini-storage

$

,000.00

3001625000

16. Construction services for maintenance and repair of commercial warehouses, such as distribution buildings and
mini-storage

$

,000.00

3002025000

17. Educational institution dormitories new constructions (by builders and at-risk project mangers)

$

,000.00

3001005000

18. Military and other public safety dormitories and barracks new constructions (by builders and at-risk project
managers)

$

,000.00

3001010000

$

,000.00

3001480000

20. Construction services for new military and other public safety dormitories and barracks

$

,000.00

3001485000

21. Construction services for additions, renovations, and alterations to educational institution dormitories

$

,000.00

3001880000

22. Construction services for additions, renovations, and alterations to military and other public safety dormitories and
barracks

$

,000.00

3001885000

$

,000.00

3002280000

$

,000.00

3002285000

25. Educational building new constructions (by builders and at-risk project managers)

$

,000.00

3000825000

26. Construction services for new educational buildings

$

,000.00

3001300000

Commercial warehouses, such as distribution buildings and mini-storage

Dormitories and barracks

19. Construction services for new educational institution dormitories

23. Construction services for maintenance and repair of educational institution dormitories

24. Construction services for maintenance and repair of military and other public safety dormitories and barracks

Educational building construction

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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27. Construction services for additions, renovations, and alterations to educational buildings

$

,000.00

3001700000

28. Construction services for maintenance and repair of educational buildings

$

,000.00

3002100000

29. Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building new
constructions (by builders and at-risk project managers)

$

,000.00

3000700000

30. Construction services for new factories, assembly plants, industrial research laboratories, and other new
manufacturing and industrial buildings

$

,000.00

3001175000

31. Construction services for additions, renovations, and alterations to factories, assembly plants, industrial research
laboratories, and other manufacturing and industrial buildings

$

,000.00

3001575000

32. Construction services for maintenance and repair of factories, assembly plants, industrial research laboratories, and
other manufacturing and industrial buildings

$

,000.00

3001975000

$

,000.00

3000975000

$

,000.00

3001450000

35. Construction services for additions, renovations, and alterations to farm buildings, nonresidential

$

,000.00

3001850000

36. Construction services for maintenance and repair of farm buildings, nonresidential

$

,000.00

3002250000

$

,000.00

3000850000

$

,000.00

3001325000

39. Construction services for additions, renovations, and alterations to health care and institutional buildings

$

,000.00

3001725000

40. Construction services for maintenance and repair of health care and institutional buildings

$

,000.00

3002125000

41. Hotel, motel, and inn new constructions (by builders and at-risk project managers)

$

,000.00

3000650000

42. Construction services for new hotels, motels, and inns

$

,000.00

3001125000

43. Construction services for additions, renovations, and alterations to hotels, motels, and inns

$

,000.00

3001525000

44. Construction services for maintenance and repair of hotels, motels, and inns

$

,000.00

3001925000

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

Farm building construction, nonresidential
33. Farm building new constructions, nonresidential (by builders and at-risk project managers)

34. Construction services for new farm buildings, nonresidential

Health care and institutional building construction
37. Health care and institutional buildings new constructions (by builders and at-risk project managers)

38. Construction services for new health care and institutional buildings

Hotel, motel, and inn construction

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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Industrial warehouse construction
45. Industrial warehouse new constructions at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000680000

46. Industrial warehouse new constructions not at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000685000

47. Construction services for new industrial warehouses at manufacturing sites

$

,000.00

3001155000

48. Construction services for new industrial warehouses not at manufacturing sites

$

,000.00

3001160000

49. Construction services for additions, renovations, and alterations to industrial warehouses at manufacturing sites

$

,000.00

3001555000

50. Construction services for additions, renovations, and alterations to industrial warehouses not at manufacturing sites

$

,000.00

3001560000

51. Construction services for maintenance and repair of industrial warehouses at manufacturing sites

$

,000.00

3001955000

$

,000.00

3001960000

53. Nonresidential mobile building new constructions, office (by builders and at-risk project managers)

$

,000.00

3000930000

54. Nonresidential mobile building new constructions, other commercial (by builders and at-risk project managers)

$

,000.00

3000935000

55. Construction services for new nonresidential mobile building constructions, office

$

,000.00

3001405000

56. Construction services for new nonresidential mobile building constructions, other commercial

$

,000.00

3001410000

57. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
office

$

,000.00

3001805000

58. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
other commercial

$

,000.00

3001810000

59. Construction services for maintenance and repair of nonresidential mobile building constructions, office

$

,000.00

3002205000

60. Construction services for maintenance and repair of nonresidential mobile building constructions, other commercial

$

,000.00

3002210000

61. Office building and data center new constructions (by builders and at-risk project managers)

$

,000.00

3000725000

62. Construction services for new office buildings and data centers

$

,000.00

3001200000

63. Construction services for additions, renovations, and alterations to office buildings and data centers

$

,000.00

3001600000

52. Construction services for maintenance and repair of industrial warehouses not at manufacturing sites

Nonresidential mobile building construction, office and other commercial

Office building construction

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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64. Construction services for maintenance and repair of office buildings and data centers

$

,000.00

3002000000

65. Public safety building new constructions (by builders and at-risk project managers)

$

,000.00

3000900000

66. Construction services for new public safety buildings

$

,000.00

3001375000

67. Construction services for additions, renovations, and alterations to public safety buildings

$

,000.00

3001775000

68. Construction services for maintenance and repair of public safety buildings

$

,000.00

3002175000

$

,000.00

3000800000

70. Construction services for new religious buildings

$

,000.00

3001275000

71. Construction services for additions, renovations, and alterations to religious buildings

$

,000.00

3001675000

72. Construction services for maintenance and repair of religious buildings

$

,000.00

3002075000

73. Store, restaurant, automobile service station, parking garage, and other commercial building new constructions
(excluding mobile buildings)(by builders and at-risk project managers)

$

,000.00

3000775000

74. Construction services for new stores, restaurants, automobile service stations, parking garages, and other
commercial buildings (excluding mobile buildings)

$

,000.00

3001250000

75. Construction services for additions, renovations, and alterations to stores, restaurants, automobile service stations,
parking garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3001650000

76. Construction services for maintenance and repair of stores, restaurants, automobile service stations, parking
garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3002050000

77. Nonresidential mobile building new constructions, classroom (by builders and at-risk project managers)

$

,000.00

3000955000

78. Nonresidential mobile building new constructions, industrial (by builders and at-risk project managers)

$

,000.00

3000960000

79. Construction services for new nonresidential mobile building constructions, classroom

$

,000.00

3001430000

80. Construction services for new nonresidential mobile building constructions, industrial

$

,000.00

3001435000

81. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, classrooms

$

,000.00

3001830000

Public safety building construction

Religious building construction
69. Religious building new constructions (by builders and at-risk project managers)

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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82. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, industrial

$

,000.00

3001835000

83. Construction services for maintenance and repair of other nonresidential mobile building constructions, classrooms

$

,000.00

3002230000

84. Construction services for maintenance and repair of other nonresidential mobile building constructions, industrial

$

,000.00

3002235000

85. All other nonresidential building new constructions (by builders and at-risk project managers)

$

,000.00

3001025000

86. Construction services for all other new nonresidential buildings

$

,000.00

3001500000

87. Construction services for additions, renovations, and alterations to all other nonresidential buildings

$

,000.00

3001900000

88. Construction services for maintenance and repair of all other nonresidential buildings

$

,000.00

3002300000

89. Constructions of new apartment type condominiums, excluding single family condominiums (by builders and at-risk
project managers)

$

,000.00

3000100000

90. Construction services for new apartment type condominiums, excluding single family condominiums

$

,000.00

3000200000

91. Construction services for additions, renovations, and alterations to apartment type condominiums, excluding single
family condominiums

$

,000.00

3000300000

92. Construction services for maintenance and repair of apartment type condominiums, excluding single family
condominiums

$

,000.00

3000400000

93. Constructions of new manufactured (mobile) homes, all width sizes (including multisection) (by builders and at-risk
project managers)

$

,000.00

3000075000

94. Construction services for new manufactured homes (mobile homes), all width sizes (including multisection)

$

,000.00

3000175000

95. Construction services for additions, renovations, and alterations to manufactured homes (mobile homes), all width
sizes (including multisection)

$

,000.00

3000275000

96. Construction services for maintenance and repair of manufactured homes (mobile homes), all width sizes (including
multisection)

$

,000.00

3000375000

97. Constructions of new single attached residential buildings, including row houses and town houses (by builders and
at-risk project managers)

$

,000.00

3000050000

98. Construction services for new single attached residential buildings, including row houses and town houses

$

,000.00

3000150000

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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99. Construction services for additions, renovations, and alterations to single attached residential buildings, including
row houses and town houses

$

,000.00

3000250000

100. Construction services for maintenance and repair of single attached residential buildings, including row houses and
town houses

$

,000.00

3000350000

101. Constructions of new single detached residential buildings (by builders and at-risk project managers)

$

,000.00

3000025000

102. Construction services for new single detached residential buildings

$

,000.00

3000125000

103. Construction services for additions, renovations, and alterations to single detached residential buildings

$

,000.00

3000225000

104. Construction services for maintenance and repair of single detached residential buildings

$

,000.00

3000325000

105. Bridge and elevated highway new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002375000

106. Construction services for new bridges and elevated highways

$

,000.00

3003025000

107. Construction services for additions, renovations, and alterations to bridges and elevated highways

$

,000.00

3003675000

108. Construction services for maintenance and repair of bridges and elevated highways

$

,000.00

3004325000

109. Conservation and development new constructions, including dams, drainage canals, and flood control projects (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002650000

110. Construction services for new conservation and development constructions, including dams, drainage canals, and
flood control projects

$

,000.00

3003300000

111. Construction services for additions, renovations, and alterations to conservation and development constructions,
including dams, drainage canals, and flood control projects

$

,000.00

3003950000

112. Construction services for maintenance and repair of conservation and development constructions, including dams,
drainage canals, and flood control projects

$

,000.00

3004600000

$

,000.00

3002825000

$

,000.00

3003475000

115. Construction services for additions, renovations, and alterations to fencing constructions

$

,000.00

3004125000

116. Construction services for maintenance and repair of fencing constructions

$

,000.00

3004750000

Single detached residential building construction

Bridge and elevated highway

Conservation and development construction, including dams, drainage canals, and flood control projects

Fencing
113. Fencing new constructions (by heavy construction contractors and at-risk project managers)

114. Construction services for new fencing constructions

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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Harbor and port facilities
117. Harbor and port facilities new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002725000

118. Construction services for new harbor and port facilities

$

,000.00

3003375000

119. Construction services for additions, renovations, and alterations to harbor and port facilities

$

,000.00

3004025000

120. Construction services for maintenance and repair of harbor and port facilities

$

,000.00

3004675000

121. Power plant new constructions, hydroelectric (by heavy construction contractors and at-risk project managers)

$

,000.00

3002575000

122. Construction services for new power plants, hydroelectric

$

,000.00

3003225000

123. Construction services for additions, renovations, and alterations to power plants, hydroelectric

$

,000.00

3003875000

124. Construction services for maintenance and repair of power plants, hydroelectric

$

,000.00

3004525000

125. Marine new constructions, including dredging, navigational channels, and locks (by heavy construction contractors
and at-risk project managers)

$

,000.00

3002750000

126. Construction services for new marine constructions, including dredging, navigational channels, and locks

$

,000.00

3003400000

127. Construction services for additions, renovations, and alterations to marine constructions, including dredging,
navigational channels, and locks

$

,000.00

3004050000

128. Construction services for maintenance and repair of marine constructions, including dredging, navigational
channels, and locks

$

,000.00

3004700000

129. Mass transit new constructions, including railroads (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002700000

130. Construction services for new mass transit constructions, including railroads

$

,000.00

3003350000

131. Construction services contractors for additions, renovations, and alterations to mass transit constructions, including
railroads

$

,000.00

3004000000

132. Construction services for maintenance and repair of mass transit constructions, including railroads

$

,000.00

3004650000

$

,000.00

3002500000

Hydroelectric power plants

Marine construction, such as dredging, navigational channels, and locks

Mass transit, including railroads

Oil and gas pipelines, pumping stations, storage tanks, and mains
133. Oil and gas pipeline, pumping station, storage tank, and main new constructions (by heavy construction
contractors and at-risk project managers)

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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134. Construction services for new oil and gas pipelines, pumping stations, storage tanks, and mains

$

,000.00

3003150000

135. Construction services for additions, renovations, and alterations to oil and gas pipelines, pumping stations, storage
tanks, and mains

$

,000.00

3003800000

136. Construction services for maintenance and repair of oil and gas pipelines, pumping stations, storage tanks, and
mains

$

,000.00

3004450000

137. Outdoor recreational area new constructions, including athletic fields, courts, golf courses, and campgrounds (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002800000

138. Construction services for new outdoor recreational areas, including athletic fields, courts, golf courses, and
campgrounds

$

,000.00

3003450000

139. Construction services for additions, renovations, and alterations to outdoor recreational area constructions,
including athletic fields, courts, golf courses, and campgrounds

$

,000.00

3004100000

140. Construction services for maintenance and repair of outdoor recreational area constructions, including athletic
fields, courts, golf courses, and campgrounds

$

,000.00

3004725000

$

,000.00

3002625000

$

,000.00

3003275000

$

,000.00

3003925000

$

,000.00

3004575000

145. Power and cogeneration plant new constructions, except hydroelectric (by heavy construction contractors and atrisk project managers)

$

,000.00

3002550000

146. Construction services for new power and cogeneration plants, except hydroelectric

$

,000.00

3003200000

147. Construction services for additions, renovations, and alterations to power and cogeneration plants, except
hydroelectric

$

,000.00

3003850000

$

,000.00

3004500000

$

,000.00

3002525000

$

,000.00

3003175000

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

Petrochemical plant and petroleum refinery construction
141. Petrochemical plant and petroleum refinery new constructions (by heavy construction contractors and at-risk
project managers)
142. Construction services for new petrochemical plants and petroleum refineries

143. Construction services for additions, renovations, and alterations to petrochemical plants and petroleum refineries

144. Construction services for maintenance and repair of petrochemical plants and petroleum refineries

Power and cogeneration plant construction, except hydroelectric construction

148. Construction services for maintenance and repair of power and cogeneration plants, except hydroelectric

Power and communication transmission line, cable, tower, and related facilities
149. Power and communication transmission line, cable, tower, and related facilities new constructions (by heavy
construction contractors and at-risk project managers)
150. Construction services for new power and communication transmission lines, cables, towers, and related facilities

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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151. Construction services for additions, renovations, and alterations to power and communication transmission lines,
cables, towers, and related facilities

$

,000.00

3003825000

152. Construction services for maintenance and repair of power and communication transmission lines, cables, towers,
and related facilities

$

,000.00

3004475000

$

,000.00

3002475000

$

,000.00

3003125000

155. Construction services for additions, renovations, and alterations to sewage and water treatment plants

$

,000.00

3003775000

156. Construction services for maintenance and repair of sewage and water treatment plants

$

,000.00

3004425000

157. Sewer, sewer line, septic system, and related facilities new constructions (by heavy construction contractors and
at-risk project managers)

$

,000.00

3002425000

158. Construction services for new sewers, sewer lines, septic systems, and related facilities

$

,000.00

3003075000

159. Construction services for additions, renovations, and alterations to sewers, sewer lines, septic systems, and
related facilities

$

,000.00

3003725000

160. Construction services for maintenance and repair of sewers, sewer lines, septic systems, and related facilities

$

,000.00

3004375000

$

,000.00

2053950000

$

,000.00

2053975000

$

,000.00

3002775000

$

,000.00

3003425000

$

,000.00

3004075000

$

,000.00

3002400000

$

,000.00

3003050000

Sewage and water treatment plants
153. Sewage and water treatment plant new constructions(by heavy construction contractors and at-risk project
managers)
154. Construction services for new sewage and water treatment plants

Sewers, sewer lines, septic systems, and related facilities

Ship maintenance and repair services
161. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, military

162. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, nonmilitary

Swimming pools
163. Swimming pool new constructions (by builders and at-risk project managers)

164. Construction services for new swimming pools

165. Construction services for additions, renovations, and alterations to swimming pools

Tunnels
166. Tunnel new constructions (by heavy construction contractors and at-risk project managers)

167. Construction services for new tunnels

2022_CC-23830_su.pdf Generated 2022-02-23 15:46:52

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168. Construction services for additions, renovations, and alterations to tunnels

$

,000.00

3003700000

$

,000.00

3004350000

$

,000.00

3002450000

$

,000.00

3003100000

$

,000.00

3003750000

$

,000.00

3004400000

$

,000.00

3002950000

$

,000.00

3003600000

176. Construction services for additions, renovations, and alterations to other nonresidential constructions, excluding
buildings

$

,000.00

3004250000

177. Construction services for maintenance and repair of all other nonresidential constructions, excluding buildings

$

,000.00

3004775000

$

,000.00

7008725003

b. Parking lot sweeping services

$

,000.00

7008725006

c. Swimming pool cleaning and maintenance services

$

,000.00

7008725009

$

,000.00

7008725012

$

,000.00

7008725000

179. Residential deck new constructions (by builders and at-risk project managers)

$

,000.00

3000425000

180. Construction services for new residential deck constructions

$

,000.00

3000450000

169. Construction services for maintenance and repair of tunnels

Water mains, storage wells, and related facilities
170. Water main, storage, well, and related facilities new constructions (by heavy construction contractors and at-risk
project managers)
171. Construction services for new water mains, storage, wells, and related facilities

172. Construction services for additions, renovations, and alterations to water mains, storage, wells, and related
facilities
173. Construction services for maintenance and repair of water mains, storage, wells, and related facilities

Other nonresidential constructions, except buildings
174. Other nonresidential new constructions, except buildings (by heavy construction contractors and at-risk project
managers)
175. Construction services for other new nonresidential constructions, excluding buildings

Other specialized cleaning services, not elsewhere classified
178. Other specialized cleaning services, not elsewhere classified
a. Drain and gutter cleaning services

d. All other specialized cleaning services, not elsewhere classified

Subtotal

Residential decks

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43

181. Construction services for additions, renovations, and alterations to residential deck constructions

$

,000.00

3000475000

$

,000.00

3000500000

a. Residential irrigation and sprinkler system new constructions (by builders and at-risk project managers)

$

,000.00

3000525003

b. Other residential landscape new constructions, excluding decks (by builders and at-risk project managers)

$

,000.00

3000525006

$

,000.00

3000525000

$

,000.00

3000550003

$

,000.00

3000550006

$

,000.00

3000550000

a. Construction services for additions, renovations, and alterations to residential irrigation and sprinkler system
constructions

$

,000.00

3000575003

b. Construction services for additions, renovations, and alterations to other residential landscape constructions,
excluding decks

$

,000.00

3000575006

Subtotal

$

,000.00

3000575000

$

,000.00

3000600003

b. Construction services for maintenance and repair of other residential landscape constructions, excluding decks

$

,000.00

3000600006

Subtotal

$

,000.00

3000600000

$

,000.00

9900000000

182. Construction services for maintenance and repair of residential deck constructions

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks
183. Residential landscape new constructions, excluding decks (by builders and at-risk project managers)

Subtotal

184. Construction services for new residential landscape constructions, excluding decks (by builders and at-risk project
managers)
a. Construction services for new residential irrigation and sprinkler system constructions

b. Construction services for other new residential landscape constructions, excluding decks

Subtotal

185. Construction services for additions, renovations, and alterations to residential landscape constructions, excluding
decks

186. Construction services for maintenance and repair of residential landscape constructions, excluding decks
a. Construction services for maintenance and repair of residential irrigation and sprinkler system constructions

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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44

Item 23: Kind of Business Activities Additional Information

ITEM 23: KIND OF BUSINESS ACTIVITIES
For the $,000.00 of sales, shipments, receipts, or revenue in 2022, please report the percent of the total represented by the following construction and non-construction business
activities. The sum of these percentages should equal 100%.
CONSTRUCTION WORK ACTIVITIES
Report only the main activities for which you were contracted. Work which was incidental to the primary activities of jobs should not be reported separately. If the construction activity is
not listed below, please enter a description of the construction activity in the “Other construction activities” write-in box, along with a percentage of the value of total business for that
specified construction activity.
OTHER BUSINESS ACTIVITIES
Report any non-construction activities. If the activity is not listed below, please enter a description of the non-construction activity in the “Other business activities” write-in box, along
with a percentage of the value of total business for that specified activity.

Description

Code

Value

Construction work activities

1. Acoustical contractor

2. Drywall contractor

3. Insulation contractor (except boiler, pipe, or duct work)

4. Fireproofing for other foundation, structure, and building exterior contractor

5. Fireproof flooring contractor

6. Plastering, lathing, or fresco contractor

7. Bridge and ship painting contractor (except lane painting for bridges)

8. Painting contractor

9. Wall covering or removal contractor

10. Carpet laying or removal contractor
11. Flooring contractor, including wood, resilient, and computer flooring (except fireproof
flooring)

12. Marble, granite, or slate contractor, interior

8310

%

8311

%

8312

%

8314

%

8315

%

8313

%

8320

%

8321

%

8322

%

8330

%

8332

%

8340

%

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45

13. Tile, terrazzo, or mosaic contractor

14. Finish carpentry contractor

15. Garage door and overhead door installation contractor, residential-type

16. Specialty sheet metal contractor, including metal ceiling, panel, or shelving installation

17. Waterproofing and weather stripping contractor

18. Framing contractor

19. Marble, granite, or slate contractor, exterior

20. Masonry contractor: brick, block, or stone (except brick paving)

21. Stucco contractor

22. Boiler, pipe, or duct work insulation contractor
23. Other kinds of construction

8341

%

8350

%

8351

%

8390

%

8391

%

8130

%

8140

%

8141

%

8143

%

8292

%

9000

%

9914

%

9915

%

9919

%

9922

%

9925

%

9929

%

8005

%

Describe

Other business activity

24. Engineering services

25. Manufacturing -- products manufactured and sold to others

26. Rental of construction machinery or equipment to others, without an operator

27. Wholesale trade

28. Retail trade
29. Other business activities
Describe

TOTAL

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Ownership of Projects Additional Information

ITEM 28: SPECIAL ITEMS - OWNERSHIP OF PROJECTS
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue) on projects owned by the following:
2022
%

1. Private businesses and individuals

%

2. State and local governments

%

3. Federal Government
TOTAL
(Percentages reported in lines 1 through 3 should equal 100%.)

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%

49

Item 28: Special Items - Construction Subcontractors

ITEM 28: SPECIAL ITEMS - CONSTRUCTION SUBCONTRACTORS
What percent of the amount you reported in Item 5 (Sales, Shipments, Receipts, or Revenue) represents work you did for other contractors or builders?
(Enter "0" if you did not subcontract work from other contractors or builders.)
2022
%

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Item 28: Special Items - Construction by State

ITEM 28: SPECIAL ITEMS - CONSTRUCTION BY STATE
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue), which occurred in each state
(The sum of the percentages reported should equal 100%.)
2022

2022
%

Montana

%

%

Nebraska

%

%

Nevada

%

%

New Hampshire

%

%

New Jersey

%

%

New Mexico

%

%

New York

%

Delaware

%

North Carolina

%

District of Columbia

%

North Dakota

%

Florida

%

Ohio

%

Georgia

%

Oklahoma

%

Hawaii

%

Oregon

%

Idaho

%

Pennsylvania

%

%

Rhode Island

%

%

South Carolina

%

%

South Dakota

%

%

Tennessee

%

%

Texas

%

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Illinois

Indiana

Iowa

Kansas

Kentucky

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51

Louisiana

%

Utah

%

Maine

%

Vermont

%

%

Virginia

%

%

Washington

%

%

West Virginia

%

%

Wisconsin

%

%

Wyoming

%

%

United States

%

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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55

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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58

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

63

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

64

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is a construction establishment which is generally a permanent office, payroll office, or other place where business activities related to
construction are conducted. A construction establishment manages one or more projects or jobs and is usually maintained on a continuing basis.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Temporary construction site

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

New single-family housing construction (excluding for-sale builders), including attached and detached housing

236115 001

New multifamily housing construction (excluding for-sale builders), including apartments and condominiums

236116 001

New housing for-sale builder of single-family housing and multifamily housing

236117 001

Residential remodeler for home improvement (e.g., adding on, renovating, maintenance, and repair), including remodeling homes for resale

236118 001

Industrial building construction (e.g., processing and assembly plants, factories, refineries, waste disposal facilities), excluding warehouses
and sewage disposal plants

236210 001

Commercial and institutional building construction (e.g., office and school buildings, hospitals, health and data facilities, stores, and
warehouses)

236220 001

Water and sewer line and related structures construction (e.g., mains, sewage disposal plants, pumping stations, and water well drilling)

237110 001

Oil and gas pipeline and related structures construction (e.g., mains, petrochemical plants, pumping stations, and oil refineries)

237120 001

Power and communication line and related structures construction (e.g., alternative energy structures, power plants, transformer stations,
high voltage transmission cable connections, and cellular phone towers)

237130 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Highway, street, and bridge construction, including curbs, airport runway construction, and line painting of streets and parking lots

237310 001

Other heavy and civil engineering construction (e.g., tunnels, railways, outside recreation areas, dams, flood and drainage control projects,
dredging, trenching, and marine facilities)

237990 001

Poured concrete foundation and structure contractor (e.g., shotcrete, mud-jacking, gunning, gunite, pumping, and placement footing)

238110 001

Structural steel and precast concrete contractor, including structural iron work

238120 001

Framing contractor, including wood and steel (excluding structural steel or precast concrete)

238130 001

Masonry contractor (e.g., brick, stone, slate, glass block, cement, cinder blocking, stucco setting and other stone work)

238140 001

Glass and glazing contractor (e.g., glass coating and tinting (excluding automotive), window pane, glass sheet, glass curtain wall, and mirror
installation)

238150 001

Roofing contractor, including treating roofs (i.e., spraying, painting or coating) and skylight installation

238160 001

Siding contractor (e.g., gutters, downspouts, fascia, soffit, eavestrough, flashing, and ice apron)

238170 001

Other foundation, structure, and building exterior contractor (e.g., awning, metal balcony and stairway, and falsework construction), including
decorative steel and wrought iron work; poured concrete form installation and dismantling; and welding at site

238190 001

Electrical and other wiring installation contractor (e.g., electronic and environmental controls, telecommunications and fiber optic equipment
(excluding transmission line), solar panel installation, traffic signals, and fire and security systems)

238210 001

Plumbing, heating, and air-conditioning (HVAC) contractor, including installation, maintenance, and repair of refrigeration systems, sprinkler
systems, water systems, gas and oil line individual hookups, and steam and pipe fittings

238220 001

Other building equipment contractor (e.g., millwrights, machine rigging), including installation, maintenance, and repair of ATM equipment,
elevators, escalators, service station gasoline pumps, commercial and industrial doors)

238290 001

Drywall and insulation contractor, including acoustical, plastering, and fireproofing contractors

238310 001

Painting and wall covering contractor, including on-site electrostatic painting, whitewashing, and rustproofing of buildings, ships, bridges,
tanks, and towers (excluding automotive)

238320 001

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Flooring contractor (e.g., laying carpet, linoleum, hardwood, laminate, and vinyl flooring), excluding fireproof, stone, concrete, and ceramic
tile flooring

238330 001

Tile and terrazzo contractor (e.g., marble, granite, slate, ceramic, stone, and mosaic work for floors, walls, and ceilings), excluding exterior
marble, granite, and slate work

238340 001

Finish carpentry contractor (e.g., door, window, cabinetry, countertop, stairway, deck, molding, trim, and paneling work, residential-type,
installation), excluding framing

238350 001

Other building finishing contractor (e.g., waterproofing, spectator seating, modular furniture system attachments, closet organizer systems,
concrete coating, window shades and blinds, and trade show exhibit installation and dismantling)

238390 001

Site preparation contractor, without land subdivision (e.g., land clearing, drilling, demolition, trenching, and earthmoving), and rental of
construction equipment with operators (excluding cranes))

238910 001

All other specialty trade contractor (e.g., driveway paving; constructions of residential and commercial parking lots, sidewalks, patios, and
outdoor swimming pools; installation of fences (excluding electric) and playground equipment; and crane rental with operator)

238990 001

Other specialty trade contractors

238900 001

Other primary business or activity

779000 001

Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Include:
Receipts (or billings) derived from contract construction work done for others
Sales of houses and other buildings you built and sold
Construction management and design-build contracts
Site preparation receipts, such as land clearing, laying roads, installing utilities, and subdividing land into lots (Exclude purchase cost of land or estimated value of raw land for
construction projects.)
Architectural services, except the design portion of integrated design-build contracts
Engineering services
Rental or lease of properties
Real estate commissions and property management fees
Rental of construction machinery or equipment to others, without an operator
Manufacturing, mining, and transportation activities
Retail and wholesale trades
Other business activities
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building structure)
Purchased cost of land or estimated value of raw land for construction projects (Include site preparation receipts.)
Non-operating income such as interest, dividends, or the sale of fixed assets.
What were the receipts for all business activities done by this establishment, including receipts, billings, or sales for
construction work? (Construction work includes new construction and remodeling as well as maintenance and repair
work. The activities of prime and trade contractors are considered to be construction. Some trades not traditionally
thought of as construction are included such as land subdivision, excavation, building demolition, painting, carpet-laying,
water well drilling, plumbing and electrical work.)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

Check
if
None

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Number of employees at this establishment
Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
If the legal form of organization for this business is a corporation, the reporting of other employees and other payroll at this establishment is required. Enter "0" if the establishment
did not have payroll and employment for specific data for this EIN. If payroll and employment for this EIN are zero, please indicate if the EIN is a joint venture or reason why data
are zero in Item 31: Remarks at the end of the survey.
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Spread on stock options that are taxable to employees at this establishment as wages
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company’s EIN (Report values in Item 16, line C1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line C1.)
Contractors, subcontractors, or independent contractors
Purchased or managed services, such as janitorial, security, or landscape services (Report values in Item 16, line C9.)
Purchased professional and technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services (Report
values in Item 16, line C9.)
Members of the Armed Forces and pensioners carried on your active rolls
Proprietors and partners, if an unincorporated concern
Number of construction workers at this establishment include:
Apprentices
Working foremen
Equipment operators and mechanics
Journeymen
Job-site record keepers
Craftsmen
Laborers
Truck drivers and helpers
Others engaged directly in construction
Number of other employees at this establishment include:
Supervisors above working foremen
Office staff
Executives
Architects
Purchasing Agents
Personnel staff
Engineers
Accounting staff
Others engaged in non-construction activities
A. Number of employees at this establishment for the pay period including the 12th of the month.
March 2022

June 2022

September 2022

December 2022

1. What was the number of construction workers
(direct labor including first-line supervisors)?

2. What was the number of other employees?

TOTAL (Add lines A1 and A2.)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

20

B. HOURS WORKED
Check
if
None

2022 Hours

What was the annual number of hours worked by the construction workers at this establishment (direct labor
including first-line supervisors) reported in line A?

,000

C. PAYROLL
Include:
Payroll for officers at this establishment
Exclude:
Income or costs not recorded as payroll for IRS by establishment.
Employer-paid annual cost for fringe benefits reported in lines 7D1 and 7D2
Check
if
None

2022

1. What was the annual payroll at this establishment before deductions for construction workers (direct labor
including first-line supervisors)?

$

,000.00

2. What was the annual payroll before deductions for other employees?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $0,000.00 reported above, what was the first quarter payroll at this establishment before deductions
(January-March 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits
Check
if
None

2022

1. What were the legally required fringe benefits? (Include employer payments for Social Security, Medicare,
unemployment compensation, workmen's compensation, and State disability programs, if required.)

$

,000.00

2. What were the voluntarily provided fringe benefits? (Include such items as payments for life insurance, medical
insurance, pensions, welfare benefits, and union-negotiated benefits.)

$

,000.00

TOTAL (Add lines D1 and D2.)

$

,000.00

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

21

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Include:
Inventories, regardless of where held, for materials and supplies owned by this establishment as of December 31
Exclude:
Work-in-progress and finished units

Using current cost, what was the value of inventories owned
by this establishment as of December 31? (If using LIFO
method of evaluation, adjust to obtain FIFO or current cost.)

Check
if
None

2022
$

2021
,000.00

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

$

,000.00

22

Item 13: Assets, Capital Expenditures, and Retirements Additional Information

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS
Exclude
Land (Report cost of land acquired during the year in Item 16A, line 5.)

Check
if
None

2022
$

,000.00

B. What were the capital expenditures for new and used depreciable assets?

$

,000.00

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc.?

$

,000.00

D. What was the value of depreciable assets at the end of the year? (Add lines A and B minus line C.)

$

,000.00

A. What was the gross value of depreciable assets (usually original cost) at the beginning of the year?

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

23

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

B. Rental or lease of machinery and equipment?
Include:
Production, loading, and transportation machinery and equipment
Construction equipment
Tools
Office equipment
Furniture
Vehicles
Exclude:
Computer time-sharing charges for machinery and equipment rentals from computer service companies where
the computer is not on site at the establishment

TOTAL (Add lines A and B.)

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24

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
A. For this establishment, what were the cost of materials, subcontract work, fuels, electricity, and land acquired in 2022 for:
Include:
Current account expenses normally considered as cost of work performed or job-specific costs

1. Cost of materials, parts, and supplies?
Include:
All job-site, office, and construction materials and supplies
Cost of materials purchased by this establishment's subcontractors
Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building
structure)
Non-construction-related expenses that were paid to subcontractors by this establishment (Report these
expense details on the next screen, Item 16: Selected Expenses - Continued, in line C.)

Check
if
None

2022
$

,000.00

$

,000.00

a. Natural gas and manufactured gas (propane)?

$

,000.00

b. Gasoline and diesel fuel - ON highway (not at site)?

$

,000.00

c. Gasoline and diesel fuel - OFF highway (at site)?

$

,000.00

$

,000.00

$

,000.00

2. Cost of construction-related work subcontracted out to others?
Exclude:
Cost of materials purchased by this establishment for subcontractors (These costs should be reported in line
A1.)

Check
if
None

3. Cost of fuels for heat, power, lubricants
Check
if
None

d. All other fuels and lubricants, including heating oils, lubricating oils, and greases?

Check
if
None
4. Cost of electricity?

5. When you answered Item 5, did you include the purchased cost of land or estimated value of raw land? Please check one, and answer the below question.
Yes
No

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

25

Check
if
None
6. What was the purchased cost of land or estimated value of raw land for reported construction projects during the
covered time?

$

,000.00

$

,000.00

Check
if
None
B. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

26

Item 16: Selected Expenses - Continued Additional Information

ITEM 16: SELECTED EXPENSES

C. What were the other operating expenses paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services your establishment paid to the Professional Employer
Organizations for the temporary staff and leased employees

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment)
Include:
Copiers
Fax machines
Telephones
Shop and lab equipment
CPUs
Monitors
Exclude:
Packaged software (Report on line C3.)
Leased and rented equipment (Report on Item 14, line B.)

3. Expensed purchases of software? (Purchases of prepackaged, custom coded or vendor customized software)
Include
Software developed or customized by others
Web-design services and purchases
Licensing agreements
Upgrades of software
Maintenance fees related to software upgrades and alterations

4. Purchased communication services?
Include:
Telephone, cellular, and fax services
Computer-related communications (e.g., Internet, connectivity, online)
Other wired and wireless communication services
Credit card transaction fees

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

27

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Computer input preparation
Data Storage
Computer time rental
Optical scanning services
Other computer-related advice and services, including training
Exclude:
Services provided by other establishments of this company (such as a separate central data processing
unit)
Expensed integrated systems (Report in line C4.)
Repair and maintenance of computer equipment (Report in line C6.)
Payroll processing and credit card transaction fees (Report payroll processing fees in line C9 and credit
card transaction fees in line C4.)
Expenses for telecommunication services (e.g., Internet, connectivity, telephone) (Report in line C4.)

$

,000.00

Exclude
Materials, parts, and supplies used for repairs and maintenance performed by this firm's employees

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments in Item 16, line A4. If the cost of these utilities is included in a leased or rental
payment, report in Item 14, line A.)
Include:
Cost of hazardous waste removal

$

,000.00

$

,000.00

$

,000.00

6. Purchased repairs and maintenance to buildings and/or machinery and equipment?

8. Purchased advertising and promotional services?
Include:
Marketing and public relations services
Exclude:
Salaries paid to employees of this establishment for advertising work

9. Purchased professional and technical services?
Include:
Management consulting
Accounting
Auditing
Bookkeeping
Legal
Actuarial
Payroll processing
Architectural
Engineering
Other Professional services (i.e. such as janitorial, security, or landscape services)
Exclude:
Salaries paid to your own employees for these services (Report in Item 7.)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

28

10. Governmental taxes and licensing fees?(Payments to government agencies for taxes and licenses)
Include:
Business and property tax fees for establishment to remain active legal operable business
Permits and licensing fees
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?

Include:
Expenses for paid temporary day labors not on your payroll or hired as construction subcontractors
Exclude:
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
The construction project types listed below are general to your industry. Select the project types that apply to your establishment. On the next screen, you will report the specific
construction products and services related to the construction projects you select. If you have revenue from other sources not listed, you will have the opportunity to report them later.
At-risk construction project management revenue should be reported with the specific construction project associated with those management services. For example, if at-risk
construction project management is for office buildings, then include the management revenue with the project for office buildings. However, at-fee project management services
should be reported in the specific project for construction project management services.
Description

Select

Amusement, social, and recreational building construction

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

Commercial warehouses, such as distribution buildings and mini-storage

Project Code

334

322

359

327

319

Dormitories and barracks

329

Educational building construction

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

323

333

Farm building construction, nonresidential

331

Health care and institutional building construction

324

Hotel, motel, and inn construction

321

Industrial warehouse construction

Nonresidential mobile building construction, office and other commercial

335

325

Office building construction

332

Public safety building construction

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

30

328

Religious building construction

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

326

336

338

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

318

314

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

317

316

Single detached residential building construction

342

Airport runways and landing fields

346

Bridge and elevated highway

392

Coal mines

Conservation and development construction, including dams, drainage canals, and flood control projects

368

378

Fencing

373

Harbor and port facilities

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

341

357

Hydroelectric power plants

Marine construction, such as dredging, navigational channels, and locks

374

366

Mass transit, including railroads

393

Metal mines

394

Nonmetallic mines

385

Oil and gas fields

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

31

Oil and gas pipelines, pumping stations, storage tanks, and mains

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

353

381

364

Petrochemical plant and petroleum refinery construction

Power and cogeneration plant construction, except hydroelectric construction

Power and communication transmission line, cable, tower, and related facilities

Private driveway and parking area construction, except garages

356

354

343

361

Sewage and water treatment plants

Sewers, sewer lines, septic systems, and related facilities

351

384

Ship maintenance and repair services

375

Swimming pools

347

Tunnels

352

Water mains, storage wells, and related facilities

395

Other nonresidential constructions, except buildings

Other specialized cleaning services, not elsewhere classified

399

376

Residential decks

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks

377

Add product/service not listed

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

32

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services associated with the construction projects you previously selected. If you have revenue from sources not listed, describe and report them in the
"All other sales, shipments, receipts, or revenue from this establishment" section at the end of this question.
At-risk construction project management revenue should be reported with the specific constructions or construction services associated with those management services. For
example, if at-risk construction project management is for entire office building constructions, then include the management revenue with the new constructions for office buildings.
However, at-fee project management services should be reported in the specific product lines for construction project management services.
New Constructions and Construction Services – Report only the main activities including the type of buildings, structures, or facilities contracted to construct or work on by this
establishment in the reporting year in which this establishment received receipts only. If you worked on more than one type of building or structure in a multipurpose complex, report
separately for each building or type of structure. However, if you worked on a building that had more than one purpose, i.e. office, residential, or commercial, classify this building by
its major purpose.
New constructions include all components of the entire original building or structure. Land development work on the site and demolition of existing structures are included with
new constructions.
Construction services for new building or structures include separate components of the original building or structure, such as electric work, painting, plumbing, etc.
Construction services for additions, renovations, and alterations to buildings or structures include construction work which adds to the value of useful life of an existing
building or structure, or which adapts a building or structure to a new or different use. Included are “major replacements” of building systems such as the installation of a new
roof or heating system, and the resurfacing of streets or highways. Exclude activities such as the repair of a hole in a roof or the routine patching of highways and streets, which
are classified as “maintenance and repair work”.
Construction services for maintenance and repair of buildings or structures include incidental construction work that keeps a property in ordinary working condition.
Exclude trash and snow removal, lawn maintenance, and janitorial services.

Description

Value

Product Code

Amusement, social, and recreational building construction
1. Amusement, social, and recreational building new constructions (by builders and at-risk project managers)

$

,000.00

3000875000

2. Construction services for new amusement, social, and recreational buildings

$

,000.00

3001350000

3. Construction services for additions, renovations, and alterations to amusement, social, and recreational buildings

$

,000.00

3001750000

4. Construction services for maintenance and repair of amusement, social, and recreational buildings

$

,000.00

3002150000

5. Apartment building (two or more units) new constructions, excluding condominiums (by builders and at-risk project
managers)

$

,000.00

3000625000

6. Construction services for new apartment buildings (two or more units), excluding condominiums

$

,000.00

3001050000

7. Construction services for additions, renovations, and alterations to apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001075000

8. Construction services for maintenance and repair of apartment buildings (two or more units), excluding
condominiums

$

,000.00

3001100000

Apartment building construction (two or more units), excluding condominiums (only rental structure)

Chemical (except petrochemical) complexes/plants, blast furnaces, and mining appurtenances

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

33

9. Chemical (except petrochemical) complex/plant, blast furnace, and mining appurtenance new constructions (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002600000

10. Construction services for new chemical (except petrochemical) complexes/plants, blast furnaces, and mining
appurtenances

$

,000.00

3003250000

11. Construction services for additions, renovations, and alterations to chemical (except petrochemical)
complexes/plants, blast furnaces, and mining appurtenances

$

,000.00

3003900000

12. Construction services for maintenance and repair of chemical (except petrochemical) complexes/plants, blast
furnaces, and mining appurtenances

$

,000.00

3004550000

13. Commercial warehouse new constructions, such as distribution buildings and mini-storage (by builders and at-risk
project managers)

$

,000.00

3000750000

14. Construction services for new commercial warehouses, such as distribution buildings and mini-storage

$

,000.00

3001225000

15. Construction services for additions, renovations, and alterations to commercial warehouses, such as distribution
buildings and mini-storage

$

,000.00

3001625000

16. Construction services for maintenance and repair of commercial warehouses, such as distribution buildings and
mini-storage

$

,000.00

3002025000

17. Educational institution dormitories new constructions (by builders and at-risk project mangers)

$

,000.00

3001005000

18. Military and other public safety dormitories and barracks new constructions (by builders and at-risk project
managers)

$

,000.00

3001010000

$

,000.00

3001480000

20. Construction services for new military and other public safety dormitories and barracks

$

,000.00

3001485000

21. Construction services for additions, renovations, and alterations to educational institution dormitories

$

,000.00

3001880000

22. Construction services for additions, renovations, and alterations to military and other public safety dormitories and
barracks

$

,000.00

3001885000

$

,000.00

3002280000

$

,000.00

3002285000

25. Educational building new constructions (by builders and at-risk project managers)

$

,000.00

3000825000

26. Construction services for new educational buildings

$

,000.00

3001300000

Commercial warehouses, such as distribution buildings and mini-storage

Dormitories and barracks

19. Construction services for new educational institution dormitories

23. Construction services for maintenance and repair of educational institution dormitories

24. Construction services for maintenance and repair of military and other public safety dormitories and barracks

Educational building construction

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

34

27. Construction services for additions, renovations, and alterations to educational buildings

$

,000.00

3001700000

28. Construction services for maintenance and repair of educational buildings

$

,000.00

3002100000

29. Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building new
constructions (by builders and at-risk project managers)

$

,000.00

3000700000

30. Construction services for new factories, assembly plants, industrial research laboratories, and other new
manufacturing and industrial buildings

$

,000.00

3001175000

31. Construction services for additions, renovations, and alterations to factories, assembly plants, industrial research
laboratories, and other manufacturing and industrial buildings

$

,000.00

3001575000

32. Construction services for maintenance and repair of factories, assembly plants, industrial research laboratories, and
other manufacturing and industrial buildings

$

,000.00

3001975000

$

,000.00

3000975000

$

,000.00

3001450000

35. Construction services for additions, renovations, and alterations to farm buildings, nonresidential

$

,000.00

3001850000

36. Construction services for maintenance and repair of farm buildings, nonresidential

$

,000.00

3002250000

$

,000.00

3000850000

$

,000.00

3001325000

39. Construction services for additions, renovations, and alterations to health care and institutional buildings

$

,000.00

3001725000

40. Construction services for maintenance and repair of health care and institutional buildings

$

,000.00

3002125000

41. Hotel, motel, and inn new constructions (by builders and at-risk project managers)

$

,000.00

3000650000

42. Construction services for new hotels, motels, and inns

$

,000.00

3001125000

43. Construction services for additions, renovations, and alterations to hotels, motels, and inns

$

,000.00

3001525000

44. Construction services for maintenance and repair of hotels, motels, and inns

$

,000.00

3001925000

Factory, assembly plant, industrial research laboratory, and other manufacturing and industrial building construction

Farm building construction, nonresidential
33. Farm building new constructions, nonresidential (by builders and at-risk project managers)

34. Construction services for new farm buildings, nonresidential

Health care and institutional building construction
37. Health care and institutional buildings new constructions (by builders and at-risk project managers)

38. Construction services for new health care and institutional buildings

Hotel, motel, and inn construction

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

35

Industrial warehouse construction
45. Industrial warehouse new constructions at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000680000

46. Industrial warehouse new constructions not at manufacturing sites (by builders and at-risk project managers)

$

,000.00

3000685000

47. Construction services for new industrial warehouses at manufacturing sites

$

,000.00

3001155000

48. Construction services for new industrial warehouses not at manufacturing sites

$

,000.00

3001160000

49. Construction services for additions, renovations, and alterations to industrial warehouses at manufacturing sites

$

,000.00

3001555000

50. Construction services for additions, renovations, and alterations to industrial warehouses not at manufacturing sites

$

,000.00

3001560000

51. Construction services for maintenance and repair of industrial warehouses at manufacturing sites

$

,000.00

3001955000

$

,000.00

3001960000

53. Nonresidential mobile building new constructions, office (by builders and at-risk project managers)

$

,000.00

3000930000

54. Nonresidential mobile building new constructions, other commercial (by builders and at-risk project managers)

$

,000.00

3000935000

55. Construction services for new nonresidential mobile building constructions, office

$

,000.00

3001405000

56. Construction services for new nonresidential mobile building constructions, other commercial

$

,000.00

3001410000

57. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
office

$

,000.00

3001805000

58. Construction services for additions, renovations, and alterations to nonresidential mobile building constructions,
other commercial

$

,000.00

3001810000

59. Construction services for maintenance and repair of nonresidential mobile building constructions, office

$

,000.00

3002205000

60. Construction services for maintenance and repair of nonresidential mobile building constructions, other commercial

$

,000.00

3002210000

61. Office building and data center new constructions (by builders and at-risk project managers)

$

,000.00

3000725000

62. Construction services for new office buildings and data centers

$

,000.00

3001200000

63. Construction services for additions, renovations, and alterations to office buildings and data centers

$

,000.00

3001600000

52. Construction services for maintenance and repair of industrial warehouses not at manufacturing sites

Nonresidential mobile building construction, office and other commercial

Office building construction

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

36

64. Construction services for maintenance and repair of office buildings and data centers

$

,000.00

3002000000

65. Public safety building new constructions (by builders and at-risk project managers)

$

,000.00

3000900000

66. Construction services for new public safety buildings

$

,000.00

3001375000

67. Construction services for additions, renovations, and alterations to public safety buildings

$

,000.00

3001775000

68. Construction services for maintenance and repair of public safety buildings

$

,000.00

3002175000

$

,000.00

3000800000

70. Construction services for new religious buildings

$

,000.00

3001275000

71. Construction services for additions, renovations, and alterations to religious buildings

$

,000.00

3001675000

72. Construction services for maintenance and repair of religious buildings

$

,000.00

3002075000

73. Store, restaurant, automobile service station, parking garage, and other commercial building new constructions
(excluding mobile buildings)(by builders and at-risk project managers)

$

,000.00

3000775000

74. Construction services for new stores, restaurants, automobile service stations, parking garages, and other
commercial buildings (excluding mobile buildings)

$

,000.00

3001250000

75. Construction services for additions, renovations, and alterations to stores, restaurants, automobile service stations,
parking garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3001650000

76. Construction services for maintenance and repair of stores, restaurants, automobile service stations, parking
garages, and other commercial buildings (excluding mobile buildings)

$

,000.00

3002050000

77. Nonresidential mobile building new constructions, classroom (by builders and at-risk project managers)

$

,000.00

3000955000

78. Nonresidential mobile building new constructions, industrial (by builders and at-risk project managers)

$

,000.00

3000960000

79. Construction services for new nonresidential mobile building constructions, classroom

$

,000.00

3001430000

80. Construction services for new nonresidential mobile building constructions, industrial

$

,000.00

3001435000

81. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, classrooms

$

,000.00

3001830000

Public safety building construction

Religious building construction
69. Religious building new constructions (by builders and at-risk project managers)

Store, restaurant, automobile service station, parking garage, and other commercial building construction

Other nonresidential mobile building construction, including classroom and industrial

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

37

82. Construction services for additions, renovations, and alterations to other nonresidential mobile building
constructions, industrial

$

,000.00

3001835000

83. Construction services for maintenance and repair of other nonresidential mobile building constructions, classrooms

$

,000.00

3002230000

84. Construction services for maintenance and repair of other nonresidential mobile building constructions, industrial

$

,000.00

3002235000

85. All other nonresidential building new constructions (by builders and at-risk project managers)

$

,000.00

3001025000

86. Construction services for all other new nonresidential buildings

$

,000.00

3001500000

87. Construction services for additions, renovations, and alterations to all other nonresidential buildings

$

,000.00

3001900000

88. Construction services for maintenance and repair of all other nonresidential buildings

$

,000.00

3002300000

89. Constructions of new apartment type condominiums, excluding single family condominiums (by builders and at-risk
project managers)

$

,000.00

3000100000

90. Construction services for new apartment type condominiums, excluding single family condominiums

$

,000.00

3000200000

91. Construction services for additions, renovations, and alterations to apartment type condominiums, excluding single
family condominiums

$

,000.00

3000300000

92. Construction services for maintenance and repair of apartment type condominiums, excluding single family
condominiums

$

,000.00

3000400000

93. Constructions of new manufactured (mobile) homes, all width sizes (including multisection) (by builders and at-risk
project managers)

$

,000.00

3000075000

94. Construction services for new manufactured homes (mobile homes), all width sizes (including multisection)

$

,000.00

3000175000

95. Construction services for additions, renovations, and alterations to manufactured homes (mobile homes), all width
sizes (including multisection)

$

,000.00

3000275000

96. Construction services for maintenance and repair of manufactured homes (mobile homes), all width sizes (including
multisection)

$

,000.00

3000375000

97. Constructions of new single attached residential buildings, including row houses and town houses (by builders and
at-risk project managers)

$

,000.00

3000050000

98. Construction services for new single attached residential buildings, including row houses and town houses

$

,000.00

3000150000

All other nonresidential building construction

Apartment building construction (two or more units), condo-type, excluding single family condominiums

Residential manufactured (mobile) home construction

Single attached residential building construction, including row houses and town houses

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

38

99. Construction services for additions, renovations, and alterations to single attached residential buildings, including
row houses and town houses

$

,000.00

3000250000

100. Construction services for maintenance and repair of single attached residential buildings, including row houses and
town houses

$

,000.00

3000350000

101. Constructions of new single detached residential buildings (by builders and at-risk project managers)

$

,000.00

3000025000

102. Construction services for new single detached residential buildings

$

,000.00

3000125000

103. Construction services for additions, renovations, and alterations to single detached residential buildings

$

,000.00

3000225000

104. Construction services for maintenance and repair of single detached residential buildings

$

,000.00

3000325000

105. Airport runway and landing field new constructions (by heavy construction contractors and at-risk project
managers)

$

,000.00

3002675000

106. Construction services for new airport runways and landing fields

$

,000.00

3003325000

107. Construction services for additions, renovations, and alterations to airport runways and landing fields

$

,000.00

3003975000

108. Construction services for maintenance and repair of airport runways and landing fields

$

,000.00

3004625000

$

,000.00

3002375000

$

,000.00

3003025000

111. Construction services for additions, renovations, and alterations to bridges and elevated highways

$

,000.00

3003675000

112. Construction services for maintenance and repair of bridges and elevated highways

$

,000.00

3004325000

113. Coal mining prospect and test drilling services

$

,000.00

1001950000

114. Sinking coal mine shafts and driving coal mine tunnels services

$

,000.00

1001975000

115. Other coal mining services, including strip, auger or underground mining, drilling, overburden stripping, recovering
culm bank, and repair and maintenance services not for your own account

$

,000.00

1002000000

116. Coal mine new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002875000

Single detached residential building construction

Airport runways and landing fields

Bridge and elevated highway
109. Bridge and elevated highway new constructions (by heavy construction contractors and at-risk project managers)

110. Construction services for new bridges and elevated highways

Coal mines

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

39

117. Construction services for new coal mine constructions

$

,000.00

3003525000

118. Construction services for additions, renovations, and alterations to coal mine constructions

$

,000.00

3004175000

119. Conservation and development new constructions, including dams, drainage canals, and flood control projects (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002650000

120. Construction services for new conservation and development constructions, including dams, drainage canals, and
flood control projects

$

,000.00

3003300000

121. Construction services for additions, renovations, and alterations to conservation and development constructions,
including dams, drainage canals, and flood control projects

$

,000.00

3003950000

122. Construction services for maintenance and repair of conservation and development constructions, including dams,
drainage canals, and flood control projects

$

,000.00

3004600000

$

,000.00

3002825000

$

,000.00

3003475000

125. Construction services for additions, renovations, and alterations to fencing constructions

$

,000.00

3004125000

126. Construction services for maintenance and repair of fencing constructions

$

,000.00

3004750000

$

,000.00

3002725000

$

,000.00

3003375000

129. Construction services for additions, renovations, and alterations to harbor and port facilities

$

,000.00

3004025000

130. Construction services for maintenance and repair of harbor and port facilities

$

,000.00

3004675000

131. Highway, street, and related work new constructions, including public sidewalks, curbs, guardrails and signs (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002325000

132. Construction services for new highways, streets, and related work, including public sidewalks, curbs, guardrails
and signs

$

,000.00

3002975000

133. Construction services for additions, renovations, and alterations to highways, streets, and related works, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3003625000

Conservation and development construction, including dams, drainage canals, and flood control projects

Fencing
123. Fencing new constructions (by heavy construction contractors and at-risk project managers)

124. Construction services for new fencing constructions

Harbor and port facilities
127. Harbor and port facilities new constructions (by heavy construction contractors and at-risk project managers)

128. Construction services for new harbor and port facilities

Highway, street, and related work construction, including public sidewalks, curbs, guardrails, and signs

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

40

134. Construction services for maintenance and repair of highways, streets, and related work constructions, including
public sidewalks, curbs, guardrails and signs

$

,000.00

3004275000

$

,000.00

3002575000

136. Construction services for new power plants, hydroelectric

$

,000.00

3003225000

137. Construction services for additions, renovations, and alterations to power plants, hydroelectric

$

,000.00

3003875000

$

,000.00

3004525000

$

,000.00

3002750000

$

,000.00

3003400000

141. Construction services for additions, renovations, and alterations to marine constructions, including dredging,
navigational channels, and locks

$

,000.00

3004050000

142. Construction services for maintenance and repair of marine constructions, including dredging, navigational
channels, and locks

$

,000.00

3004700000

$

,000.00

3002700000

$

,000.00

3003350000

145. Construction services contractors for additions, renovations, and alterations to mass transit constructions, including
railroads

$

,000.00

3004000000

146. Construction services for maintenance and repair of mass transit constructions, including railroads

$

,000.00

3004650000

$

,000.00

1002025000

$

,000.00

1002050000

149. Metal mining prospect services and test drilling services

$

,000.00

1002075000

150. Sinking metal mine shafts and driving metal mine tunnels services

$

,000.00

1002100000

$

,000.00

1002125000

Hydroelectric power plants
135. Power plant new constructions, hydroelectric (by heavy construction contractors and at-risk project managers)

138. Construction services for maintenance and repair of power plants, hydroelectric

Marine construction, such as dredging, navigational channels, and locks
139. Marine new constructions, including dredging, navigational channels, and locks (by heavy construction contractors
and at-risk project managers)
140. Construction services for new marine constructions, including dredging, navigational channels, and locks

Mass transit, including railroads
143. Mass transit new constructions, including railroads (by heavy construction contractors and at-risk project
managers)
144. Construction services for new mass transit constructions, including railroads

Metal mines
147. Metal mining exploration work, excluding prospect services, test drilling, and geophysical surveying services

148. Open-pit metal ores mining not for your own account

151. Other metal mining services, including overburden stripping and repair and maintenance services

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

41

152. Metal mine new constructions (by heavy construction contractors and at-risk project managers)

$

,000.00

3002900000

153. Construction services for new metal mine constructions

$

,000.00

3003550000

$

,000.00

3004200000

$

,000.00

1002150000

156. Nonmetallic mineral prospect services and test drilling services

$

,000.00

1002175000

157. Other nonmetallic mineral services, including overburden stripping, drilling services, blasting, and repair and
maintenance services

$

,000.00

1002200000

$

,000.00

3002925000

$

,000.00

3003575000

$

,000.00

3004225000

$

,000.00

1001800000

162. Perforating oil and gas well casings

$

,000.00

1001825000

163. Installing oil and gas field production equipment, including wellhead fittings, pumps, and engines

$

,000.00

1001850000

$

,000.00

1001875000

$

,000.00

1001900000

$

,000.00

1001925000

$

,000.00

3002850000

$

,000.00

3003500000

$

,000.00

3004150000

$

,000.00

3002500000

154. Construction services for additions, renovations, and alterations to metal mine constructions

Nonmetallic mines
155. Open-pit or quarry nonmetallic minerals mining not for your own account

158. Nonmetallic mine new constructions (by heavy construction contractors and at-risk project managers)

159. Construction services for new nonmetallic mine constructions

160. Construction services for additions, renovations, and alterations to nonmetallic mine constructions

Oil and gas fields
161. Oil and gas field gathering services

164. Pumping oil and gas wells but not operating leases

165. Other oil and gas field repair and maintenance services

166. All other oil and gas field services

167. Oil and gas field new constructions (by heavy construction contractors and at-risk project managers)

168. Construction services for new oil and gas field constructions

169. Construction services for additions, renovations, and alterations to oil and gas field constructions

Oil and gas pipelines, pumping stations, storage tanks, and mains
170. Oil and gas pipeline, pumping station, storage tank, and main new constructions (by heavy construction
contractors and at-risk project managers)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

42

171. Construction services for new oil and gas pipelines, pumping stations, storage tanks, and mains

$

,000.00

3003150000

172. Construction services for additions, renovations, and alterations to oil and gas pipelines, pumping stations, storage
tanks, and mains

$

,000.00

3003800000

173. Construction services for maintenance and repair of oil and gas pipelines, pumping stations, storage tanks, and
mains

$

,000.00

3004450000

174. Outdoor recreational area new constructions, including athletic fields, courts, golf courses, and campgrounds (by
heavy construction contractors and at-risk project managers)

$

,000.00

3002800000

175. Construction services for new outdoor recreational areas, including athletic fields, courts, golf courses, and
campgrounds

$

,000.00

3003450000

176. Construction services for additions, renovations, and alterations to outdoor recreational area constructions,
including athletic fields, courts, golf courses, and campgrounds

$

,000.00

3004100000

177. Construction services for maintenance and repair of outdoor recreational area constructions, including athletic
fields, courts, golf courses, and campgrounds

$

,000.00

3004725000

178. Petrochemical plant and petroleum refinery new constructions (by heavy construction contractors and at-risk
project managers)

$

,000.00

3002625000

179. Construction services for new petrochemical plants and petroleum refineries

$

,000.00

3003275000

180. Construction services for additions, renovations, and alterations to petrochemical plants and petroleum refineries

$

,000.00

3003925000

$

,000.00

3004575000

$

,000.00

3002550000

$

,000.00

3003200000

184. Construction services for additions, renovations, and alterations to power and cogeneration plants, except
hydroelectric

$

,000.00

3003850000

185. Construction services for maintenance and repair of power and cogeneration plants, except hydroelectric

$

,000.00

3004500000

186. Power and communication transmission line, cable, tower, and related facilities new constructions (by heavy
construction contractors and at-risk project managers)

$

,000.00

3002525000

187. Construction services for new power and communication transmission lines, cables, towers, and related facilities

$

,000.00

3003175000

Outdoor recreational area construction, including athletic fields, courts, golf courses, and campgrounds

Petrochemical plant and petroleum refinery construction

181. Construction services for maintenance and repair of petrochemical plants and petroleum refineries

Power and cogeneration plant construction, except hydroelectric construction
182. Power and cogeneration plant new constructions, except hydroelectric (by heavy construction contractors and atrisk project managers)
183. Construction services for new power and cogeneration plants, except hydroelectric

Power and communication transmission line, cable, tower, and related facilities

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

43

188. Construction services for additions, renovations, and alterations to power and communication transmission lines,
cables, towers, and related facilities

$

,000.00

3003825000

189. Construction services for maintenance and repair of power and communication transmission lines, cables, towers,
and related facilities

$

,000.00

3004475000

190. Private driveway and parking area new constructions, except garages (by heavy construction contractors and atrisk project managers)

$

,000.00

3002350000

191. Construction services for new private driveways and parking areas, excluding garages

$

,000.00

3003000000

192. Construction services for additions, renovations, and alterations to private driveways and parking areas, excluding
garages

$

,000.00

3003650000

193. Construction services for maintenance and repair of private driveways and parking areas, excluding garages

$

,000.00

3004300000

$

,000.00

3002475000

$

,000.00

3003125000

196. Construction services for additions, renovations, and alterations to sewage and water treatment plants

$

,000.00

3003775000

197. Construction services for maintenance and repair of sewage and water treatment plants

$

,000.00

3004425000

198. Sewer, sewer line, septic system, and related facilities new constructions (by heavy construction contractors and
at-risk project managers)

$

,000.00

3002425000

199. Construction services for new sewers, sewer lines, septic systems, and related facilities

$

,000.00

3003075000

200. Construction services for additions, renovations, and alterations to sewers, sewer lines, septic systems, and
related facilities

$

,000.00

3003725000

201. Construction services for maintenance and repair of sewers, sewer lines, septic systems, and related facilities

$

,000.00

3004375000

$

,000.00

2053950000

$

,000.00

2053975000

$

,000.00

3002775000

Private driveway and parking area construction, except garages

Sewage and water treatment plants
194. Sewage and water treatment plant new constructions(by heavy construction contractors and at-risk project
managers)
195. Construction services for new sewage and water treatment plants

Sewers, sewer lines, septic systems, and related facilities

Ship maintenance and repair services
202. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, military

203. Ship modification, conversion, overhaul, and other manufacturing services performed in a shipyard, nonmilitary

Swimming pools
204. Swimming pool new constructions (by builders and at-risk project managers)

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

44

205. Construction services for new swimming pools

$

,000.00

3003425000

206. Construction services for additions, renovations, and alterations to swimming pools

$

,000.00

3004075000

$

,000.00

3002400000

$

,000.00

3003050000

$

,000.00

3003700000

$

,000.00

3004350000

211. Water main, storage, well, and related facilities new constructions (by heavy construction contractors and at-risk
project managers)

$

,000.00

3002450000

212. Construction services for new water mains, storage, wells, and related facilities

$

,000.00

3003100000

213. Construction services for additions, renovations, and alterations to water mains, storage, wells, and related
facilities

$

,000.00

3003750000

214. Construction services for maintenance and repair of water mains, storage, wells, and related facilities

$

,000.00

3004400000

$

,000.00

3002950000

$

,000.00

3003600000

$

,000.00

3004250000

$

,000.00

3004775000

$

,000.00

7008725003

$

,000.00

7008725006

$

,000.00

7008725009

Tunnels
207. Tunnel new constructions (by heavy construction contractors and at-risk project managers)

208. Construction services for new tunnels

209. Construction services for additions, renovations, and alterations to tunnels

210. Construction services for maintenance and repair of tunnels

Water mains, storage wells, and related facilities

Other nonresidential constructions, except buildings
215. Other nonresidential new constructions, except buildings (by heavy construction contractors and at-risk project
managers)
216. Construction services for other new nonresidential constructions, excluding buildings

217. Construction services for additions, renovations, and alterations to other nonresidential constructions, excluding
buildings
218. Construction services for maintenance and repair of all other nonresidential constructions, excluding buildings

Other specialized cleaning services, not elsewhere classified
219. Other specialized cleaning services, not elsewhere classified
a. Drain and gutter cleaning services

b. Parking lot sweeping services

c. Swimming pool cleaning and maintenance services

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

45

d. All other specialized cleaning services, not elsewhere classified

$

,000.00

7008725012

$

,000.00

7008725000

$

,000.00

3000425000

$

,000.00

3000450000

$

,000.00

3000475000

$

,000.00

3000500000

$

,000.00

3000525003

$

,000.00

3000525006

$

,000.00

3000525000

a. Construction services for new residential irrigation and sprinkler system constructions

$

,000.00

3000550003

b. Construction services for other new residential landscape constructions, excluding decks

$

,000.00

3000550006

$

,000.00

3000550000

a. Construction services for additions, renovations, and alterations to residential irrigation and sprinkler system
constructions

$

,000.00

3000575003

b. Construction services for additions, renovations, and alterations to other residential landscape constructions,
excluding decks

$

,000.00

3000575006

$

,000.00

3000575000

$

,000.00

3000600003

Subtotal

Residential decks
220. Residential deck new constructions (by builders and at-risk project managers)

221. Construction services for new residential deck constructions

222. Construction services for additions, renovations, and alterations to residential deck constructions

223. Construction services for maintenance and repair of residential deck constructions

Residential landscape constructions, including irrigation and sprinkler systems, excluding decks
224. Residential landscape new constructions, excluding decks (by builders and at-risk project managers)
a. Residential irrigation and sprinkler system new constructions (by builders and at-risk project managers)

b. Other residential landscape new constructions, excluding decks (by builders and at-risk project managers)

Subtotal

225. Construction services for new residential landscape constructions, excluding decks (by builders and at-risk project
managers)

Subtotal

226. Construction services for additions, renovations, and alterations to residential landscape constructions, excluding
decks

Subtotal

227. Construction services for maintenance and repair of residential landscape constructions, excluding decks
a. Construction services for maintenance and repair of residential irrigation and sprinkler system constructions

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

46

b. Construction services for maintenance and repair of other residential landscape constructions, excluding decks

Subtotal

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

3000600006

$

,000.00

3000600000

$

,000.00

9900000000

Add product/service not listed

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

47

Item 23: Kind of Business Activities Additional Information

ITEM 23: KIND OF BUSINESS ACTIVITIES
For the $,000.00 of sales, shipments, receipts, or revenue in 2022, please report the percent of the total represented by the following construction and non-construction business
activities. The sum of these percentages should equal 100%.

CONSTRUCTION WORK ACTIVITIES
Report only the main activities for which you were contracted. Work which was incidental to the primary activities of jobs should not be reported separately. If the construction activity is
not listed below, please enter a description of the construction activity in the “Other construction activities” write-in box, along with a percentage of the value of total business for that
specified construction activity.
OTHER BUSINESS ACTIVITIES
Report any non-construction activities. If the activity is not listed below, please enter a description of the non-construction activity in the “Other business activities” write-in box, along
with a percentage of the value of total business for that specified activity.

Description

Code

Value

Construction work activities
8910

%

8911

%

8914

%

8915

%

8916

%

8991

%

8913

%

7991

%

8912

%

7992

%

11. Asphalt, concrete, and brick paving contractor, residential or commercial driveways and
parking areas

8990

%

12. Ornamental metal contractor, including metal stairway, balcony, and wrought iron
installation

8191

%

1. Septic tank, cesspool, and dry well contractor (except sewer hookups to buildings)

2. Excavation work, earthmoving, or land clearing contractor

3. Wrecking, demolition, or blasting contractor

4. Concrete cutting or drilling contractor

5. Rental of construction machinery or equipment (except cranes) with operator

6. Rental of cranes with operator

7. Trenching contractor (except underwater)

8. Trenching contractor, underwater

9. Foundation digging, drilling, or pile driving contractor (except underwater)

10. Pile driving contractor, underwater

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

48

13. Fence construction contractor

14. Swimming pool contractor
15. Other kinds of construction

8992

%

8993

%

9000

%

9916

%

9919

%

9925

%

9929

%

8005

%

Describe

Other business activity

16. Mining -- minerals produced and sold to others

17. Rental of construction machinery or equipment to others, without an operator

18. Retail trade
19. Other business activities
Describe

TOTAL

2022_CC-23890_su.pdf Generated 2022-02-23 15:51:40

49

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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50

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Ownership of Projects Additional Information

ITEM 28: SPECIAL ITEMS - OWNERSHIP OF PROJECTS
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue) on projects owned by the following:
2022
%

1. Private businesses and individuals

%

2. State and local governments

%

3. Federal Government
TOTAL
(Percentages reported in lines 1 through 3 should equal 100%.)

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%

52

Item 28: Special Items - Construction Subcontractors

ITEM 28: SPECIAL ITEMS - CONSTRUCTION SUBCONTRACTORS
What percent of the amount you reported in Item 5 (Sales, Shipments, Receipts, or Revenue) represents work you did for other contractors or builders?
(Enter "0" if you did not subcontract work from other contractors or builders.)
2022
%

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Item 28: Special Items - Construction by State

ITEM 28: SPECIAL ITEMS - CONSTRUCTION BY STATE
Percent of the construction work reported in Item 5 (Sales, Shipments, Receipts, or Revenue), which occurred in each state
(The sum of the percentages reported should equal 100%.)
2022

2022
%

Montana

%

%

Nebraska

%

%

Nevada

%

%

New Hampshire

%

%

New Jersey

%

Colorado

%

New Mexico

%

Connecticut

%

New York

%

Delaware

%

North Carolina

%

District of Columbia

%

North Dakota

%

Florida

%

Ohio

%

Georgia

%

Oklahoma

%

Hawaii

%

Oregon

%

%

Pennsylvania

%

%

Rhode Island

%

%

South Carolina

%

%

South Dakota

%

%

Tennessee

%

%

Texas

%

Alabama

Alaska

Arizona

Arkansas

California

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

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54

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

%

Utah

%

%

Vermont

%

%

Virginia

%

%

Washington

%

%

West Virginia

%

%

Wisconsin

%

%

Wyoming

%

%

United States

%

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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58

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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60

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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63

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

66

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

67

Attachment D-5
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 31-33

Attachment Sector

D-5

31-33

Instrument
Path
Instrument Path Title

33153
33242
33591
33640

Nonferrous Metal Die-Casting Foundries
Metal Can Manufacturing
Primary Battery Manufacturing
Aircraft Manufacturing

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Iron foundry

331511 001

Steel investment foundry

331512 001

Steel foundry (excluding investment)

331513 001

Nonferrous metal die-casting foundry

331523 001

Aluminum foundry (excluding die-casting)

331524 001

Other nonferrous metal foundry (excluding die-casting)

331529 001

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE More
A. What was the total value of products shipped and other receipts for this establishment?
(Report detail in Item 22.)
Include:
All products physically shipped from this establishment during 2022
Products donated and physically shipped from this establishment during 2022
Shipments to other domestic plants of your company for further assembly, fabrication, or manufacture
Exclude:
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

B. What percent of the $,000.00 reported in Item 5, line A was for goods that were ordered or whose movement was
controlled or coordinated over electronic networks?
(Report whole percent.)
E-shipments are online orders accepted for manufactured products from customers. These include shipments to other
domestic plants of your own company for further manufacture, assembly, or fabrication. The price and terms of sale for
these shipments are negotiated over an online system. Payment may or may not be made online.
Include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems

%

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Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report values in Item 16, line D1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line D1.)
Purchased professional and technical services (Report values in Item 16, line D9.)
Subcontractors and their employees (Report cost of contract work in Item 16, line A3.)
Fishermen, agricultural employees, members of the Armed Forces, and pensioners carried on your active rolls
A. TOTAL EMPLOYMENT AND PAYROLL More
For all employees at this establishment, what was the:
Check
if
None

2022 Number

1. Total number of employees for the pay period including March 12?
2. Total annual payroll (before deductions)?

2022

Exclude: Employer-paid annual cost for fringe benefits reported in lines E1 through E3

3. Total first quarter payroll (January - March)?

$

,000.00

$

,000.00

B. PRODUCTION WORKER EMPLOYMENT AND PAYROLL More
For production workers at this establishment (direct labor including first-line supervisors), what was the:
1. Number of employees for the pay period including March 12?
Include:
Workers engaged in fabricating, processing, assembling, inspecting, receiving, packing, warehousing,
shipping (but not delivering), maintenance, repair, janitorial, guard services, product development, auxiliary
production for plant’s own use (e.g., power plant), recordkeeping, and other closely associated services
(including truck drivers delivering ready-mixed concrete)

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

C. NON-PRODUCTION EMPLOYMENT AND PAYROLL
For non-production employees at this establishment, what was the:

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19

1. Number of employees for the pay period including March 12?
Include:
Officers at this establishment, if a corporation
Supervision above line-supervisor level
Sales employees, including delivery (truck driver and helpers)
Advertising, clerical, credit, collection, purchasing, finance, legal, executive, and technical employees
Employees installing and servicing this establishment's products
Exclude:
Proprietors and partners, if an unincorporated concern

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

D. HOURS WORKED More
Check
if
None

2022 Hours

What was the annual number of hours worked by the production workers at this establishment (direct labor
including first-line supervisors) reported in line B1?

,000

E. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS More
What were the employer's annual costs at this establishment for:

Check
if
None
1. Health Insurance? - Insurance premiums on hospitals, medical plans, and single-service plans such as dental,
vision, and prescription drug plans

2022
$

,000.00

$

,000.00

$

,000.00

2. Retirement Plans?
a. Defined benefit pension plans (qualified and nonqualified) - Plans that specify the benefit to be paid to
employees upon retirement, generally either a specific amount or a percentage of compensation. Employer
contributions are based on actuarial computations that include employee's compensation and years of service
and are not allocated to specific accounts maintained for employees.
b. Defined contribution plans - Plans that define the employer contributions to a separate account provided for
each employee. The employee "benefit" at retirement depends on the amount contributed and the results of the
account's activity.
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

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20

3. Payroll taxes, employer-paid insurance premiums, and other employer-paid benefits?
Include:
Legally-required fringe benefits (e.g., Social Security, workers compensation insurance, state disability
insurance programs, long- and short- term disability, unemployment tax, and Medicare)
"Quality of life” benefits (e.g., childcare assistance, education assistance, subsidized commuting)
Other benefits not specified above
More

4. TOTAL (Add lines E1 through E3.)

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

$

,000.00

$

,000.00

21

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES More
Report inventories at cost or market using generally accepted accounting practices, and report all inventories owned by this establishment regardless of where the inventories are held. If
this establishment is part of a multiple-establishment company, assign to each establishment those inventories that the establishment is responsible for as if it owned them.
What was the value of inventories owned by this establishment as of December 31 before Last-In, First-Out (LIFO) adjustment (if any) for:
Check
if
None
A. Finished goods (final output of this establishment, but still
within ownership)?

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

B. Work-in-process (goods that have been substantially
transformed in the manufacturing process, but are not yet
the final output of the establishment)?

$

,000.00

$

,000.00

C. Materials, supplies, fuels, etc. (goods that are raw inputs
to the manufacturing process and will be substantially
altered to produce this establishment’s output)?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through C.)

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Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD More
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this establishment as of December 31, 2022, and the $,000.00 reported in Item 9 as the total value of
inventories owned by this establishment as of December 31, 2021, how much is subject to the following valuation methods:

A. Non-LIFO (Last-In, First-Out) valuation methods
Check
if
None

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

2. Average Cost?

$

,000.00

$

,000.00

3. Standard Cost?

$

,000.00

$

,000.00

4. Other non-LIFO valuation method(s)?

$

,000.00

$

,000.00

TOTAL (Add lines A1 through A4.)

$

,000.00

$

,000.00

B. LIFO Valuation Method (gross LIFO amount)?

$

,000.00

$

,000.00

TOTAL Non-LIFO and LIFO methods (Add TOTAL of lines A1
through A4 and B.)

$

,000.00

$

,000.00

C. What is the amount of LIFO reserve (if any)?
(If the value of reserve is negative, use "-".)

$

,000.00

$

,000.00

1. First-In, First-Out (FIFO)?

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

23

Item 13: Assets, Capital Expenditures, and Retirements

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS More
Include:
Dollar value of capital expenditures
Buildings, structures, and equipment used directly or indirectly by this establishment to produce the goods and services reported in Item 5, line A and Item 22

A. What was the gross value of depreciable assets (acquisition costs) at this establishment at the beginning of the year for:
Check
if
None

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines A1 and A2)

$

,000.00

B. What were the capital expenditures for new and used depreciable assets at this establishment in 2022 for:
Check
if
None
1. New and used buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

a. Automobiles, trucks, etc. for highway use?

$

,000.00

b. Computers and peripheral data processing equipment?

$

,000.00

c. All other expenditures for machinery and equipment?

$

,000.00

$

,000.00

2. New and used machinery and equipment?

TOTAL (Add lines B1 and B2a through B2c.)

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc. at this establishment for:
Check
if
None

2022

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

24

D. What was the value of depreciable assets at this establishment at the end of the year for:
Check
if
None

2022

1. Buildings and other structures? (Add lines A1 and B1, and subtract line C1)
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment (Add lines A2 and B2, and subtract line C2)

$

,000.00

TOTAL (Add lines D1 and D2)

$

,000.00

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

25

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS More
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

B. Rental or lease of machinery and equipment?

$

,000.00

TOTAL (Add lines A and B.)

$

,000.00

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

26

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES More
A. For this establishment, what were the production-related costs in 2022 for:
1. Materials, parts, containers, packaging, supplies, etc. used for manufacturing processes, repairs, services for
others, or other operating supplies? (Report detail in Item 18.)
Include:
Cost of production-related materials purchased by this establishment for other companies (contractors).
Exclude:
Non-production-related expenses that were paid to other companies (contractors) by this establishment.
(Report these expenses on the next screen in Item 16, line D.)

Check
if
None

2022
$

,000.00

2. Products bought and sold without further processing? (Report associated sales in Item 5, line A and in Wholesale
product codes in Item 22.)

$

,000.00

3. Work done for you by others on your materials (work contracted to others)? (Report on line A1 the cost of
production-related materials purchased by this establishment for other companies (contractors).)

$

,000.00

4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report on line B2 the quantity of
electricity generated (Gross less generating station use).) More

$

,000.00

5. Purchased electricity? (Report comparable quantity on line B1.) More

$

,000.00

TOTAL (Add lines A1 through A5.)

$

,000.00

B. For this establishment, what was the quantity of:
Check
if
None

2022 Kilowatt Hours
,000

1. Purchased electricity? (Quantity comparable to cost reported in line A5)

2. Generated electricity (gross less generating station use)? (Quantity comparable to cost reported in line A4) More

,000

3. Electricity sold or transferred to other establishments? (Also include quantity on lines B1 and/or B2.) More

,000

Check
if
None
C. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

2022
$

,000.00

27

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

D. What were the other operating expenses (expenses normally considered as non-production-related costs purchased from other companies) paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment) More

$

,000.00

3. Expensed purchases of software? (Purchases of prepackaged, custom-coded or vendor-customized
software) More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments on line A5. If the costs of these utilities are included in a lease or rental payment,
report in Item 14, line A.) More

$

,000.00

8. Purchased advertising and promotional services? More

$

,000.00

9. Purchased professional and technical services? More

$

,000.00

4. Purchased communication services?
Include:
Telephone, cellular, and Internet services
Other wired and wireless communication services
Credit card transaction fees

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Data storage
Other computer-related advice and services, including training
More
6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof repairs, replacing parts, overhauling of equipment, and other repairs chargeable
as current operating costs
Exclude:
Extensive "repairs" or reconstruction that is capitalized. Report these as a capital expenditure in Item 13.
More

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28

10. Governmental taxes and licensing fees? (Payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?
Exclude:
Other expenses reported in Items 7, 13, 14, and 16
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

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29

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
General - The sum of the costs of the itemized materials in this section should equal the figure reported on Item 16, line A1 (Cost of materials, parts, containers, packaging, etc.
used). The following is a breakout of the $,000.00 currently reported there.
Please review the entire list and report separately each item consumed.
Report materials, parts, and supplies purchased, transferred from other plants of your company, or withdrawn from inventory.
If the information as requested cannot be taken directly from your book records, reasonable estimates are acceptable.
Exclude:
Products bought and sold without further processing, reported in Item 16, line A2
Materials owned by other companies but used by this establishment to make products under contract or commission

Description

Census
Material
Code

Value

1. Nonferrous metal shapes, forms, sheet, strip, powder, and wire (excluding castings and forgings), excluding
aluminum and copper

$

,000.00

33141000

2. Miscellaneous fabricated metal products, excluding hardware, containers, screw machine products (bolts, nuts,
screws, etc.), bearing components, castings, forgings, and wire products

$

,000.00

33200091

3. Miscellaneous aluminum and aluminum-base alloy shapes and forms, including powder (excluding castings,
forgings, ingot, pig, shot, wire, sheet, plate, foil, welded tubing, rods, bars, and pipe)

$

,000.00

33131020

4. Aluminum and aluminum-base alloy scrap, excluding home scrap

$

,000.00

33000042

5. Grinding wheels and other abrasive products, excluding industrial diamonds

$

,000.00

32791010

6. Cost of all other materials and components, parts, containers, and supplies consumed

$

,000.00

00970099

$

,000.00

77100000

Describe

TOTAL

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

30

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contribute to the sales, shipments, receipts or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for a product or service.
Select ALL that apply, at the most detailed level possible.
For manufacturing products, include:
Products made in this establishment and shipped
Products transferred to other establishments within your company
Products made elsewhere by others from materials supplied by this establishment
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer)
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts

Description

Select

Product Code

Manufacturing of:
2028100000

1. Aluminum and aluminum-base alloy die-castings

2. Nonferrous metals and alloys (excluding aluminum) die-castings

3. Steel investment castings, including carbon, alloy and stainless steel, hi-temp metal (iron, nickel or cobalt-based alloys)

2028250000

2028025000

2016225000

4. Punches, die parts, and other special tooling
All other sales, shipments, receipts, or revenue from this establishment

Add product/service not listed

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

31

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
If quantities are requested, please use the unit of measure specified.
Below are the products and services you previously selected. If you make products or have revenue from sources not listed, click the “Add product/service not listed” button and
search for a product or service.
For manufacturing products – Report the value of the products shipped and services performed at the net selling value, free on board (FOB) plant to the customer, after discounts
and allowances.
Include:
Products made in this establishment and shipped, excluding freight charged and excise taxes
Products transferred to other establishments within your company. These products should be assigned the full economic value (market value); i.e., include all direct costs of
production and a reasonable proportion of all other costs and profits.
Products made elsewhere by others from materials supplied by this establishment. Report these products on the specific lines as if they were made in this establishment.
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer). Report your commission or contract receipts in the appropriate Contract Manufacturing products line(s)
you selected or “Add product/service not listed”
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts
Description

Value

Product Code

Manufacturing of:
$

,000.00

2028100000

$

,000.00

2028250000

3. Steel investment castings, including carbon, alloy and stainless steel, hi-temp metal (iron, nickel or cobalt-based
alloys)

$

,000.00

2028025000

4. Punches, die parts, and other special tooling

$

,000.00

2016225000

$

,000.00

9900000000

1. Aluminum and aluminum-base alloy die-castings

2. Nonferrous metals and alloys (excluding aluminum) die-castings

All other sales, shipments, receipts, or revenue from this establishment

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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32

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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33

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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34

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

35

Item 28: Industrial Robots and Robotic Equipment

ITEM 28: INDUSTRIAL ROBOTS AND ROBOTIC EQUIPMENT

INDUSTRIAL ROBOTIC EQUIPMENT
Industrial robotic equipment (or industrial robots) are automatically controlled, reprogrammable, and multipurpose
machines used in the industrial automated operations.
Industrial robots may be mobile, incorporated into stand-alone stations, or integrated into a production line.
An industrial robot may be part of a robotic cell (or work cell) or incorporated into another piece of equipment.
Industrial robots are commonly used in operations such as welding, material handling, machine tending, dispensing,
cleanroom, and pick and place.
REPORTING INDUSTRIAL ROBOTIC EQUIPMENT
Estimates are acceptable.
In (A), report capital expenditures for new and used industrial robotic equipment for this establishment. Include other
one-time costs, including software and installation.
In (B) and (C), report the number of industrial robots in operation at this establishment and purchased for this
establishment.
For robots purchased as part of a work cell or other integrated robotic equipment, it may not be possible to report the
expenditures on only the robots. In this case, report the expenditures on the integrated robotic equipment.
Examples of operations industrial robotic equipment can perform may include:
Palletizing
Pick and place
Machine tending
Machine handling
Dispensing
Welding
Packing/repacking
Exclude:
Automated guided vehicles (AGVs)
Driverless forklifts
Automated storage and retrieval systems
CNC machining equipment
Check
if
None

2022

A. What were the capital expenditures for new and used industrial robotic equipment, including software, installation, and
other one-time costs?

$

B. What was the number of industrial robots IN OPERATION at this plant? Refer to instructions above for definitions.

2022 Number

,000.00

If you are unable to provide the number of industrial robots IN OPERATION, please explain:

C. What was the number of industrial robots PURCHASED for this plant? Refer to instructions above for definitions.

2022 Number

If you are unable to provide the number of industrial robots PURCHASED, please explain:

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

36

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

37

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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38

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

39

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

41

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

42

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

45

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MC-33153_su.pdf Generated 2022-02-24 07:22:40

,000.00

46

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Metal can manufacturing, including lids and ends

332431 001

Other metal container manufacturing, light gauge, including barrels, drums, mailboxes, etc.

332439 001

Metal tank (heavy gauge) manufacturing, including cutting, forming, and joining heavy gauge metal

332420 001

Power boiler and heat exchanger manufacturing

332410 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

17

Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE More
A. What was the total value of products shipped and other receipts for this establishment?
(Report detail in Item 22.)
Include:
All products physically shipped from this establishment during 2022
Products donated and physically shipped from this establishment during 2022
Shipments to other domestic plants of your company for further assembly, fabrication, or manufacture
Exclude:
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

B. What percent of the $,000.00 reported in Item 5, line A was for goods that were ordered or whose movement was
controlled or coordinated over electronic networks?
(Report whole percent.)
E-shipments are online orders accepted for manufactured products from customers. These include shipments to other
domestic plants of your own company for further manufacture, assembly, or fabrication. The price and terms of sale for
these shipments are negotiated over an online system. Payment may or may not be made online.
Include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems

%

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

18

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report values in Item 16, line D1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line D1.)
Purchased professional and technical services (Report values in Item 16, line D9.)
Subcontractors and their employees (Report cost of contract work in Item 16, line A3.)
Fishermen, agricultural employees, members of the Armed Forces, and pensioners carried on your active rolls
A. TOTAL EMPLOYMENT AND PAYROLL More
For all employees at this establishment, what was the:
Check
if
None

2022 Number

1. Total number of employees for the pay period including March 12?
2. Total annual payroll (before deductions)?

2022

Exclude: Employer-paid annual cost for fringe benefits reported in lines E1 through E3

3. Total first quarter payroll (January - March)?

$

,000.00

$

,000.00

B. PRODUCTION WORKER EMPLOYMENT AND PAYROLL More
For production workers at this establishment (direct labor including first-line supervisors), what was the:
1. Number of employees for the pay period including March 12?
Include:
Workers engaged in fabricating, processing, assembling, inspecting, receiving, packing, warehousing,
shipping (but not delivering), maintenance, repair, janitorial, guard services, product development, auxiliary
production for plant’s own use (e.g., power plant), recordkeeping, and other closely associated services
(including truck drivers delivering ready-mixed concrete)

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

C. NON-PRODUCTION EMPLOYMENT AND PAYROLL
For non-production employees at this establishment, what was the:

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

19

1. Number of employees for the pay period including March 12?
Include:
Officers at this establishment, if a corporation
Supervision above line-supervisor level
Sales employees, including delivery (truck driver and helpers)
Advertising, clerical, credit, collection, purchasing, finance, legal, executive, and technical employees
Employees installing and servicing this establishment's products
Exclude:
Proprietors and partners, if an unincorporated concern

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

D. HOURS WORKED More
Check
if
None

2022 Hours

What was the annual number of hours worked by the production workers at this establishment (direct labor
including first-line supervisors) reported in line B1?

,000

E. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS More
What were the employer's annual costs at this establishment for:

Check
if
None
1. Health Insurance? - Insurance premiums on hospitals, medical plans, and single-service plans such as dental,
vision, and prescription drug plans

2022
$

,000.00

$

,000.00

$

,000.00

2. Retirement Plans?
a. Defined benefit pension plans (qualified and nonqualified) - Plans that specify the benefit to be paid to
employees upon retirement, generally either a specific amount or a percentage of compensation. Employer
contributions are based on actuarial computations that include employee's compensation and years of service
and are not allocated to specific accounts maintained for employees.
b. Defined contribution plans - Plans that define the employer contributions to a separate account provided for
each employee. The employee "benefit" at retirement depends on the amount contributed and the results of the
account's activity.
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

20

3. Payroll taxes, employer-paid insurance premiums, and other employer-paid benefits?
Include:
Legally-required fringe benefits (e.g., Social Security, workers compensation insurance, state disability
insurance programs, long- and short- term disability, unemployment tax, and Medicare)
"Quality of life” benefits (e.g., childcare assistance, education assistance, subsidized commuting)
Other benefits not specified above
More

4. TOTAL (Add lines E1 through E3.)

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

$

,000.00

$

,000.00

21

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES More
Report inventories at cost or market using generally accepted accounting practices, and report all inventories owned by this establishment regardless of where the inventories are held. If
this establishment is part of a multiple-establishment company, assign to each establishment those inventories that the establishment is responsible for as if it owned them.
What was the value of inventories owned by this establishment as of December 31 before Last-In, First-Out (LIFO) adjustment (if any) for:
Check
if
None
A. Finished goods (final output of this establishment, but still
within ownership)?

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

B. Work-in-process (goods that have been substantially
transformed in the manufacturing process, but are not yet
the final output of the establishment)?

$

,000.00

$

,000.00

C. Materials, supplies, fuels, etc. (goods that are raw inputs
to the manufacturing process and will be substantially
altered to produce this establishment’s output)?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through C.)

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

22

Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD More
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this establishment as of December 31, 2022, and the $,000.00 reported in Item 9 as the total value of
inventories owned by this establishment as of December 31, 2021, how much is subject to the following valuation methods:

A. Non-LIFO (Last-In, First-Out) valuation methods
Check
if
None

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

2. Average Cost?

$

,000.00

$

,000.00

3. Standard Cost?

$

,000.00

$

,000.00

4. Other non-LIFO valuation method(s)?

$

,000.00

$

,000.00

TOTAL (Add lines A1 through A4.)

$

,000.00

$

,000.00

B. LIFO Valuation Method (gross LIFO amount)?

$

,000.00

$

,000.00

TOTAL Non-LIFO and LIFO methods (Add TOTAL of lines A1
through A4 and B.)

$

,000.00

$

,000.00

C. What is the amount of LIFO reserve (if any)?
(If the value of reserve is negative, use "-".)

$

,000.00

$

,000.00

1. First-In, First-Out (FIFO)?

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23

Item 13: Assets, Capital Expenditures, and Retirements

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS More
Include:
Dollar value of capital expenditures
Buildings, structures, and equipment used directly or indirectly by this establishment to produce the goods and services reported in Item 5, line A and Item 22

A. What was the gross value of depreciable assets (acquisition costs) at this establishment at the beginning of the year for:
Check
if
None

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines A1 and A2)

$

,000.00

B. What were the capital expenditures for new and used depreciable assets at this establishment in 2022 for:
Check
if
None
1. New and used buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

a. Automobiles, trucks, etc. for highway use?

$

,000.00

b. Computers and peripheral data processing equipment?

$

,000.00

c. All other expenditures for machinery and equipment?

$

,000.00

$

,000.00

2. New and used machinery and equipment?

TOTAL (Add lines B1 and B2a through B2c.)

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc. at this establishment for:
Check
if
None

2022

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

24

D. What was the value of depreciable assets at this establishment at the end of the year for:
Check
if
None

2022

1. Buildings and other structures? (Add lines A1 and B1, and subtract line C1)
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment (Add lines A2 and B2, and subtract line C2)

$

,000.00

TOTAL (Add lines D1 and D2)

$

,000.00

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25

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS More
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

B. Rental or lease of machinery and equipment?

$

,000.00

TOTAL (Add lines A and B.)

$

,000.00

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26

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES More
A. For this establishment, what were the production-related costs in 2022 for:
1. Materials, parts, containers, packaging, supplies, etc. used for manufacturing processes, repairs, services for
others, or other operating supplies? (Report detail in Item 18.)
Include:
Cost of production-related materials purchased by this establishment for other companies (contractors).
Exclude:
Non-production-related expenses that were paid to other companies (contractors) by this establishment.
(Report these expenses on the next screen in Item 16, line D.)

Check
if
None

2022
$

,000.00

2. Products bought and sold without further processing? (Report associated sales in Item 5, line A and in Wholesale
product codes in Item 22.)

$

,000.00

3. Work done for you by others on your materials (work contracted to others)? (Report on line A1 the cost of
production-related materials purchased by this establishment for other companies (contractors).)

$

,000.00

4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report on line B2 the quantity of
electricity generated (Gross less generating station use).) More

$

,000.00

5. Purchased electricity? (Report comparable quantity on line B1.) More

$

,000.00

TOTAL (Add lines A1 through A5.)

$

,000.00

B. For this establishment, what was the quantity of:
Check
if
None

2022 Kilowatt Hours
,000

1. Purchased electricity? (Quantity comparable to cost reported in line A5)

2. Generated electricity (gross less generating station use)? (Quantity comparable to cost reported in line A4) More

,000

3. Electricity sold or transferred to other establishments? (Also include quantity on lines B1 and/or B2.) More

,000

Check
if
None
C. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

2022
$

,000.00

27

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

D. What were the other operating expenses (expenses normally considered as non-production-related costs purchased from other companies) paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment) More

$

,000.00

3. Expensed purchases of software? (Purchases of prepackaged, custom-coded or vendor-customized
software) More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments on line A5. If the costs of these utilities are included in a lease or rental payment,
report in Item 14, line A.) More

$

,000.00

8. Purchased advertising and promotional services? More

$

,000.00

9. Purchased professional and technical services? More

$

,000.00

4. Purchased communication services?
Include:
Telephone, cellular, and Internet services
Other wired and wireless communication services
Credit card transaction fees

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Data storage
Other computer-related advice and services, including training
More
6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof repairs, replacing parts, overhauling of equipment, and other repairs chargeable
as current operating costs
Exclude:
Extensive "repairs" or reconstruction that is capitalized. Report these as a capital expenditure in Item 13.
More

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28

10. Governmental taxes and licensing fees? (Payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?
Exclude:
Other expenses reported in Items 7, 13, 14, and 16
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

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29

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
General - The sum of the costs of the itemized materials in this section should equal the figure reported on Item 16, line A1 (Cost of materials, parts, containers, packaging, etc.
used). The following is a breakout of the $,000.00 currently reported there.
Please review the entire list and report separately each item consumed.
Report materials, parts, and supplies purchased, transferred from other plants of your company, or withdrawn from inventory.
If the information as requested cannot be taken directly from your book records, reasonable estimates are acceptable.
Exclude:
Products bought and sold without further processing, reported in Item 16, line A2
Materials owned by other companies but used by this establishment to make products under contract or commission

Description

Census
Material
Code

Value

$

,000.00

33120073

2. Miscellaneous iron, steel, and ferroalloy ingot, shapes, and forms (excluding castings, forgings, bars, structural
shapes, wire, sheet, strip, and semifinished shapes)

$

,000.00

33110090

3. Aluminum and aluminum-base alloy sheet, plate, foil (including packaging products), and welded tubing

$

,000.00

33131501

4. Miscellaneous aluminum and aluminum-base alloy shapes and forms, including powder (excluding castings,
forgings, ingot, pig, shot, wire, sheet, plate, foil, welded tubing, rods, bars, and pipe)

$

,000.00

33131020

5. Nonferrous metal shapes, forms, sheet, strip, powder, and wire (excluding castings and forgings), excluding
aluminum and copper

$

,000.00

33141000

6. Metal containers, cans, lids, ends, and parts

$

,000.00

33200030

7. Paints, varnishes, stains, lacquers, shellacs, japans, enamels, and allied products

$

,000.00

32551002

$

,000.00

00970099

$

,000.00

77100000

1. Steel sheet, steel strip, and tin mill products

8. Cost of all other materials and components, parts, containers, and supplies consumed
Describe

TOTAL

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30

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contribute to the sales, shipments, receipts or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for a product or service.
Select ALL that apply, at the most detailed level possible.
For manufacturing products, include:
Products made in this establishment and shipped
Products transferred to other establishments within your company
Products made elsewhere by others from materials supplied by this establishment
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer)
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts

Description

Select

Product Code

Manufacturing of:

1. Steel cans and tinware end products, including ice cream cans, lids, ends, and parts

2048550000

2048575000

2. Aluminum cans, including lids, ends, and parts
3. Other metal processing and metalworking contract manufacturing services, performed using materials owned by others (i.e., the
customer)

2053610000

All other sales, shipments, receipts, or revenue from this establishment
4003650000

4. Wholesale sales of recyclable ferrous metal scrap

4003675000

5. Wholesale sales of recyclable nonferrous metal scrap

Add product/service not listed

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

31

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
If quantities are requested, please use the unit of measure specified.
Below are the products and services you previously selected. If you make products or have revenue from sources not listed, click the “Add product/service not listed” button and
search for a product or service.
For manufacturing products – Report the value of the products shipped and services performed at the net selling value, free on board (FOB) plant to the customer, after discounts
and allowances.
Include:
Products made in this establishment and shipped, excluding freight charged and excise taxes
Products transferred to other establishments within your company. These products should be assigned the full economic value (market value); i.e., include all direct costs of
production and a reasonable proportion of all other costs and profits.
Products made elsewhere by others from materials supplied by this establishment. Report these products on the specific lines as if they were made in this establishment.
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer). Report your commission or contract receipts in the appropriate Contract Manufacturing products line(s)
you selected or “Add product/service not listed”
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts
Description

Value

Product Code

Manufacturing of:
$

,000.00

2048550000

$

,000.00

2048575000

$

,000.00

2053610000

4. Wholesale sales of recyclable ferrous metal scrap

$

,000.00

4003650000

5. Wholesale sales of recyclable nonferrous metal scrap

$

,000.00

4003675000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

1. Steel cans and tinware end products, including ice cream cans, lids, ends, and parts

2. Aluminum cans, including lids, ends, and parts
3. Other metal processing and metalworking contract manufacturing services, performed using materials owned by
others (i.e., the customer)
All other sales, shipments, receipts, or revenue from this establishment

Add product/service not listed

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32

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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33

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

34

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_MC-33242_su.pdf Generated 2022-02-24 07:23:50

35

Item 28: Industrial Robots and Robotic Equipment

ITEM 28: INDUSTRIAL ROBOTS AND ROBOTIC EQUIPMENT

INDUSTRIAL ROBOTIC EQUIPMENT
Industrial robotic equipment (or industrial robots) are automatically controlled, reprogrammable, and multipurpose
machines used in the industrial automated operations.
Industrial robots may be mobile, incorporated into stand-alone stations, or integrated into a production line.
An industrial robot may be part of a robotic cell (or work cell) or incorporated into another piece of equipment.
Industrial robots are commonly used in operations such as welding, material handling, machine tending, dispensing,
cleanroom, and pick and place.
REPORTING INDUSTRIAL ROBOTIC EQUIPMENT
Estimates are acceptable.
In (A), report capital expenditures for new and used industrial robotic equipment for this establishment. Include other
one-time costs, including software and installation.
In (B) and (C), report the number of industrial robots in operation at this establishment and purchased for this
establishment.
For robots purchased as part of a work cell or other integrated robotic equipment, it may not be possible to report the
expenditures on only the robots. In this case, report the expenditures on the integrated robotic equipment.
Examples of operations industrial robotic equipment can perform may include:
Palletizing
Pick and place
Machine tending
Machine handling
Dispensing
Welding
Packing/repacking
Exclude:
Automated guided vehicles (AGVs)
Driverless forklifts
Automated storage and retrieval systems
CNC machining equipment
Check
if
None

2022

A. What were the capital expenditures for new and used industrial robotic equipment, including software, installation, and
other one-time costs?

$

B. What was the number of industrial robots IN OPERATION at this plant? Refer to instructions above for definitions.

2022 Number

,000.00

If you are unable to provide the number of industrial robots IN OPERATION, please explain:

C. What was the number of industrial robots PURCHASED for this plant? Refer to instructions above for definitions.

2022 Number

If you are unable to provide the number of industrial robots PURCHASED, please explain:

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36

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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37

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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38

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

45

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

46

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Primary battery manufacturing

335912 001

Storage battery manufacturing

335911 001

Fiber optic cable manufacturing, made from purchased fiber optic strand

335921 001

Other communication and energy wire manufacturing

335929 001

Current-carrying wiring device manufacturing

335931 001

Noncurrent-carrying wiring device manufacturing

335932 001

Carbon and graphite product manufacturing

335991 001

All other miscellaneous electrical equipment and component manufacturing, including laser systems and equipment, surge suppressors,
semiconductor power conversion apparatus, etc.

335999 001

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE More
A. What was the total value of products shipped and other receipts for this establishment?
(Report detail in Item 22.)
Include:
All products physically shipped from this establishment during 2022
Products donated and physically shipped from this establishment during 2022
Shipments to other domestic plants of your company for further assembly, fabrication, or manufacture
Exclude:
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

B. What percent of the $,000.00 reported in Item 5, line A was for goods that were ordered or whose movement was
controlled or coordinated over electronic networks?
(Report whole percent.)
E-shipments are online orders accepted for manufactured products from customers. These include shipments to other
domestic plants of your own company for further manufacture, assembly, or fabrication. The price and terms of sale for
these shipments are negotiated over an online system. Payment may or may not be made online.
Include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems

%

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18

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report values in Item 16, line D1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line D1.)
Purchased professional and technical services (Report values in Item 16, line D9.)
Subcontractors and their employees (Report cost of contract work in Item 16, line A3.)
Fishermen, agricultural employees, members of the Armed Forces, and pensioners carried on your active rolls
A. TOTAL EMPLOYMENT AND PAYROLL More
For all employees at this establishment, what was the:
Check
if
None

2022 Number

1. Total number of employees for the pay period including March 12?
2. Total annual payroll (before deductions)?

2022

Exclude: Employer-paid annual cost for fringe benefits reported in lines E1 through E3

3. Total first quarter payroll (January - March)?

$

,000.00

$

,000.00

B. PRODUCTION WORKER EMPLOYMENT AND PAYROLL More
For production workers at this establishment (direct labor including first-line supervisors), what was the:
1. Number of employees for the pay period including March 12?
Include:
Workers engaged in fabricating, processing, assembling, inspecting, receiving, packing, warehousing,
shipping (but not delivering), maintenance, repair, janitorial, guard services, product development, auxiliary
production for plant’s own use (e.g., power plant), recordkeeping, and other closely associated services
(including truck drivers delivering ready-mixed concrete)

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

C. NON-PRODUCTION EMPLOYMENT AND PAYROLL
For non-production employees at this establishment, what was the:

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19

1. Number of employees for the pay period including March 12?
Include:
Officers at this establishment, if a corporation
Supervision above line-supervisor level
Sales employees, including delivery (truck driver and helpers)
Advertising, clerical, credit, collection, purchasing, finance, legal, executive, and technical employees
Employees installing and servicing this establishment's products
Exclude:
Proprietors and partners, if an unincorporated concern

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

D. HOURS WORKED More
Check
if
None

2022 Hours

What was the annual number of hours worked by the production workers at this establishment (direct labor
including first-line supervisors) reported in line B1?

,000

E. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS More
What were the employer's annual costs at this establishment for:

Check
if
None
1. Health Insurance? - Insurance premiums on hospitals, medical plans, and single-service plans such as dental,
vision, and prescription drug plans

2022
$

,000.00

$

,000.00

$

,000.00

2. Retirement Plans?
a. Defined benefit pension plans (qualified and nonqualified) - Plans that specify the benefit to be paid to
employees upon retirement, generally either a specific amount or a percentage of compensation. Employer
contributions are based on actuarial computations that include employee's compensation and years of service
and are not allocated to specific accounts maintained for employees.
b. Defined contribution plans - Plans that define the employer contributions to a separate account provided for
each employee. The employee "benefit" at retirement depends on the amount contributed and the results of the
account's activity.
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

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20

3. Payroll taxes, employer-paid insurance premiums, and other employer-paid benefits?
Include:
Legally-required fringe benefits (e.g., Social Security, workers compensation insurance, state disability
insurance programs, long- and short- term disability, unemployment tax, and Medicare)
"Quality of life” benefits (e.g., childcare assistance, education assistance, subsidized commuting)
Other benefits not specified above
More

4. TOTAL (Add lines E1 through E3.)

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

$

,000.00

$

,000.00

21

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES More
Report inventories at cost or market using generally accepted accounting practices, and report all inventories owned by this establishment regardless of where the inventories are held. If
this establishment is part of a multiple-establishment company, assign to each establishment those inventories that the establishment is responsible for as if it owned them.
What was the value of inventories owned by this establishment as of December 31 before Last-In, First-Out (LIFO) adjustment (if any) for:
Check
if
None
A. Finished goods (final output of this establishment, but still
within ownership)?

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

B. Work-in-process (goods that have been substantially
transformed in the manufacturing process, but are not yet
the final output of the establishment)?

$

,000.00

$

,000.00

C. Materials, supplies, fuels, etc. (goods that are raw inputs
to the manufacturing process and will be substantially
altered to produce this establishment’s output)?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through C.)

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Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD More
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this establishment as of December 31, 2022, and the $,000.00 reported in Item 9 as the total value of
inventories owned by this establishment as of December 31, 2021, how much is subject to the following valuation methods:

A. Non-LIFO (Last-In, First-Out) valuation methods
Check
if
None

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

2. Average Cost?

$

,000.00

$

,000.00

3. Standard Cost?

$

,000.00

$

,000.00

4. Other non-LIFO valuation method(s)?

$

,000.00

$

,000.00

TOTAL (Add lines A1 through A4.)

$

,000.00

$

,000.00

B. LIFO Valuation Method (gross LIFO amount)?

$

,000.00

$

,000.00

TOTAL Non-LIFO and LIFO methods (Add TOTAL of lines A1
through A4 and B.)

$

,000.00

$

,000.00

C. What is the amount of LIFO reserve (if any)?
(If the value of reserve is negative, use "-".)

$

,000.00

$

,000.00

1. First-In, First-Out (FIFO)?

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Item 13: Assets, Capital Expenditures, and Retirements

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS More
Include:
Dollar value of capital expenditures
Buildings, structures, and equipment used directly or indirectly by this establishment to produce the goods and services reported in Item 5, line A and Item 22

A. What was the gross value of depreciable assets (acquisition costs) at this establishment at the beginning of the year for:
Check
if
None

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines A1 and A2)

$

,000.00

B. What were the capital expenditures for new and used depreciable assets at this establishment in 2022 for:
Check
if
None
1. New and used buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

a. Automobiles, trucks, etc. for highway use?

$

,000.00

b. Computers and peripheral data processing equipment?

$

,000.00

c. All other expenditures for machinery and equipment?

$

,000.00

$

,000.00

2. New and used machinery and equipment?

TOTAL (Add lines B1 and B2a through B2c.)

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc. at this establishment for:
Check
if
None

2022

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

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24

D. What was the value of depreciable assets at this establishment at the end of the year for:
Check
if
None

2022

1. Buildings and other structures? (Add lines A1 and B1, and subtract line C1)
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment (Add lines A2 and B2, and subtract line C2)

$

,000.00

TOTAL (Add lines D1 and D2)

$

,000.00

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Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS More
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

B. Rental or lease of machinery and equipment?

$

,000.00

TOTAL (Add lines A and B.)

$

,000.00

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

26

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES More
A. For this establishment, what were the production-related costs in 2022 for:
1. Materials, parts, containers, packaging, supplies, etc. used for manufacturing processes, repairs, services for
others, or other operating supplies? (Report detail in Item 18.)
Include:
Cost of production-related materials purchased by this establishment for other companies (contractors).
Exclude:
Non-production-related expenses that were paid to other companies (contractors) by this establishment.
(Report these expenses on the next screen in Item 16, line D.)

Check
if
None

2022
$

,000.00

2. Products bought and sold without further processing? (Report associated sales in Item 5, line A and in Wholesale
product codes in Item 22.)

$

,000.00

3. Work done for you by others on your materials (work contracted to others)? (Report on line A1 the cost of
production-related materials purchased by this establishment for other companies (contractors).)

$

,000.00

4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report on line B2 the quantity of
electricity generated (Gross less generating station use).) More

$

,000.00

5. Purchased electricity? (Report comparable quantity on line B1.) More

$

,000.00

TOTAL (Add lines A1 through A5.)

$

,000.00

B. For this establishment, what was the quantity of:
Check
if
None

2022 Kilowatt Hours
,000

1. Purchased electricity? (Quantity comparable to cost reported in line A5)

2. Generated electricity (gross less generating station use)? (Quantity comparable to cost reported in line A4) More

,000

3. Electricity sold or transferred to other establishments? (Also include quantity on lines B1 and/or B2.) More

,000

Check
if
None
C. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

2022
$

,000.00

27

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

D. What were the other operating expenses (expenses normally considered as non-production-related costs purchased from other companies) paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment) More

$

,000.00

3. Expensed purchases of software? (Purchases of prepackaged, custom-coded or vendor-customized
software) More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments on line A5. If the costs of these utilities are included in a lease or rental payment,
report in Item 14, line A.) More

$

,000.00

8. Purchased advertising and promotional services? More

$

,000.00

9. Purchased professional and technical services? More

$

,000.00

4. Purchased communication services?
Include:
Telephone, cellular, and Internet services
Other wired and wireless communication services
Credit card transaction fees

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Data storage
Other computer-related advice and services, including training
More
6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof repairs, replacing parts, overhauling of equipment, and other repairs chargeable
as current operating costs
Exclude:
Extensive "repairs" or reconstruction that is capitalized. Report these as a capital expenditure in Item 13.
More

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

28

10. Governmental taxes and licensing fees? (Payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?
Exclude:
Other expenses reported in Items 7, 13, 14, and 16
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

29

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
General - The sum of the costs of the itemized materials in this section should equal the figure reported on Item 16, line A1 (Cost of materials, parts, containers, packaging, etc.
used). The following is a breakout of the $,000.00 currently reported there.
Please review the entire list and report separately each item consumed.
Report materials, parts, and supplies purchased, transferred from other plants of your company, or withdrawn from inventory.
If the information as requested cannot be taken directly from your book records, reasonable estimates are acceptable.
Exclude:
Products bought and sold without further processing, reported in Item 16, line A2
Materials owned by other companies but used by this establishment to make products under contract or commission

Description

Census
Material
Code

Value

$

,000.00

33599100

2. Metal crowns, closures, and other stamped metal products

$

,000.00

33211900

3. Miscellaneous fabricated metal products, excluding hardware, containers, screw machine products (bolts, nuts,
screws, etc.), bearing components, castings, forgings, and wire products

$

,000.00

33200091

4. Nonferrous metal shapes, forms, sheet, strip, powder, and wire (excluding castings and forgings), excluding
aluminum and copper

$

,000.00

33141000

5. Plastics products, including packaging, foam products, film, sheet, rod, tube, fabricated shapes, bottles, etc.
(excluding containers, hoses, belting, and gaskets)

$

,000.00

32610001

6. Paper and paperboard products

$

,000.00

32200000

7. All basic organic and inorganic chemicals, excluding petrochemicals

$

,000.00

32518000

8. Thermoplastic and thermosetting resins and plastics materials

$

,000.00

32521100

9. Cost of all other materials and components, parts, containers, and supplies consumed

$

,000.00

00970099

$

,000.00

77100000

1. Carbon and graphite products, including electrodes

Describe

TOTAL

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

30

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contribute to the sales, shipments, receipts or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for a product or service.
Select ALL that apply, at the most detailed level possible.
For manufacturing products, include:
Products made in this establishment and shipped
Products transferred to other establishments within your company
Products made elsewhere by others from materials supplied by this establishment
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer)
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts

Description

Select

Product Code

Manufacturing of:

1. Primary batteries, including parts (excluding lead acid batteries and battery cases and containers)
2. Other nonferrous metals and alloys, including lead, tungsten, and molybdenum, rolled, drawn, and extruded shapes (including sheet,
strip, traps, etc.), excluding pipe, tube and wire

3. Nickel, nickel-base alloy, lead, zinc, and tin plumbing pipe and tube
4. Nickel, nickel-base alloy, and other nonferrous metal and alloy pipes and tubes, including lead, zinc, tin, tungsten, and molybdenum
(excluding plumbing pipe and tube)

5. Storage batteries, lead-acid-type, BCI dimensional size group 8D (1.5 cu ft (.042 cu m) and smaller)

6. Storage batteries, including lithium-ion (excluding lead acid)
7. Motive-power-type lead acid storage batteries, larger than BCI dimensional size group 8D (1.5 cu ft (.042 cu m)) (including mining
and industrial locomotive)

8. Parts for all storage batteries (excluding cases and containers)
9. All other lead acid storage batteries, larger than BCI dimensional size group 8D (1.6 cu ft (.042 cu m)) (including communication and
standby emergency)

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

2010950000

2027426000

2038270000

2027580000

2030050000

2030125000

2030075000

2030150000

2030100000

31

2043900000

10. Semiconductor battery chargers

11. Power wire and cable, made from nonferrous metals for electric transmission and distribution

2039275000

All other sales, shipments, receipts, or revenue from this establishment
4001700000

12. Wholesale sales of batteries, except automotive

Add product/service not listed

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

32

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
If quantities are requested, please use the unit of measure specified.
Below are the products and services you previously selected. If you make products or have revenue from sources not listed, click the “Add product/service not listed” button and
search for a product or service.
For manufacturing products – Report the value of the products shipped and services performed at the net selling value, free on board (FOB) plant to the customer, after discounts
and allowances.
Include:
Products made in this establishment and shipped, excluding freight charged and excise taxes
Products transferred to other establishments within your company. These products should be assigned the full economic value (market value); i.e., include all direct costs of
production and a reasonable proportion of all other costs and profits.
Products made elsewhere by others from materials supplied by this establishment. Report these products on the specific lines as if they were made in this establishment.
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer). Report your commission or contract receipts in the appropriate Contract Manufacturing products line(s)
you selected or “Add product/service not listed”
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts
Description

Value

Product Code

Manufacturing of:

1. Primary batteries, including parts (excluding lead acid batteries and battery cases and containers)

$

,000.00

2010950000

2. Other nonferrous metals and alloys, including lead, tungsten, and molybdenum, rolled, drawn, and extruded shapes
(including sheet, strip, traps, etc.), excluding pipe, tube and wire

$

,000.00

2027426000

3. Nickel, nickel-base alloy, lead, zinc, and tin plumbing pipe and tube

$

,000.00

2038270000

4. Nickel, nickel-base alloy, and other nonferrous metal and alloy pipes and tubes, including lead, zinc, tin, tungsten, and
molybdenum (excluding plumbing pipe and tube)

$

,000.00

2027580000

5. Storage batteries, lead-acid-type, BCI dimensional size group 8D (1.5 cu ft (.042 cu m) and smaller)

$

,000.00

2030050000

6. Storage batteries, including lithium-ion (excluding lead acid)

$

,000.00

2030125000

7. Motive-power-type lead acid storage batteries, larger than BCI dimensional size group 8D (1.5 cu ft (.042 cu m))
(including mining and industrial locomotive)

$

,000.00

2030075000

8. Parts for all storage batteries (excluding cases and containers)

$

,000.00

2030150000

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

33

9. All other lead acid storage batteries, larger than BCI dimensional size group 8D (1.6 cu ft (.042 cu m)) (including
communication and standby emergency)

$

,000.00

2030100000

10. Semiconductor battery chargers

$

,000.00

2043900000

11. Power wire and cable, made from nonferrous metals for electric transmission and distribution

$

,000.00

2039275000

12. Wholesale sales of batteries, except automotive

$

,000.00

4001700000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

All other sales, shipments, receipts, or revenue from this establishment

Add product/service not listed

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

34

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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35

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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36

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

37

Item 28: Industrial Robots and Robotic Equipment

ITEM 28: INDUSTRIAL ROBOTS AND ROBOTIC EQUIPMENT

INDUSTRIAL ROBOTIC EQUIPMENT
Industrial robotic equipment (or industrial robots) are automatically controlled, reprogrammable, and multipurpose
machines used in the industrial automated operations.
Industrial robots may be mobile, incorporated into stand-alone stations, or integrated into a production line.
An industrial robot may be part of a robotic cell (or work cell) or incorporated into another piece of equipment.
Industrial robots are commonly used in operations such as welding, material handling, machine tending, dispensing,
cleanroom, and pick and place.
REPORTING INDUSTRIAL ROBOTIC EQUIPMENT
Estimates are acceptable.
In (A), report capital expenditures for new and used industrial robotic equipment for this establishment. Include other
one-time costs, including software and installation.
In (B) and (C), report the number of industrial robots in operation at this establishment and purchased for this
establishment.
For robots purchased as part of a work cell or other integrated robotic equipment, it may not be possible to report the
expenditures on only the robots. In this case, report the expenditures on the integrated robotic equipment.
Examples of operations industrial robotic equipment can perform may include:
Palletizing
Pick and place
Machine tending
Machine handling
Dispensing
Welding
Packing/repacking
Exclude:
Automated guided vehicles (AGVs)
Driverless forklifts
Automated storage and retrieval systems
CNC machining equipment
Check
if
None

2022

A. What were the capital expenditures for new and used industrial robotic equipment, including software, installation, and
other one-time costs?

$

B. What was the number of industrial robots IN OPERATION at this plant? Refer to instructions above for definitions.

2022 Number

,000.00

If you are unable to provide the number of industrial robots IN OPERATION, please explain:

C. What was the number of industrial robots PURCHASED for this plant? Refer to instructions above for definitions.

2022 Number

If you are unable to provide the number of industrial robots PURCHASED, please explain:

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

38

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

39

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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40

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

41

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

42

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

44

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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45

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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46

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

47

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MC-33591_su.pdf Generated 2022-02-24 07:21:30

,000.00

48

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Under construction, development, or exploration
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Aircraft manufacturing, including manufacturing complete aircraft, developing and making aircraft prototypes, aircraft conversion, and
complete aircraft overhaul and rebuilding

336411 001

Aircraft engine and engine parts manufacturing, including developing and making prototypes of aircraft engines and engine parts, aircraft
propulsion system conversion, and aircraft propulsions systems overhaul and rebuilding

336412 001

Other aircraft parts and auxiliary equipment manufacturing, including manufacturing aircraft subassemblies, parts, or auxiliary equipment,
and/or developing and making prototypes of aircraft parts and auxiliary equipment

336413 001

Guided missile and space vehicle manufacturing, including developing and making prototypes of guided missiles and space vehicles

336414 001

Guided missile and space vehicle propulsion unit and propulsion unit parts manufacturing, including developing and making prototypes of
propulsion units and propulsion unit parts

336415 001

Other guided missile and space vehicle parts and auxiliary equipment manufacturing, including developing and making prototypes

336419 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

17

Item 5: Sales, Shipments, Receipts, or Revenue

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE More
A. What was the total value of products shipped and other receipts for this establishment?
(Report detail in Item 22.)
Include:
All products physically shipped from this establishment during 2022
Products donated and physically shipped from this establishment during 2022
Shipments to other domestic plants of your company for further assembly, fabrication, or manufacture
Exclude:
Freight charges
Excise taxes

Check
if
None

2022
$

,000.00

B. What percent of the $,000.00 reported in Item 5, line A was for goods that were ordered or whose movement was
controlled or coordinated over electronic networks?
(Report whole percent.)
E-shipments are online orders accepted for manufactured products from customers. These include shipments to other
domestic plants of your own company for further manufacture, assembly, or fabrication. The price and terms of sale for
these shipments are negotiated over an online system. Payment may or may not be made online.
Include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems

%

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

18

Item 7: Employment and Payroll

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
All persons on paid sick leave, paid holidays, and paid vacation during the year at this establishment
Exclude:
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN (Report values in Item 16, line D1.)
Temporary staffing obtained from a staffing service (Report values in Item 16, line D1.)
Purchased professional and technical services (Report values in Item 16, line D9.)
Subcontractors and their employees (Report cost of contract work in Item 16, line A3.)
Fishermen, agricultural employees, members of the Armed Forces, and pensioners carried on your active rolls
A. TOTAL EMPLOYMENT AND PAYROLL More
For all employees at this establishment, what was the:
Check
if
None

2022 Number

1. Total number of employees for the pay period including March 12?
2. Total annual payroll (before deductions)?

2022

Exclude: Employer-paid annual cost for fringe benefits reported in lines E1 through E3

3. Total first quarter payroll (January - March)?

$

,000.00

$

,000.00

B. PRODUCTION WORKER EMPLOYMENT AND PAYROLL More
For production workers at this establishment (direct labor including first-line supervisors), what was the:
1. Number of employees for the pay period including March 12?
Include:
Workers engaged in fabricating, processing, assembling, inspecting, receiving, packing, warehousing,
shipping (but not delivering), maintenance, repair, janitorial, guard services, product development, auxiliary
production for plant’s own use (e.g., power plant), recordkeeping, and other closely associated services
(including truck drivers delivering ready-mixed concrete)

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

C. NON-PRODUCTION EMPLOYMENT AND PAYROLL
For non-production employees at this establishment, what was the:

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

19

1. Number of employees for the pay period including March 12?
Include:
Officers at this establishment, if a corporation
Supervision above line-supervisor level
Sales employees, including delivery (truck driver and helpers)
Advertising, clerical, credit, collection, purchasing, finance, legal, executive, and technical employees
Employees installing and servicing this establishment's products
Exclude:
Proprietors and partners, if an unincorporated concern

Check
if
None

2022 Number

2022
2. Annual payroll (before deductions)?

3. First quarter payroll (January - March)?

$

,000.00

$

,000.00

D. HOURS WORKED More
Check
if
None

2022 Hours

What was the annual number of hours worked by the production workers at this establishment (direct labor
including first-line supervisors) reported in line B1?

,000

E. EMPLOYER-PAID ANNUAL COST FOR FRINGE BENEFITS More
What were the employer's annual costs at this establishment for:

Check
if
None
1. Health Insurance? - Insurance premiums on hospitals, medical plans, and single-service plans such as dental,
vision, and prescription drug plans

2022
$

,000.00

$

,000.00

$

,000.00

2. Retirement Plans?
a. Defined benefit pension plans (qualified and nonqualified) - Plans that specify the benefit to be paid to
employees upon retirement, generally either a specific amount or a percentage of compensation. Employer
contributions are based on actuarial computations that include employee's compensation and years of service
and are not allocated to specific accounts maintained for employees.
b. Defined contribution plans - Plans that define the employer contributions to a separate account provided for
each employee. The employee "benefit" at retirement depends on the amount contributed and the results of the
account's activity.
Examples:
Profit sharing plans
Money purchases (e.g., 401k, 403b)
Stock bonus plans (e.g., ESOPs)

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

20

3. Payroll taxes, employer-paid insurance premiums, and other employer-paid benefits?
Include:
Legally-required fringe benefits (e.g., Social Security, workers compensation insurance, state disability
insurance programs, long- and short- term disability, unemployment tax, and Medicare)
"Quality of life” benefits (e.g., childcare assistance, education assistance, subsidized commuting)
Other benefits not specified above
More

4. TOTAL (Add lines E1 through E3.)

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

$

,000.00

$

,000.00

21

Item 9: Value of Inventories

ITEM 9: VALUE OF INVENTORIES More
Report inventories at cost or market using generally accepted accounting practices, and report all inventories owned by this establishment regardless of where the inventories are held. If
this establishment is part of a multiple-establishment company, assign to each establishment those inventories that the establishment is responsible for as if it owned them.
What was the value of inventories owned by this establishment as of December 31 before Last-In, First-Out (LIFO) adjustment (if any) for:
Check
if
None
A. Finished goods (final output of this establishment, but still
within ownership)?

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

B. Work-in-process (goods that have been substantially
transformed in the manufacturing process, but are not yet
the final output of the establishment)?

$

,000.00

$

,000.00

C. Materials, supplies, fuels, etc. (goods that are raw inputs
to the manufacturing process and will be substantially
altered to produce this establishment’s output)?

$

,000.00

$

,000.00

$

,000.00

$

,000.00

TOTAL (Add lines A through C.)

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

22

Item 10: Inventories by Valuation Method

ITEM 10: INVENTORIES BY VALUATION METHOD More
Of the $,000.00 reported in Item 9 as the total value of inventories owned by this establishment as of December 31, 2022, and the $,000.00 reported in Item 9 as the total value of
inventories owned by this establishment as of December 31, 2021, how much is subject to the following valuation methods:

A. Non-LIFO (Last-In, First-Out) valuation methods
Check
if
None

Check
if
None

End of 2022

End of 2021

$

,000.00

$

,000.00

2. Average Cost?

$

,000.00

$

,000.00

3. Standard Cost?

$

,000.00

$

,000.00

4. Other non-LIFO valuation method(s)?

$

,000.00

$

,000.00

TOTAL (Add lines A1 through A4.)

$

,000.00

$

,000.00

B. LIFO Valuation Method (gross LIFO amount)?

$

,000.00

$

,000.00

TOTAL Non-LIFO and LIFO methods (Add TOTAL of lines A1
through A4 and B.)

$

,000.00

$

,000.00

C. What is the amount of LIFO reserve (if any)?
(If the value of reserve is negative, use "-".)

$

,000.00

$

,000.00

1. First-In, First-Out (FIFO)?

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23

Item 13: Assets, Capital Expenditures, and Retirements

ITEM 13: ASSETS, CAPITAL EXPENDITURES, AND RETIREMENTS More
Include:
Dollar value of capital expenditures
Buildings, structures, and equipment used directly or indirectly by this establishment to produce the goods and services reported in Item 5, line A and Item 22

A. What was the gross value of depreciable assets (acquisition costs) at this establishment at the beginning of the year for:
Check
if
None

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines A1 and A2)

$

,000.00

B. What were the capital expenditures for new and used depreciable assets at this establishment in 2022 for:
Check
if
None
1. New and used buildings and other structures?
(Exclude the value of land on which structures stand)

2022
$

,000.00

a. Automobiles, trucks, etc. for highway use?

$

,000.00

b. Computers and peripheral data processing equipment?

$

,000.00

c. All other expenditures for machinery and equipment?

$

,000.00

$

,000.00

2. New and used machinery and equipment?

TOTAL (Add lines B1 and B2a through B2c.)

C. What was the gross value of depreciable assets sold, retired, scrapped, destroyed, etc. at this establishment for:
Check
if
None

2022

1. Buildings and other structures?
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment?

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

24

D. What was the value of depreciable assets at this establishment at the end of the year for:
Check
if
None

2022

1. Buildings and other structures? (Add lines A1 and B1, and subtract line C1)
(Exclude the value of land on which structures stand)

$

,000.00

2. Machinery and equipment (Add lines A2 and B2, and subtract line C2)

$

,000.00

TOTAL (Add lines D1 and D2)

$

,000.00

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

25

Item 14: Rental Payments

ITEM 14: RENTAL PAYMENTS More
Include:
Operating leases
Exclude:
Capital leases (leases with a contract to own at the end of the lease)
At this establishment, what were the payments for:
A. Rental or lease of buildings and other structures?
Include:
Job-site trailers
Land on which the buildings and other structures stand

Check
if
None

2022
$

,000.00

B. Rental or lease of machinery and equipment?

$

,000.00

TOTAL (Add lines A and B.)

$

,000.00

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

26

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES More
A. For this establishment, what were the production-related costs in 2022 for:
1. Materials, parts, containers, packaging, supplies, etc. used for manufacturing processes, repairs, services for
others, or other operating supplies? (Report detail in Item 18.)
Include:
Cost of production-related materials purchased by this establishment for other companies (contractors).
Exclude:
Non-production-related expenses that were paid to other companies (contractors) by this establishment.
(Report these expenses on the next screen in Item 16, line D.)

Check
if
None

2022
$

,000.00

2. Products bought and sold without further processing? (Report associated sales in Item 5, line A and in Wholesale
product codes in Item 22.)

$

,000.00

3. Work done for you by others on your materials (work contracted to others)? (Report on line A1 the cost of
production-related materials purchased by this establishment for other companies (contractors).)

$

,000.00

4. Purchased fuels consumed for heat, power, or the generation of electricity? (Report on line B2 the quantity of
electricity generated (Gross less generating station use).) More

$

,000.00

5. Purchased electricity? (Report comparable quantity on line B1.) More

$

,000.00

TOTAL (Add lines A1 through A5.)

$

,000.00

B. For this establishment, what was the quantity of:
Check
if
None

2022 Kilowatt Hours
,000

1. Purchased electricity? (Quantity comparable to cost reported in line A5)

2. Generated electricity (gross less generating station use)? (Quantity comparable to cost reported in line A4) More

,000

3. Electricity sold or transferred to other establishments? (Also include quantity on lines B1 and/or B2.) More

,000

Check
if
None
C. For this establishment, what were the depreciation/amortization charges for the current year obtained from your income
statement? (Include depreciation on all assets reported in Item 13.)

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

2022
$

,000.00

27

Item 16: Selected Expenses - Continued

ITEM 16: SELECTED EXPENSES

D. What were the other operating expenses (expenses normally considered as non-production-related costs purchased from other companies) paid by this establishment in 2022 for:
1. Temporary staff and leased employees? (Professional Employer Organizations and staffing agencies for
personnel)
Include:
All charges for payroll, benefits, and services

Check
if
None

2022
$

,000.00

2. Expensed equipment? (Expensed computer hardware and other equipment) More

$

,000.00

3. Expensed purchases of software? (Purchases of prepackaged, custom-coded or vendor-customized
software) More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

7. Water, sewer, refuse removal, and other non-electric utility payments?
(Report electric utility payments on line A5. If the costs of these utilities are included in a lease or rental payment,
report in Item 14, line A.) More

$

,000.00

8. Purchased advertising and promotional services? More

$

,000.00

9. Purchased professional and technical services? More

$

,000.00

4. Purchased communication services?
Include:
Telephone, cellular, and Internet services
Other wired and wireless communication services
Credit card transaction fees

5. Data processing and other purchased computer services?
Include:
Computer facilities management services
Data storage
Other computer-related advice and services, including training
More
6. Purchased repairs and maintenance to buildings and/or machinery and equipment?
Include:
Repairs for painting, roof repairs, replacing parts, overhauling of equipment, and other repairs chargeable
as current operating costs
Exclude:
Extensive "repairs" or reconstruction that is capitalized. Report these as a capital expenditure in Item 13.
More

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28

10. Governmental taxes and licensing fees? (Payments to government agencies for taxes and licenses)
Include:
Business and property taxes
Exclude:
Income taxes

$

,000.00

$

,000.00

$

,000.00

11. All other operating expenses not reported elsewhere?
Exclude:
Other expenses reported in Items 7, 13, 14, and 16
Purchases of merchandise for resale
Non-operating expenses

Describe

TOTAL (Add lines 1 through 11.)

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29

Item 18: Detailed Cost of Materials, Parts, and Supplies

ITEM 18: DETAILED COST OF MATERIALS, PARTS, AND SUPPLIES
Of the $,000.00 of materials, parts, and supplies in 2022, reported on Item 16, line A1, how much was for the following specified materials?
General - The sum of the costs of the itemized materials in this section should equal the figure reported on Item 16, line A1 (Cost of materials, parts, containers, packaging, etc.
used). The following is a breakout of the $,000.00 currently reported there.
Please review the entire list and report separately each item consumed.
Report materials, parts, and supplies purchased, transferred from other plants of your company, or withdrawn from inventory.
If the information as requested cannot be taken directly from your book records, reasonable estimates are acceptable.
Exclude:
Products bought and sold without further processing, reported in Item 16, line A2
Materials owned by other companies but used by this establishment to make products under contract or commission

Description

Census
Material
Code

Value

$

,000.00

33641201

2. Aircraft engine parts, excluding instruments

$

,000.00

33641203

3. Structural landing gear, fuselage, empennage, and wing components including other structural components and
engine mounts

$

,000.00

33641312

4. Complete mechanical, hydraulic and pneumatic subassemblies

$

,000.00

33291209

5. Electronic communication systems and equipment, including wireless, radio, television, satellite, and airborne
transmitters and receivers (microwave, UHF, VHF, etc.)

$

,000.00

33422005

6. Nautical and navigation equipment

$

,000.00

33451105

7. Measuring and controlling instruments and devices (seismometers, surveying and plotting instruments, aircraft
engine instruments, etc.)

$

,000.00

33451920

8. Semiconductors, including transistors, diodes, rectifiers, and integrated circuits for electronic circuitry, and
related devices, including electronic control modules

$

,000.00

33441310

9. Metal crowns, closures, and other stamped metal products

$

,000.00

33211900

$

,000.00

33261011

$

,000.00

33636000

$

,000.00

00970099

$

,000.00

77100000

1. Aircraft engines

10. Aircraft metal hardware, including metal bolts, nuts, screws, washers, rivets, and other screw machine products

11. Motor vehicle seating and interior trim
12. Cost of all other materials and components, parts, containers, and supplies consumed
Describe

TOTAL

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

30

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

31

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contribute to the sales, shipments, receipts or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for a product or service.
Select ALL that apply, at the most detailed level possible.
For manufacturing products, include:
Products made in this establishment and shipped
Products transferred to other establishments within your company
Products made elsewhere by others from materials supplied by this establishment
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer)
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts

Description

Select

Product Code

Manufacturing of:
2012125000

1. Civilian aircraft

2012125003

a. Manned civilian aircraft

2012125006

b. Unmanned robotic civilian aircraft

2. Military aircraft, including all aircraft for U.S. military and any other aircraft built to military specifications

a. Manned military aircraft, including manned aircraft for U.S. military and any other manned aircraft built to military specifications
b. Unmanned robotic military aircraft, including unmanned aircraft for U.S. military and any other unmanned aircraft built to military
specifications

3. Modification, conversion, and overhaul of previously accepted aircraft

a. Modification, conversion, and overhaul of previously accepted aircraft for civilian customers

b. Modification, conversion, and overhaul of military aircraft and all other aircraft built to military specifications

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

2012100000

2012100003

2012100006

2054050000

2054050006

2054050003

32

4. Aeronautical services on complete aircraft for civilian customers

5. Aeronautical services on complete aircraft for military customers

2053835000

2053825000

2019200000

6. Developing and making prototypes of complete aircraft

7. Developing and making prototypes of aircraft parts (excluding engines)

2019250000

2029425000

8. Civilian aircraft engines

9. Military aircraft engines (including other aircraft engines built to military specifications)

2029400000

2029475000

10. Parts and accessories for civilian aircraft engines

2029450000

11. Parts and accessories for military aircraft engines

12. Aircraft propellers and helicopter rotors, including blades and parts

2029500000

2032450000

13. Aircraft landing gear for civilian and military aircraft

14. Search, detection, navigation, and guidance systems and equipment

15. Other aircraft subassemblies and parts for civilian aircraft

16. Other aircraft subassemblies and parts for military aircraft (including other aircraft built to military specifications)

2017500000

2032500000

2032475000

All other sales, shipments, receipts, or revenue from this establishment

17. Wholesale sales of aircraft equipment and supplies, including engines and engine parts

4004300000

4002000000

18. Wholesale sales of aircraft and aeronautical equipment

Add product/service not listed

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

33

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
General – Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
If quantities are requested, please use the unit of measure specified.
Below are the products and services you previously selected. If you make products or have revenue from sources not listed, click the “Add product/service not listed” button and
search for a product or service.
For manufacturing products – Report the value of the products shipped and services performed at the net selling value, free on board (FOB) plant to the customer, after discounts
and allowances.
Include:
Products made in this establishment and shipped, excluding freight charged and excise taxes
Products transferred to other establishments within your company. These products should be assigned the full economic value (market value); i.e., include all direct costs of
production and a reasonable proportion of all other costs and profits.
Products made elsewhere by others from materials supplied by this establishment. Report these products on the specific lines as if they were made in this establishment.
For contract manufacturing products, include:
Products made from materials owned by others (i.e., the customer). Report your commission or contract receipts in the appropriate Contract Manufacturing products line(s)
you selected or “Add product/service not listed”
For wholesale products, include:
Products that are bought from other establishments or transferred or imported from other establishments of your company and then sold without further manufacture,
processing, or assembly by this establishment
For other non-manufacturing products or services, please select a product or service listed below or “Add product/service not listed”.
Examples: Receipts for construction, installation, repair, and service contracts
Description

Value

Product Code

Manufacturing of:
1. Civilian aircraft

a. Manned civilian aircraft

$

,000.00

2012125003

b. Unmanned robotic civilian aircraft

$

,000.00

2012125006

Subtotal

$

,000.00

2012125000

a. Manned military aircraft, including manned aircraft for U.S. military and any other manned aircraft built to military
specifications

$

,000.00

2012100003

b. Unmanned robotic military aircraft, including unmanned aircraft for U.S. military and any other unmanned aircraft
built to military specifications

$

,000.00

2012100006

Subtotal

$

,000.00

2012100000

2. Military aircraft, including all aircraft for U.S. military and any other aircraft built to military specifications

3. Modification, conversion, and overhaul of previously accepted aircraft

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

34

a. Modification, conversion, and overhaul of previously accepted aircraft for civilian customers

$

,000.00

2054050006

b. Modification, conversion, and overhaul of military aircraft and all other aircraft built to military specifications

$

,000.00

2054050003

Subtotal

$

,000.00

2054050000

4. Aeronautical services on complete aircraft for civilian customers

$

,000.00

2053835000

5. Aeronautical services on complete aircraft for military customers

$

,000.00

2053825000

6. Developing and making prototypes of complete aircraft

$

,000.00

2019200000

7. Developing and making prototypes of aircraft parts (excluding engines)

$

,000.00

2019250000

$

,000.00

2029425000

9. Military aircraft engines (including other aircraft engines built to military specifications)

$

,000.00

2029400000

10. Parts and accessories for civilian aircraft engines

$

,000.00

2029475000

11. Parts and accessories for military aircraft engines

$

,000.00

2029450000

12. Aircraft propellers and helicopter rotors, including blades and parts

$

,000.00

2029500000

13. Aircraft landing gear for civilian and military aircraft

$

,000.00

2032450000

14. Search, detection, navigation, and guidance systems and equipment

$

,000.00

2017500000

15. Other aircraft subassemblies and parts for civilian aircraft

$

,000.00

2032500000

16. Other aircraft subassemblies and parts for military aircraft (including other aircraft built to military specifications)

$

,000.00

2032475000

$

,000.00

4004300000

18. Wholesale sales of aircraft and aeronautical equipment

$

,000.00

4002000000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

8. Civilian aircraft engines

All other sales, shipments, receipts, or revenue from this establishment

17. Wholesale sales of aircraft equipment and supplies, including engines and engine parts

Add product/service not listed

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

35

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

36

Item 28: Special Items - Defense-Related Manufacturing Activity

ITEM 28: SPECIAL ITEMS - DEFENSE-RELATED MANUFACTURING ACTIVITY
Did this establishment ship national defense related products in 2022?
Yes
No

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37

Item 28: Special Items - Defense-Related Manufacturing Activity - Continued

ITEM 28: SPECIAL ITEMS - DEFENSE-RELATED MANUFACTURING ACTIVITY
For this physical location, report the value of sales, shipments, receipts, or revenue generated in 2022 where the Department of Defense (DOD) was the ultimate customer.

Include:
Domestic U.S. Manufacturing activity (50 states and the District of Columbia).
Shipments for which the DOD was the ultimate customer (U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marines).
Interplant Transfers to other locations, divisions or subsidiaries of your company.
Exported products.
Shipments to commercial entities or subcontractors who sell to the DOD.
Exclude:
Nonmanufacturing activities (i.e. services, wholesale).
Shipments to Government agencies such as National Aeronautics and Space Administration, Department of Energy, Federal Aviation Administration, Department of Homeland
Security, U.S. Coast Guard, U.S. Merchant Marine, and foreign governments.
Resale of purchased merchandise (sale of products bought and sold without further processing or transformation).
Shipments from foreign subsidiaries or affiliates.
Special notes for Aerospace Industries (NAICS 336411, 336412, 336413, 336414, 336415, 336419 Only):
Fixed Price Contract: Report the value of sales during the year of complete aircraft, missiles, and space vehicles. Long term fixed price contracts may be recorded as payments
received, keeping consistent with the financial reports of the establishment.
Cost Plus Contract: Report the value of work done during the year. This may be calculated by multiplying the estimated percentage of work completed during the year by the
contract price of the aircraft or missile.

2022
$

,000.00

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

38

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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39

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

40

Item 28: Industrial Robots and Robotic Equipment

ITEM 28: INDUSTRIAL ROBOTS AND ROBOTIC EQUIPMENT

INDUSTRIAL ROBOTIC EQUIPMENT
Industrial robotic equipment (or industrial robots) are automatically controlled, reprogrammable, and multipurpose
machines used in the industrial automated operations.
Industrial robots may be mobile, incorporated into stand-alone stations, or integrated into a production line.
An industrial robot may be part of a robotic cell (or work cell) or incorporated into another piece of equipment.
Industrial robots are commonly used in operations such as welding, material handling, machine tending, dispensing,
cleanroom, and pick and place.
REPORTING INDUSTRIAL ROBOTIC EQUIPMENT
Estimates are acceptable.
In (A), report capital expenditures for new and used industrial robotic equipment for this establishment. Include other
one-time costs, including software and installation.
In (B) and (C), report the number of industrial robots in operation at this establishment and purchased for this
establishment.
For robots purchased as part of a work cell or other integrated robotic equipment, it may not be possible to report the
expenditures on only the robots. In this case, report the expenditures on the integrated robotic equipment.
Examples of operations industrial robotic equipment can perform may include:
Palletizing
Pick and place
Machine tending
Machine handling
Dispensing
Welding
Packing/repacking
Exclude:
Automated guided vehicles (AGVs)
Driverless forklifts
Automated storage and retrieval systems
CNC machining equipment
Check
if
None

2022

A. What were the capital expenditures for new and used industrial robotic equipment, including software, installation, and
other one-time costs?

$

B. What was the number of industrial robots IN OPERATION at this plant? Refer to instructions above for definitions.

2022 Number

,000.00

If you are unable to provide the number of industrial robots IN OPERATION, please explain:

C. What was the number of industrial robots PURCHASED for this plant? Refer to instructions above for definitions.

2022 Number

If you are unable to provide the number of industrial robots PURCHASED, please explain:

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

41

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

42

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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43

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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45

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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46

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

47

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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48

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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49

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

1000

characters remaining

50

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MC-33640_su.pdf Generated 2022-02-24 07:20:04

,000.00

51

Attachment D-6
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 42

Attachment Sector

D-6

42

Instrument
Path
Instrument Path Title

42311
42435
42441
42542

Motor Vehicles
Clothing and Accessories
General-Line Groceries
Pharmaceuticals, Cosmetics, and Toiletries Agents and Brokers

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

14

Item 4A: Primary Business or Activity Additional Information

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

New and used automobiles and motorcycles

423110 101

Retail new and used motor vehicle dealer

441110 003

Automobile auction, wholesale

425120 315

Light trucks and cargo vans, 14,000 lb. or less

423110 301

Medium trucks and tractors, 14,001 lb. to 33,000 lb.

423110 401

Heavy trucks, road tractors, and truck trailers, over 33,000 lb.

423110 501

Buses, recreational vehicles (RVs), motor homes, and campers

423110 201

Truck equipment distributor/upfitter primarily completing trucks by installing and assembling truck bodies and/or other equipment onto truck
chassis

336211 002

All-terrain vehicles (ATVs), snowmobiles, motor scooters, and mopeds

423110 102

New motor vehicle parts, warehouse distributor, sold primarily to jobbers or other wholesalers

423120 101

New motor vehicle parts, jobber, sold primarily to retailers and repair shops

423120 201

Used motor vehicle parts and supplies dealer

423140 001

Other primary business or activity

779000 001

Select Sector

Describe

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15

Item 4B: Type of Operation Additional Information

ITEM 4B: TYPE OF OPERATION
Which ONE of the following best describes this establishment's primary type of operation in 2022?
For further clarification, click the "Additional Information" link above.

Merchant wholesaler, buying and selling on own account
12

Importer

13

Exporter

11

Merchant wholesale distributor or jobber

14

Own-brand importer and marketer

20

Manufacturers' sales branch or office

Agent, broker, or commission merchant
46

Manufacturers' representative or agent

41

Auction company

42

Broker, representing buyers and sellers

43

Commission merchant

44

Import agent

45

Export agent

49

Electronic market - business-to-business marketplace that facilitates the sale of goods via the Internet or other electronic
means, and operates on a commission or fee basis

Other type of operation
77

Other type of operation
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

A. What were the sales and operating receipts?
(Include the gross selling value of business conducted for others. Include shipping and handling charges. Exclude
sales taxes and Hawaii’s General Excise Tax.)

Check
if
None

2022
$

,000.00

B. Did this establishment earn commissions for the sale of merchandise?
Yes
No

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19

Item 5: Sales, Shipments, Receipts, or Revenue - Commissions Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - COMMISSIONS

C. What was the gross selling value of goods sold on a commission basis?
(This value should be included in the $,000.00 of sales and operating receipts reported in Item 5, line A.
For further clarification, click the "Additional Information" link above.)

2022
$

,000.00

2022
D. What were the commissions, including selling or listing fees, received on transactions reported on line C?

$

,000.00

2022
E. What was this establishment's average commission rate earned for the transactions reported on line C?
(For this response, you may report up to two decimal places.)

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

%

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - CONTINUED
F. During 2022, what was the percent of total revenue (as reported in Item 5, line A ($,000.00)) from products sold by this establishment that were manufactured or mined in the United
States by your company or its subsidiaries?
0%
1-25%
26-49%
50-75%
76-100%
G. Did e-commerce account for more than 50% of this establishment's sales and/or operating receipts as reported in Item 5, line A ($,000.00)?
E-commerce sales and operating receipts are sales of goods and services where an order is placed by the buyer, or price and terms of sale are negotiated, over an Internet, mobile
device, extranet, Electronic Data Interchange (EDI) network, electronic mail, or other online system/application. Payment may or may not be made online.
Yes
No

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21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

2022
$

,000.00

$

,000.00

22

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
For further clarification, click the "Additional Information" link above.
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

23

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES
What were the inventories and Last-in, First-out (LIFO) adjustment, if any, for products owned by this establishment as of December 31?
For further clarification, click the "Additional Information" link above.
Check
if
None

Check
if
None

End of 2022

End of 2021

1. Total inventories before LIFO adjustment
(if any)

$

,000.00

$

,000.00

2. LIFO reserve
(if any)

$

,000.00

$

,000.00

3. Total inventories after LIFO adjustment
(Line 1 minus line 2.)

$

,000.00

$

,000.00

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

24

Item 10: Inventories by Valuation Method Additional Information

ITEM 10: INVENTORIES BY VALUATION METHOD
How much of the inventory reported in Item 9, line 1, for 2022 ($,000.00) is subject to the following valuation methods?
For further clarification, click the "Additional Information" link above.

Check
if
None

End of 2022
$

,000.00

B. First-in, First-out (FIFO)

$

,000.00

C. Average cost

$

,000.00

D. Standard cost

$

,000.00

E. Other valuation method

$

,000.00

$

,000.00

A. LIFO valuation method before adjustment

Describe

F. TOTAL (Sum of lines A through E should equal Item 9, line 1.)

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

25

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

For further clarification, click the "Additional Information" link above.

Check
if
None

2022

A. What were the operating expenses?
(Include payroll. Exclude cost of goods sold and interest expense.)

$

,000.00

B. What were purchases of merchandise for resale, net of returns, allowances, and trade and cash discounts?
(Include amounts allowed for trade-ins.)

$

,000.00

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

26

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
For further clarification, click the "Additional Information" link above.

2022
%

1. Household consumers and individuals

%

2. Export sales

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Repair shops for use in repair work

%

6. Manufacturing and mining industrial users for use as input goods in production

%

7. Restaurants, hotels, food services, and contract feeding

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Building contractors, heavy construction, and special trade contractors

%

%

10. Farmers for use in farm production

%

11. Governmental bodies (Federal, state, and local)

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

27

%

12. Other

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

%

28

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contributed to the sales, shipments, receipts, or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for the product or service.
For further clarification, click the "Additional Information" link above.

Description

Select

1. Wholesale sales of new and used automobiles, including crossovers

Product Code

4001325000

4001325004

a. Wholesale sales of new automobiles, nonelectric

b. Wholesale sales of new automobiles, electric and hybrid

4001325005

4001325007

c. Wholesale sales of used automobiles, nonelectric

d. Wholesale sales of used automobiles, electric and hybrid

2. Wholesale sales of new and used light trucks, 14,000 lb. or less, including vans, cargo vans, and SUVs

a. Wholesale sales of new light trucks and SUVs, nonelectric

b. Wholesale sales of new light trucks and SUVs, electric and hybrid

c. Wholesale sales of used light trucks and SUVs, nonelectric

d. Wholesale sales of used light trucks and SUVs, electric and hybrid

e. Wholesale sales of new and used vans and cargo vans, nonelectric

f. Wholesale sales of new and used vans and cargo vans, electric and hybrid

4001325008

4001350000

4001350004

4001350005

4001350007

4001350008

4001350011

4001350012

4004200000

3. Wholesale sales of new light truck, van, and SUV bodies

4. Wholesale sales of medium trucks and tractors, 14,001 lb. to 33,000 lb.

4001950000

4001950003

a. Wholesale sales of new medium trucks and tractors

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

30

4001950006

b. Wholesale sales of used medium trucks and tractors

4004325000

5. Wholesale sales of new medium truck bodies

6. Wholesale sales of heavy trucks, trailers, and road tractors, more than 33,000 lb.

4001975000

4001975003

a. Wholesale sales of new heavy trucks

4001975006

b. Wholesale sales of new heavy truck tractors

4001975009

c. Wholesale sales of new truck trailers

d. Wholesale sales of used heavy trucks, tractors, and trailers

4001975012

4004350000

7. Wholesale sales of new heavy truck bodies

8. Wholesale sales of motorcycles and other sports vehicles, including utility trailers

4001250000

4001250003

a. Wholesale sales of motorcycles

4001250006

b. Wholesale sales of utility trailers
c. Wholesale sales of all-terrain vehicles (ATVs), snowmobiles, motor scooters, mopeds, and other motorized recreational-use
vehicles

4001250009

4001925000

9. Wholesale sales of buses

10. Wholesale sales of motor homes, travel trailers, and campers

11. Wholesale sales of new and rebuilt automotive, light truck, and trailer parts and supplies, except automotive bodies and chemicals

a. Wholesale sales of hoses, belts, gaskets, and wiper blades

b. Wholesale sales of filters, including oil, air, gas, and transmission

c. Wholesale sales of engine parts, except electrical parts

d. Wholesale sales of suspension parts, including shocks, struts, and ball joints

4001375000

4004175000

4004175021

4004175024

4004175027

4004175033

4004175003

e. Wholesale sales of automotive batteries

4004175006

f. Wholesale sales of complete engines

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

31

g. Wholesale sales of electrical engine parts, including ignition parts

h. Wholesale sales of brake parts, including fluid and all disk and drum parts

4004175009

4004175012

4004175015

i. Wholesale sales of exhaust system parts

4004175018

j. Wholesale sales of automotive glass

4004175031

k. Wholesale sales of body parts and repair materials

l. Wholesale sales of automotive accessories, except car stereos and CD players

m. Wholesale sales of other automotive parts and supplies

12. Wholesale sales of car stereos, tape players, and CD players

13. Wholesale sales of used automotive parts and accessories

4004175039

4004175036

4004195000

4004250000

4004150000

14. Wholesale sales of tires and tubes

4004150003

a. Wholesale sales of new automobile tires and tubes

b. Wholesale sales of re-treaded and used automobile tires and repair materials

c. Wholesale sales of new truck and bus tires, including industrial, off-road, and farm tractor tires
d. Wholesale sales of re-treaded and used truck and bus tires and repair materials, including industrial, off-road, and farm tractor
tires

4004150006

4004150009

4004150012

4004150015

e. Wholesale sales of aircraft tires

15. Wholesale sales of automotive chemicals, including polishes and cleaners, fuel and oil additives, and antifreeze

16. Wholesale sales of refined petroleum products, except liquefied petroleum (LP)

4004225000

4002775000

4002050000

17. Wholesale sales of other transportation equipment

4002075000

18. Wholesale sales of farm machinery and equipment

19. Wholesale sales of construction, forestry, and mining machinery and equipment, including attachments

20. Maintenance and repair services for automobiles and light-duty trucks

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

4002100000

7002625000

32

7003800000

21. Rental of automobiles and light-duty trucks
22. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles, and musical
instruments)

23. Rental and leasing of heavy trucks, truck trailers, and buses

24. Maintenance and repair services for heavy trucks and buses
25. Maintenance and repair services for other industrial, commercial, and service industry machinery and equipment, not elsewhere
classified

26. Rental and leasing services for motor homes, travel trailers, campers, and utility trailers

7001800000

7009275000

7009375000

7009490000

7002875000

Add product/service not listed

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

33

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services that you previously selected. If a product or service is not listed, click the “Add product/service not listed” button and search for the product or
service.
For further clarification, click the "Additional Information" link above.

Description

Value

Product Code

1. Wholesale sales of new and used automobiles, including crossovers

a. Wholesale sales of new automobiles, nonelectric

$

,000.00

4001325004

b. Wholesale sales of new automobiles, electric and hybrid

$

,000.00

4001325005

$

,000.00

4001325007

d. Wholesale sales of used automobiles, electric and hybrid

$

,000.00

4001325008

Subtotal

$

,000.00

4001325000

a. Wholesale sales of new light trucks and SUVs, nonelectric

$

,000.00

4001350004

b. Wholesale sales of new light trucks and SUVs, electric and hybrid

$

,000.00

4001350005

c. Wholesale sales of used light trucks and SUVs, nonelectric

$

,000.00

4001350007

d. Wholesale sales of used light trucks and SUVs, electric and hybrid

$

,000.00

4001350008

e. Wholesale sales of new and used vans and cargo vans, nonelectric

$

,000.00

4001350011

f. Wholesale sales of new and used vans and cargo vans, electric and hybrid

$

,000.00

4001350012

Subtotal

$

,000.00

4001350000

$

,000.00

4004200000

c. Wholesale sales of used automobiles, nonelectric

2. Wholesale sales of new and used light trucks, 14,000 lb. or less, including vans, cargo vans, and SUVs

3. Wholesale sales of new light truck, van, and SUV bodies
4. Wholesale sales of medium trucks and tractors, 14,001 lb. to 33,000 lb.

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

34

a. Wholesale sales of new medium trucks and tractors

$

,000.00

4001950003

b. Wholesale sales of used medium trucks and tractors

$

,000.00

4001950006

Subtotal

$

,000.00

4001950000

$

,000.00

4004325000

a. Wholesale sales of new heavy trucks

$

,000.00

4001975003

b. Wholesale sales of new heavy truck tractors

$

,000.00

4001975006

c. Wholesale sales of new truck trailers

$

,000.00

4001975009

d. Wholesale sales of used heavy trucks, tractors, and trailers

$

,000.00

4001975012

$

,000.00

4001975000

$

,000.00

4004350000

a. Wholesale sales of motorcycles

$

,000.00

4001250003

b. Wholesale sales of utility trailers

$

,000.00

4001250006

c. Wholesale sales of all-terrain vehicles (ATVs), snowmobiles, motor scooters, mopeds, and other motorized
recreational-use vehicles

$

,000.00

4001250009

Subtotal

$

,000.00

4001250000

9. Wholesale sales of buses

$

,000.00

4001925000

10. Wholesale sales of motor homes, travel trailers, and campers

$

,000.00

4001375000

a. Wholesale sales of hoses, belts, gaskets, and wiper blades

$

,000.00

4004175021

b. Wholesale sales of filters, including oil, air, gas, and transmission

$

,000.00

4004175024

5. Wholesale sales of new medium truck bodies
6. Wholesale sales of heavy trucks, trailers, and road tractors, more than 33,000 lb.

Subtotal

7. Wholesale sales of new heavy truck bodies
8. Wholesale sales of motorcycles and other sports vehicles, including utility trailers

11. Wholesale sales of new and rebuilt automotive, light truck, and trailer parts and supplies, except automotive bodies
and chemicals

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

35

c. Wholesale sales of engine parts, except electrical parts

$

,000.00

4004175027

d. Wholesale sales of suspension parts, including shocks, struts, and ball joints

$

,000.00

4004175033

e. Wholesale sales of automotive batteries

$

,000.00

4004175003

$

,000.00

4004175006

g. Wholesale sales of electrical engine parts, including ignition parts

$

,000.00

4004175009

h. Wholesale sales of brake parts, including fluid and all disk and drum parts

$

,000.00

4004175012

i. Wholesale sales of exhaust system parts

$

,000.00

4004175015

j. Wholesale sales of automotive glass

$

,000.00

4004175018

$

,000.00

4004175031

l. Wholesale sales of automotive accessories, except car stereos and CD players

$

,000.00

4004175039

m. Wholesale sales of other automotive parts and supplies

$

,000.00

4004175036

Subtotal

$

,000.00

4004175000

12. Wholesale sales of car stereos, tape players, and CD players

$

,000.00

4004195000

13. Wholesale sales of used automotive parts and accessories

$

,000.00

4004250000

a. Wholesale sales of new automobile tires and tubes

$

,000.00

4004150003

b. Wholesale sales of re-treaded and used automobile tires and repair materials

$

,000.00

4004150006

c. Wholesale sales of new truck and bus tires, including industrial, off-road, and farm tractor tires

$

,000.00

4004150009

d. Wholesale sales of re-treaded and used truck and bus tires and repair materials, including industrial, off-road, and
farm tractor tires

$

,000.00

4004150012

e. Wholesale sales of aircraft tires

$

,000.00

4004150015

Subtotal

$

,000.00

4004150000

f. Wholesale sales of complete engines

k. Wholesale sales of body parts and repair materials

14. Wholesale sales of tires and tubes

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

36

15. Wholesale sales of automotive chemicals, including polishes and cleaners, fuel and oil additives, and antifreeze

$

,000.00

4004225000

16. Wholesale sales of refined petroleum products, except liquefied petroleum (LP)

$

,000.00

4002775000

17. Wholesale sales of other transportation equipment

$

,000.00

4002050000

18. Wholesale sales of farm machinery and equipment

$

,000.00

4002075000

$

,000.00

4002100000

20. Maintenance and repair services for automobiles and light-duty trucks

$

,000.00

7002625000

21. Rental of automobiles and light-duty trucks

$

,000.00

7003800000

22. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles,
and musical instruments)

$

,000.00

7001800000

$

,000.00

7009275000

24. Maintenance and repair services for heavy trucks and buses

$

,000.00

7009375000

25. Maintenance and repair services for other industrial, commercial, and service industry machinery and equipment,
not elsewhere classified

$

,000.00

7009490000

26. Rental and leasing services for motor homes, travel trailers, campers, and utility trailers

$

,000.00

7002875000

$

,000.00

9900000000

19. Wholesale sales of construction, forestry, and mining machinery and equipment, including attachments

23. Rental and leasing of heavy trucks, truck trailers, and buses

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

37

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 28: Special Items - Employment by Primary Function Additional Information

ITEM 28: SPECIAL ITEMS - EMPLOYMENT BY PRIMARY FUNCTION
List the number of employees reported in Item 7, line A (), by the employee's primary function.
For further clarification, click the "Additional Information" link above.

2022 Paid
Employees
1. Selling

2. Sales support - including office, clerical, warehousing, customer service, maintenance employees, and drivers
3. General support of other establishments in your company - including central administrative, accounting, research, and other support
employees

4. Packaging
5. Production - including employees who manufacture products from raw materials or semi-finished products
(Report 'knockdown' assembly employees on line 6 below.)

6. 'Knockdown' assembly - assembling prefabricated components designed for a single application or reassembly of completed products

7. Other

Describe

8. TOTAL
(Sum of lines 1 through 7 should equal Item 7, line A.)

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

1000

characters remaining

51

Item 32: Establishment Information Additional Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

Type of operation at this location
(For further clarification, click the "Additional
Information" link above.)

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_WH-42311_su.pdf Generated 2022-02-23 16:44:02

,000.00

52

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4A: Primary Business or Activity Additional Information

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Women's, children's, and infants' clothing and accessories, including uniforms, handbags, and unisex clothing

424330 003

Men's and boys' clothing and accessories, including uniforms

424320 002

Sporting and recreational goods and supplies

423910 001

Footwear

424340 001

Advertising specialty (e.g., keychain, magnet, pen) distribution services

541890 202

Other primary business or activity

779000 001

Select Sector

Describe

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

15

Item 4B: Type of Operation Additional Information

ITEM 4B: TYPE OF OPERATION
Which ONE of the following best describes this establishment's primary type of operation in 2022?
For further clarification, click the "Additional Information" link above.

Merchant wholesaler, buying and selling on own account
12

Importer

13

Exporter

11

Merchant wholesale distributor or jobber

14

Own-brand importer and marketer

20

Manufacturers' sales branch or office

Agent, broker, or commission merchant
46

Manufacturers' representative or agent

41

Auction company

42

Broker, representing buyers and sellers

43

Commission merchant

44

Import agent

45

Export agent

49

Electronic market - business-to-business marketplace that facilitates the sale of goods via the Internet or other electronic
means, and operates on a commission or fee basis

Other type of operation
77

Other type of operation
Describe

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

A. What were the sales and operating receipts?
(Include the gross selling value of business conducted for others. Include shipping and handling charges. Exclude
sales taxes and Hawaii’s General Excise Tax.)

Check
if
None

2022
$

,000.00

B. Did this establishment earn commissions for the sale of merchandise?
Yes
No

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19

Item 5: Sales, Shipments, Receipts, or Revenue - Commissions Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - COMMISSIONS

C. What was the gross selling value of goods sold on a commission basis?
(This value should be included in the $,000.00 of sales and operating receipts reported in Item 5, line A.
For further clarification, click the "Additional Information" link above.)

2022
$

,000.00

2022
D. What were the commissions, including selling or listing fees, received on transactions reported on line C?

$

,000.00

2022
E. What was this establishment's average commission rate earned for the transactions reported on line C?
(For this response, you may report up to two decimal places.)

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%

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - CONTINUED
F. During 2022, what was the percent of total revenue (as reported in Item 5, line A ($,000.00)) from products sold by this establishment that were manufactured or mined in the United
States by your company or its subsidiaries?
0%
1-25%
26-49%
50-75%
76-100%
G. Did e-commerce account for more than 50% of this establishment's sales and/or operating receipts as reported in Item 5, line A ($,000.00)?
E-commerce sales and operating receipts are sales of goods and services where an order is placed by the buyer, or price and terms of sale are negotiated, over an Internet, mobile
device, extranet, Electronic Data Interchange (EDI) network, electronic mail, or other online system/application. Payment may or may not be made online.
Yes
No

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21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

2022
$

,000.00

$

,000.00

22

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
For further clarification, click the "Additional Information" link above.
Yes
No

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

23

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES
What were the inventories and Last-in, First-out (LIFO) adjustment, if any, for products owned by this establishment as of December 31?
For further clarification, click the "Additional Information" link above.
Check
if
None

Check
if
None

End of 2022

End of 2021

1. Total inventories before LIFO adjustment
(if any)

$

,000.00

$

,000.00

2. LIFO reserve
(if any)

$

,000.00

$

,000.00

3. Total inventories after LIFO adjustment
(Line 1 minus line 2.)

$

,000.00

$

,000.00

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24

Item 10: Inventories by Valuation Method Additional Information

ITEM 10: INVENTORIES BY VALUATION METHOD
How much of the inventory reported in Item 9, line 1, for 2022 ($,000.00) is subject to the following valuation methods?
For further clarification, click the "Additional Information" link above.

Check
if
None

End of 2022
$

,000.00

B. First-in, First-out (FIFO)

$

,000.00

C. Average cost

$

,000.00

D. Standard cost

$

,000.00

E. Other valuation method

$

,000.00

$

,000.00

A. LIFO valuation method before adjustment

Describe

F. TOTAL (Sum of lines A through E should equal Item 9, line 1.)

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25

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

For further clarification, click the "Additional Information" link above.

Check
if
None

2022

A. What were the operating expenses?
(Include payroll. Exclude cost of goods sold and interest expense.)

$

,000.00

B. What were purchases of merchandise for resale, net of returns, allowances, and trade and cash discounts?
(Include amounts allowed for trade-ins.)

$

,000.00

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26

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
For further clarification, click the "Additional Information" link above.

2022
%

1. Household consumers and individuals

%

2. Export sales

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Repair shops for use in repair work

%

6. Manufacturing and mining industrial users for use as input goods in production

%

7. Restaurants, hotels, food services, and contract feeding

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Building contractors, heavy construction, and special trade contractors

%

%

10. Farmers for use in farm production

%

11. Governmental bodies (Federal, state, and local)

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

27

%

12. Other

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

%

28

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included? Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contributed to the sales, shipments, receipts, or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for the product or service.
For further clarification, click the "Additional Information" link above.

Description

Select

1. Wholesale sales of women's, misses', and girls' clothing, including socks and hosiery

a. Wholesale sales of women's, misses', and girls' dresses, blouses, and sweaters, including unisex t-shirts and other clothing

b. Wholesale sales of women's, misses', and girls' suits and coats

c. Wholesale sales of women's, misses', and girls' outerwear, including skirts, slacks, and jeans

d. Wholesale sales of women's, misses', and girls' underwear and sleepwear

e. Wholesale sales of other women's, misses', and girls' clothing (except accessories), including uniforms

Product Code

4000525000

4000525003

4000525006

4000525009

4000525012

4000525015

4000500000

2. Wholesale sales of men's and boys' clothing

a. Wholesale sales of men's and boys' suits, coats, and formal wear

b. Wholesale sales of men's and boys' dress and casual shirts, sweaters, slacks, and jeans

c. Wholesale sales of men's and boys' underwear and sleepwear

d. Wholesale sales of men's and boys' work clothing and uniforms, except athletic uniforms

e. Wholesale sales of other men's and boys' clothing, except accessories

3. Wholesale sales of men's and women's clothing accessories (except infants' and children's)

a. Wholesale sales of men's clothing accessories, including hats, gloves, and neckwear

b. Wholesale sales of women's clothing accessories, including hats, gloves, and handbags

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

4000500003

4000500006

4000500009

4000500012

4000500015

4000625000

4000625003

4000625006

30

4. Wholesale sales of infants' and children's clothing, to size 6X, including accessories

4000550000

4000600000

5. Wholesale sales of footwear and footwear accessories

a. Wholesale sales of athletic footwear, except cleated and other specialized athletic footwear

4000600003

4000600006

b. Wholesale sales of infants' footwear

c. Wholesale sales of women's, misses', and girls' footwear (including slippers), except athletic footwear

d. Wholesale sales of men's and boys' footwear (including slippers), except athletic footwear

e. Wholesale sales of shoe accessories (polishes, laces, trees, storage bags, etc.)
6. Coordinating the production of advertising specialties bearing the logo and/or name of a business for purposes of promoting the
business and its products or services, and delivering the finished advertising specialties to the client (may include clothing items,
mugs, key chains, and other novelties or promotional items)

4000600009

4000600012

4000600015

7012750000

4001400000

7. Wholesale sales of luggage, including backpacks

4004625000

8. Wholesale sales of textile bags, bagging and burlap

4000575000

9. Wholesale sales of athletic uniforms

4001175000

10. Wholesale sales of sporting and recreational equipment

4001775000

11. Wholesale sales of infants' goods and accessories

4000650000

12. Wholesale sales of costume jewelry

4000675000

13. Wholesale sales of jewelry, except costume

14. Wholesale sales of general household furnishings, except artificial flowers, plants, and trees
15. Wholesale sales of other textile house furnishings (except floor coverings), including bedspreads, blankets, bedding, towels,
washcloths, other linens and domestics

16. Wholesale sales of personal safety equipment, supplies, and devices, including work gloves (except disposable)

17. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry

4000850000

4000800000

4005492000

7000200000

Add product/service not listed

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31

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services that you previously selected. If a product or service is not listed, click the “Add product/service not listed” button and search for the product or
service.
For further clarification, click the "Additional Information" link above.

Description

Value

Product Code

1. Wholesale sales of women's, misses', and girls' clothing, including socks and hosiery
a. Wholesale sales of women's, misses', and girls' dresses, blouses, and sweaters, including unisex t-shirts and other
clothing

$

,000.00

4000525003

b. Wholesale sales of women's, misses', and girls' suits and coats

$

,000.00

4000525006

c. Wholesale sales of women's, misses', and girls' outerwear, including skirts, slacks, and jeans

$

,000.00

4000525009

d. Wholesale sales of women's, misses', and girls' underwear and sleepwear

$

,000.00

4000525012

$

,000.00

4000525015

$

,000.00

4000525000

a. Wholesale sales of men's and boys' suits, coats, and formal wear

$

,000.00

4000500003

b. Wholesale sales of men's and boys' dress and casual shirts, sweaters, slacks, and jeans

$

,000.00

4000500006

c. Wholesale sales of men's and boys' underwear and sleepwear

$

,000.00

4000500009

d. Wholesale sales of men's and boys' work clothing and uniforms, except athletic uniforms

$

,000.00

4000500012

e. Wholesale sales of other men's and boys' clothing, except accessories

$

,000.00

4000500015

Subtotal

$

,000.00

4000500000

$

,000.00

4000625003

e. Wholesale sales of other women's, misses', and girls' clothing (except accessories), including uniforms

Subtotal
2. Wholesale sales of men's and boys' clothing

3. Wholesale sales of men's and women's clothing accessories (except infants' and children's)

a. Wholesale sales of men's clothing accessories, including hats, gloves, and neckwear

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

32

b. Wholesale sales of women's clothing accessories, including hats, gloves, and handbags

$

,000.00

4000625006

Subtotal

$

,000.00

4000625000

$

,000.00

4000550000

a. Wholesale sales of athletic footwear, except cleated and other specialized athletic footwear

$

,000.00

4000600003

b. Wholesale sales of infants' footwear

$

,000.00

4000600006

c. Wholesale sales of women's, misses', and girls' footwear (including slippers), except athletic footwear

$

,000.00

4000600009

$

,000.00

4000600012

e. Wholesale sales of shoe accessories (polishes, laces, trees, storage bags, etc.)

$

,000.00

4000600015

Subtotal

$

,000.00

4000600000

6. Coordinating the production of advertising specialties bearing the logo and/or name of a business for purposes of
promoting the business and its products or services, and delivering the finished advertising specialties to the client
(may include clothing items, mugs, key chains, and other novelties or promotional items)

$

,000.00

7012750000

7. Wholesale sales of luggage, including backpacks

$

,000.00

4001400000

8. Wholesale sales of textile bags, bagging and burlap

$

,000.00

4004625000

$

,000.00

4000575000

10. Wholesale sales of sporting and recreational equipment

$

,000.00

4001175000

11. Wholesale sales of infants' goods and accessories

$

,000.00

4001775000

12. Wholesale sales of costume jewelry

$

,000.00

4000650000

13. Wholesale sales of jewelry, except costume

$

,000.00

4000675000

$

,000.00

4000850000

15. Wholesale sales of other textile house furnishings (except floor coverings), including bedspreads, blankets, bedding,
towels, washcloths, other linens and domestics

$

,000.00

4000800000

16. Wholesale sales of personal safety equipment, supplies, and devices, including work gloves (except disposable)

$

,000.00

4005492000

4. Wholesale sales of infants' and children's clothing, to size 6X, including accessories
5. Wholesale sales of footwear and footwear accessories

d. Wholesale sales of men's and boys' footwear (including slippers), except athletic footwear

9. Wholesale sales of athletic uniforms

14. Wholesale sales of general household furnishings, except artificial flowers, plants, and trees

2022_WH-42435_su.pdf Generated 2022-02-23 17:50:47

33

17. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry

$

,000.00

7000200000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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34

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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35

Item 28: Special Items - Employment by Primary Function Additional Information

ITEM 28: SPECIAL ITEMS - EMPLOYMENT BY PRIMARY FUNCTION
List the number of employees reported in Item 7, line A (), by the employee's primary function.
For further clarification, click the "Additional Information" link above.

2022 Paid
Employees
1. Selling

2. Sales support - including office, clerical, warehousing, customer service, maintenance employees, and drivers
3. General support of other establishments in your company - including central administrative, accounting, research, and other support
employees

4. Packaging
5. Production - including employees who manufacture products from raw materials or semi-finished products
(Report 'knockdown' assembly employees on line 6 below.)

6. 'Knockdown' assembly - assembling prefabricated components designed for a single application or reassembly of completed products

7. Other

Describe

8. TOTAL
(Sum of lines 1 through 7 should equal Item 7, line A.)

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36

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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37

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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38

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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39

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

47

Item 32: Establishment Information Additional Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

Type of operation at this location
(For further clarification, click the "Additional
Information" link above.)

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

48

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4A: Primary Business or Activity Additional Information

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

General-line groceries

424410 001

Soft drinks, bottled water, juices, and nonalcoholic beverages, including beverage concentrates

424490 301

Coffee, tea, and powdered drink mixes

424490 101

Bread and baked goods, including baking ingredients, spices, and cooking oil

424490 202

Nonperishable (canned and packaged) food, including condensed and evaporated milk

424490 401

Packaged frozen food, excluding dairy products

424420 001

Confectioneries, including candy, nuts, chips, and popcorn

424450 001

Fresh fruits and vegetables

424480 001

Dairy products, excluding dried, canned, and raw milk and cream

424430 201

Eggs, poultry, and poultry products, excluding live, canned, or frozen packaged poultry

424440 201

Meat and meat products

424470 001

Fish and seafood

424460 001

Other grocery specialties, including breakfast cereals, dried fruit, dried milk, polished rice, and pet food

424490 604

Other primary business or activity

779000 001

Select Sector

Describe

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Item 4B: Type of Operation Additional Information

ITEM 4B: TYPE OF OPERATION
Which ONE of the following best describes this establishment's primary type of operation in 2022?
For further clarification, click the "Additional Information" link above.

Merchant wholesaler, buying and selling on own account
12

Importer

13

Exporter

11

Merchant wholesale distributor or jobber

14

Own-brand importer and marketer

20

Manufacturers' sales branch or office

Agent, broker, or commission merchant
46

Manufacturers' representative or agent

41

Auction company

42

Broker, representing buyers and sellers

43

Commission merchant

44

Import agent

45

Export agent

49

Electronic market - business-to-business marketplace that facilitates the sale of goods via the Internet or other electronic
means, and operates on a commission or fee basis

Other type of operation
77

Other type of operation
Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

A. What were the sales and operating receipts?
(Include the gross selling value of business conducted for others. Include shipping and handling charges. Exclude
sales taxes and Hawaii’s General Excise Tax.)

Check
if
None

2022
$

,000.00

B. Did this establishment earn commissions for the sale of merchandise?
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Commissions Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - COMMISSIONS

C. What was the gross selling value of goods sold on a commission basis?
(This value should be included in the $,000.00 of sales and operating receipts reported in Item 5, line A.
For further clarification, click the "Additional Information" link above.)

2022
$

,000.00

2022
D. What were the commissions, including selling or listing fees, received on transactions reported on line C?

$

,000.00

2022
E. What was this establishment's average commission rate earned for the transactions reported on line C?
(For this response, you may report up to two decimal places.)

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%

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - CONTINUED
F. During 2022, what was the percent of total revenue (as reported in Item 5, line A ($,000.00)) from products sold by this establishment that were manufactured or mined in the United
States by your company or its subsidiaries?
0%
1-25%
26-49%
50-75%
76-100%
G. Did e-commerce account for more than 50% of this establishment's sales and/or operating receipts as reported in Item 5, line A ($,000.00)?
E-commerce sales and operating receipts are sales of goods and services where an order is placed by the buyer, or price and terms of sale are negotiated, over an Internet, mobile
device, extranet, Electronic Data Interchange (EDI) network, electronic mail, or other online system/application. Payment may or may not be made online.
Yes
No

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Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

22

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES
What were the inventories and Last-in, First-out (LIFO) adjustment, if any, for products owned by this establishment as of December 31?
For further clarification, click the "Additional Information" link above.
Check
if
None

Check
if
None

End of 2022

End of 2021

1. Total inventories before LIFO adjustment
(if any)

$

,000.00

$

,000.00

2. LIFO reserve
(if any)

$

,000.00

$

,000.00

3. Total inventories after LIFO adjustment
(Line 1 minus line 2.)

$

,000.00

$

,000.00

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Item 10: Inventories by Valuation Method Additional Information

ITEM 10: INVENTORIES BY VALUATION METHOD
How much of the inventory reported in Item 9, line 1, for 2022 ($,000.00) is subject to the following valuation methods?
For further clarification, click the "Additional Information" link above.

Check
if
None

End of 2022
$

,000.00

B. First-in, First-out (FIFO)

$

,000.00

C. Average cost

$

,000.00

D. Standard cost

$

,000.00

E. Other valuation method

$

,000.00

$

,000.00

A. LIFO valuation method before adjustment

Describe

F. TOTAL (Sum of lines A through E should equal Item 9, line 1.)

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Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

For further clarification, click the "Additional Information" link above.

Check
if
None

2022

A. What were the operating expenses?
(Include payroll. Exclude cost of goods sold and interest expense.)

$

,000.00

B. What were purchases of merchandise for resale, net of returns, allowances, and trade and cash discounts?
(Include amounts allowed for trade-ins.)

$

,000.00

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Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
For further clarification, click the "Additional Information" link above.

2022
%

1. Household consumers and individuals

%

2. Export sales

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Repair shops for use in repair work

%

6. Manufacturing and mining industrial users for use as input goods in production

%

7. Restaurants, hotels, food services, and contract feeding

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Building contractors, heavy construction, and special trade contractors

%

%

10. Farmers for use in farm production

%

11. Governmental bodies (Federal, state, and local)

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%

12. Other

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

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%

28

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contributed to the sales, shipments, receipts, or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for the product or service.
For further clarification, click the "Additional Information" link above.

Description

Select

1. Wholesale sales of nonperishable (canned and packaged) food

a. Wholesale sales of nonperishable (canned and packaged) fruits and vegetables

b. Wholesale sales of nonperishable (canned and packaged) fish and seafood

c. Wholesale sales of nonperishable (canned and packaged) meat

d. Wholesale sales of nonperishable (canned and packaged) milk

e. Wholesale sales of sauces, salad dressing, dips, and vinegar

f. Wholesale sales of preserves, jellies, jams, peanut butter, and honey

Product Code

4000250000

4000250003

4000250012

4000250009

4000250015

4000250024

4000250021

4000250018

g. Wholesale sales of pickles and olives

4000250027

h. Wholesale sales of condiments

4000250033

i. Wholesale sales of soup

4000250006

j. Wholesale sales of baby food

k. Wholesale sales of other nonperishable (canned and packaged) food, including nonperishable poultry

4000250036

4000025000

2. Wholesale sales of packaged frozen food

4000025009

a. Wholesale sales of frozen vegetables

4000025006

b. Wholesale sales of frozen fish and seafood products

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30

4000025015

c. Wholesale sales of frozen meat products

4000025018

d. Wholesale sales of frozen baked goods

4000025021

e. Wholesale sales of frozen poultry products

4000025012

f. Wholesale sales of frozen fruits and fruit juices

4000025003

g. Wholesale sales of frozen meals

h. Wholesale sales of other frozen foods, except frozen dairy products

4000025024

4000275000

3. Wholesale sales of grocery specialties

4000275006

a. Wholesale sales of pasta

4000275009

b. Wholesale sales of polished rice

4000275003

c. Wholesale sales of breakfast cereals and bars

4000275012

d. Wholesale sales of packaged meals, except frozen

e. Wholesale sales of other grocery specialties, including dried and soy milk, and edible dried beans

4000275015

4000225000

4. Wholesale sales of baking ingredients

a. Wholesale sales of cooking oils and margarine (butter substitutes)

4000225003

4000225012

b. Wholesale sales of spices

4000225006

c. Wholesale sales of flour

4000225009

d. Wholesale sales of refined sugar

4000225015

e. Wholesale sales of baking mixes and dough

5. Wholesale sales of dairy products, except dried, canned, condensed, and evaporated dairy products

4000050000

4000050006

a. Wholesale sales of cheese

b. Wholesale sales of milk and cream, except raw milk and cream

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

4000050009

31

4000050003

c. Wholesale sales of butter

d. Wholesale sales of ice cream and other frozen dairy products

4000050012

4000050015

e. Wholesale sales of yogurt

4000050018

f. Wholesale sales of other dairy products

6. Wholesale sales of soft drinks, bottled water, juices, and nonalcoholic beverages

4000350000

4000350003

a. Wholesale sales of packaged soft drinks

4000350009

b. Wholesale sales of bottled water

c. Wholesale sales of nonfrozen fruit and vegetable juices

d. Wholesale sales of sport and energy drinks, including bottled and canned coffee and tea

e. Wholesale sales of pre-mix and post-mix bulk soft drinks

4000350018

4000350015

4000350006

4000350012

f. Wholesale sales of nonalcoholic beer and mixers

7. Wholesale sales of coffee, tea, and powdered drink mixes

4000300000

4000300003

a. Wholesale sales of coffee, except bottled and canned

4000300006

b. Wholesale sales of tea, except bottled and canned

4000300009

c. Wholesale sales of powdered drink mixes

8. Wholesale sales of confectionery and snack foods, including chips (except cannabis-infused)

4000110000

4000110003

a. Wholesale sales of candy, including chocolate

4000110012

b. Wholesale sales of chips and popcorn

4000110009

c. Wholesale sales of nuts, except raw

4000110006

d. Wholesale sales of chewing gum

4000110015

e. Wholesale sales of other confectioneries

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

32

9. Wholesale sales of fresh meat and meat products, except canned and frozen

4000175000

4000175003

a. Wholesale sales of beef

4000175012

b. Wholesale sales of pork

c. Wholesale sales of fresh sausage and prepared meats

4000175015

4000175006

d. Wholesale sales of veal

4000175009

e. Wholesale sales of lamb and mutton

f. Wholesale sales of other meat and meat products, including bison, venison, deli (sliced) meats, and edible organs

10. Wholesale sales of eggs and poultry, except canned and frozen poultry products

4000175018

4000075000

4000200000

11. Wholesale sales of fresh fruits and vegetables

4000125000

12. Wholesale sales of cookies, bread, and baked goods

4000125006

a. Wholesale sales of cookies and cakes

4000125003

b. Wholesale sales of bread and rolls

c. Wholesale sales of other baked goods, including crackers

13. Wholesale sales of fish and seafood, except canned and frozen fish

14. Wholesale sales of grains, beans, and seeds used in food production
15. Wholesale sales of food and beverage basic materials, including flavoring extracts, fruit peel, sausage casings, hop extract, malt,
and yeast

4000125009

4000150000

4002875000

4000325000

4002925000

16. Wholesale sales of raw milk and cream

17. Wholesale sales of restaurant, commercial food service and hotel equipment

4002560000

4005230000

18. Wholesale sales of cleaning chemicals

19. Wholesale sales of disposable paper and plastic products, including cups, plates, and containers

20. Wholesale sales of tableware, kitchenware, cookware, and glassware, except cutlery and novelty glassware

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

4005280000

4000900000

33

21. Wholesale sales of bath, facial, and hand soaps, including shampoos and hand sanitizers

4001600000

4001305000

22. Wholesale sales of pet food
23. Wholesale sales of cosmetics, beauty supplies, perfumes and colognes, including hair preparations and hair brushes (except
cannabis-based topicals)

24. Wholesale sales of other personal care supplies, including toothbrushes (except electric), razor blades, and razors (except electric)

25. Wholesale sales of wine and distilled liquor, including premixed alcoholic drinks

26. Wholesale sales of tobacco products and electronic cigarettes

4001565000

4001650000

4000400000

4000450000

Add product/service not listed

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

34

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services that you previously selected. If a product or service is not listed, click the “Add product/service not listed” button and search for the product or
service.
For further clarification, click the "Additional Information" link above.

Description

Value

Product Code

1. Wholesale sales of nonperishable (canned and packaged) food

a. Wholesale sales of nonperishable (canned and packaged) fruits and vegetables

$

,000.00

4000250003

b. Wholesale sales of nonperishable (canned and packaged) fish and seafood

$

,000.00

4000250012

c. Wholesale sales of nonperishable (canned and packaged) meat

$

,000.00

4000250009

$

,000.00

4000250015

e. Wholesale sales of sauces, salad dressing, dips, and vinegar

$

,000.00

4000250024

f. Wholesale sales of preserves, jellies, jams, peanut butter, and honey

$

,000.00

4000250021

g. Wholesale sales of pickles and olives

$

,000.00

4000250018

h. Wholesale sales of condiments

$

,000.00

4000250027

i. Wholesale sales of soup

$

,000.00

4000250033

j. Wholesale sales of baby food

$

,000.00

4000250006

k. Wholesale sales of other nonperishable (canned and packaged) food, including nonperishable poultry

$

,000.00

4000250036

Subtotal

$

,000.00

4000250000

$

,000.00

4000025009

d. Wholesale sales of nonperishable (canned and packaged) milk

2. Wholesale sales of packaged frozen food

a. Wholesale sales of frozen vegetables

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

35

b. Wholesale sales of frozen fish and seafood products

$

,000.00

4000025006

c. Wholesale sales of frozen meat products

$

,000.00

4000025015

d. Wholesale sales of frozen baked goods

$

,000.00

4000025018

$

,000.00

4000025021

f. Wholesale sales of frozen fruits and fruit juices

$

,000.00

4000025012

g. Wholesale sales of frozen meals

$

,000.00

4000025003

h. Wholesale sales of other frozen foods, except frozen dairy products

$

,000.00

4000025024

Subtotal

$

,000.00

4000025000

a. Wholesale sales of pasta

$

,000.00

4000275006

b. Wholesale sales of polished rice

$

,000.00

4000275009

c. Wholesale sales of breakfast cereals and bars

$

,000.00

4000275003

d. Wholesale sales of packaged meals, except frozen

$

,000.00

4000275012

e. Wholesale sales of other grocery specialties, including dried and soy milk, and edible dried beans

$

,000.00

4000275015

Subtotal

$

,000.00

4000275000

a. Wholesale sales of cooking oils and margarine (butter substitutes)

$

,000.00

4000225003

b. Wholesale sales of spices

$

,000.00

4000225012

c. Wholesale sales of flour

$

,000.00

4000225006

$

,000.00

4000225009

$

,000.00

4000225015

e. Wholesale sales of frozen poultry products

3. Wholesale sales of grocery specialties

4. Wholesale sales of baking ingredients

d. Wholesale sales of refined sugar

e. Wholesale sales of baking mixes and dough

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

36

$

,000.00

4000225000

a. Wholesale sales of cheese

$

,000.00

4000050006

b. Wholesale sales of milk and cream, except raw milk and cream

$

,000.00

4000050009

c. Wholesale sales of butter

$

,000.00

4000050003

d. Wholesale sales of ice cream and other frozen dairy products

$

,000.00

4000050012

$

,000.00

4000050015

f. Wholesale sales of other dairy products

$

,000.00

4000050018

Subtotal

$

,000.00

4000050000

a. Wholesale sales of packaged soft drinks

$

,000.00

4000350003

b. Wholesale sales of bottled water

$

,000.00

4000350009

c. Wholesale sales of nonfrozen fruit and vegetable juices

$

,000.00

4000350018

d. Wholesale sales of sport and energy drinks, including bottled and canned coffee and tea

$

,000.00

4000350015

e. Wholesale sales of pre-mix and post-mix bulk soft drinks

$

,000.00

4000350006

f. Wholesale sales of nonalcoholic beer and mixers

$

,000.00

4000350012

Subtotal

$

,000.00

4000350000

a. Wholesale sales of coffee, except bottled and canned

$

,000.00

4000300003

b. Wholesale sales of tea, except bottled and canned

$

,000.00

4000300006

c. Wholesale sales of powdered drink mixes

$

,000.00

4000300009

Subtotal

$

,000.00

4000300000

Subtotal
5. Wholesale sales of dairy products, except dried, canned, condensed, and evaporated dairy products

e. Wholesale sales of yogurt

6. Wholesale sales of soft drinks, bottled water, juices, and nonalcoholic beverages

7. Wholesale sales of coffee, tea, and powdered drink mixes

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

37

8. Wholesale sales of confectionery and snack foods, including chips (except cannabis-infused)

a. Wholesale sales of candy, including chocolate

$

,000.00

4000110003

b. Wholesale sales of chips and popcorn

$

,000.00

4000110012

c. Wholesale sales of nuts, except raw

$

,000.00

4000110009

d. Wholesale sales of chewing gum

$

,000.00

4000110006

e. Wholesale sales of other confectioneries

$

,000.00

4000110015

Subtotal

$

,000.00

4000110000

$

,000.00

4000175003

$

,000.00

4000175012

c. Wholesale sales of fresh sausage and prepared meats

$

,000.00

4000175015

d. Wholesale sales of veal

$

,000.00

4000175006

e. Wholesale sales of lamb and mutton

$

,000.00

4000175009

f. Wholesale sales of other meat and meat products, including bison, venison, deli (sliced) meats, and edible organs

$

,000.00

4000175018

Subtotal

$

,000.00

4000175000

10. Wholesale sales of eggs and poultry, except canned and frozen poultry products

$

,000.00

4000075000

11. Wholesale sales of fresh fruits and vegetables

$

,000.00

4000200000

$

,000.00

4000125006

b. Wholesale sales of bread and rolls

$

,000.00

4000125003

c. Wholesale sales of other baked goods, including crackers

$

,000.00

4000125009

Subtotal

$

,000.00

4000125000

9. Wholesale sales of fresh meat and meat products, except canned and frozen

a. Wholesale sales of beef

b. Wholesale sales of pork

12. Wholesale sales of cookies, bread, and baked goods

a. Wholesale sales of cookies and cakes

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

38

13. Wholesale sales of fish and seafood, except canned and frozen fish

$

,000.00

4000150000

14. Wholesale sales of grains, beans, and seeds used in food production

$

,000.00

4002875000

15. Wholesale sales of food and beverage basic materials, including flavoring extracts, fruit peel, sausage casings, hop
extract, malt, and yeast

$

,000.00

4000325000

16. Wholesale sales of raw milk and cream

$

,000.00

4002925000

17. Wholesale sales of restaurant, commercial food service and hotel equipment

$

,000.00

4002560000

18. Wholesale sales of cleaning chemicals

$

,000.00

4005230000

19. Wholesale sales of disposable paper and plastic products, including cups, plates, and containers

$

,000.00

4005280000

20. Wholesale sales of tableware, kitchenware, cookware, and glassware, except cutlery and novelty glassware

$

,000.00

4000900000

21. Wholesale sales of bath, facial, and hand soaps, including shampoos and hand sanitizers

$

,000.00

4001600000

22. Wholesale sales of pet food

$

,000.00

4001305000

23. Wholesale sales of cosmetics, beauty supplies, perfumes and colognes, including hair preparations and hair
brushes (except cannabis-based topicals)

$

,000.00

4001565000

24. Wholesale sales of other personal care supplies, including toothbrushes (except electric), razor blades, and razors
(except electric)

$

,000.00

4001650000

25. Wholesale sales of wine and distilled liquor, including premixed alcoholic drinks

$

,000.00

4000400000

26. Wholesale sales of tobacco products and electronic cigarettes

$

,000.00

4000450000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

39

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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40

Item 28: Special Items - Employment by Primary Function Additional Information

ITEM 28: SPECIAL ITEMS - EMPLOYMENT BY PRIMARY FUNCTION
List the number of employees reported in Item 7, line A (), by the employee's primary function.
For further clarification, click the "Additional Information" link above.

2022 Paid
Employees
1. Selling

2. Sales support - including office, clerical, warehousing, customer service, maintenance employees, and drivers
3. General support of other establishments in your company - including central administrative, accounting, research, and other support
employees

4. Packaging
5. Production - including employees who manufacture products from raw materials or semi-finished products
(Report 'knockdown' assembly employees on line 6 below.)

6. 'Knockdown' assembly - assembling prefabricated components designed for a single application or reassembly of completed products

7. Other

Describe

8. TOTAL
(Sum of lines 1 through 7 should equal Item 7, line A.)

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41

Item 28: Special Items - Goods Purchased from Farmers Additional Information

ITEM 28: SPECIAL ITEMS - GOODS PURCHASED FROM FARMERS
Were 50 percent or more of the goods sold by this establishment in 2022 purchased directly from farmers?
For further clarification, click the "Additional Information" link above.

Yes
No

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42

Item 28: Special Items - General Line Groceries

ITEM 28: SPECIAL ITEMS - GENERAL LINE GROCERIES
Which ONE of the following is this establishment?
Voluntary group wholesaler (An establishment affiliated with independent retailers engaged in joint sales promotions under a group name)
Retail-cooperative wholesaler (An establishment owned and operated cooperatively by independent retailers buying collectively)
Other grocery wholesaler

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43

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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44

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

45

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

46

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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47

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

48

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

49

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

50

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

51

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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52

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

53

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

1000

characters remaining

54

Item 32: Establishment Information Additional Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

Type of operation at this location
(For further clarification, click the "Additional
Information" link above.)

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_WH-42441_su.pdf Generated 2022-02-23 17:53:08

,000.00

55

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4A: Primary Business or Activity Additional Information

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Health and beauty accessories manufacturer's representatives, agents, or brokers, including cosmetics, toiletries, vitamins, and first aid
supplies

425120 423

General-line drugs manufacturer's representatives, agents, or brokers, including over-the-counter drugs, antibiotics, and dietary supplements

425120 421

Specialty-line drugs manufacturer's representatives, agents, or brokers, including those which require special handling, injectables, short
shelf life, experimental, and nuclear

425120 422

Miscellaneous nondurable goods manufacturer's representatives, agents, or brokers

425120 491

Medical, dental, hospital, and ophthalmic equipment, devices, and supplies manufacturer's representatives, agents, or brokers

425120 345

Pharmaceuticals, cosmetics, and toiletries electronic markets

425110 421

Cannabis and marijuana (recreational or medical) wholesaling, excluding growing

424590 601

Cannabidiol (CBD oil) and other cannabis and hemp extracts and concentrates

424690 301

Cannabis-based topicals, including gels, creams, lotions, and balms

424210 303

Other primary business or activity

779000 001

Select Sector

Describe

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

15

Item 4B: Type of Operation Additional Information

ITEM 4B: TYPE OF OPERATION
Which ONE of the following best describes this establishment's primary type of operation in 2022?
For further clarification, click the "Additional Information" link above.

Merchant wholesaler, buying and selling on own account
12

Importer

13

Exporter

11

Merchant wholesale distributor or jobber

14

Own-brand importer and marketer

20

Manufacturers' sales branch or office

Agent, broker, or commission merchant
46

Manufacturers' representative or agent

41

Auction company

42

Broker, representing buyers and sellers

43

Commission merchant

44

Import agent

45

Export agent

49

Electronic market - business-to-business marketplace that facilitates the sale of goods via the Internet or other electronic
means, and operates on a commission or fee basis

Other type of operation
77

Other type of operation
Describe

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

A. What were the sales and operating receipts?
(Include the gross selling value of business conducted for others. Include shipping and handling charges. Exclude
sales taxes and Hawaii’s General Excise Tax.)

Check
if
None

2022
$

,000.00

B. Did this establishment earn commissions for the sale of merchandise?
Yes
No

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19

Item 5: Sales, Shipments, Receipts, or Revenue - Commissions Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - COMMISSIONS

C. What was the gross selling value of goods sold on a commission basis?
(This value should be included in the $,000.00 of sales and operating receipts reported in Item 5, line A.
For further clarification, click the "Additional Information" link above.)

2022
$

,000.00

2022
D. What were the commissions, including selling or listing fees, received on transactions reported on line C?

$

,000.00

2022
E. What was this establishment's average commission rate earned for the transactions reported on line C?
(For this response, you may report up to two decimal places.)

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%

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - CONTINUED
F. During 2022, what was the percent of total revenue (as reported in Item 5, line A ($,000.00)) from products sold by this establishment that were manufactured or mined in the United
States by your company or its subsidiaries?
0%
1-25%
26-49%
50-75%
76-100%
G. Did e-commerce account for more than 50% of this establishment's sales and/or operating receipts as reported in Item 5, line A ($,000.00)?
E-commerce sales and operating receipts are sales of goods and services where an order is placed by the buyer, or price and terms of sale are negotiated, over an Internet, mobile
device, extranet, Electronic Data Interchange (EDI) network, electronic mail, or other online system/application. Payment may or may not be made online.
Yes
No

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Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

22

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
For further clarification, click the "Additional Information" link above.
Yes
No

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23

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES
What were the inventories and Last-in, First-out (LIFO) adjustment, if any, for products owned by this establishment as of December 31?
For further clarification, click the "Additional Information" link above.
Check
if
None

Check
if
None

End of 2022

End of 2021

1. Total inventories before LIFO adjustment
(if any)

$

,000.00

$

,000.00

2. LIFO reserve
(if any)

$

,000.00

$

,000.00

3. Total inventories after LIFO adjustment
(Line 1 minus line 2.)

$

,000.00

$

,000.00

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24

Item 10: Inventories by Valuation Method Additional Information

ITEM 10: INVENTORIES BY VALUATION METHOD
How much of the inventory reported in Item 9, line 1, for 2022 ($,000.00) is subject to the following valuation methods?
For further clarification, click the "Additional Information" link above.

Check
if
None

End of 2022
$

,000.00

B. First-in, First-out (FIFO)

$

,000.00

C. Average cost

$

,000.00

D. Standard cost

$

,000.00

E. Other valuation method

$

,000.00

$

,000.00

A. LIFO valuation method before adjustment

Describe

F. TOTAL (Sum of lines A through E should equal Item 9, line 1.)

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25

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES

For further clarification, click the "Additional Information" link above.

Check
if
None

2022

A. What were the operating expenses?
(Include payroll. Exclude cost of goods sold and interest expense.)

$

,000.00

B. What were purchases of merchandise for resale, net of returns, allowances, and trade and cash discounts?
(Include amounts allowed for trade-ins.)

$

,000.00

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Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
For further clarification, click the "Additional Information" link above.

2022
%

1. Household consumers and individuals

%

2. Export sales

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Repair shops for use in repair work

%

6. Manufacturing and mining industrial users for use as input goods in production

%

7. Restaurants, hotels, food services, and contract feeding

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Building contractors, heavy construction, and special trade contractors

%

%

10. Farmers for use in farm production

%

11. Governmental bodies (Federal, state, and local)

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

27

%

12. Other

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

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%

28

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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29

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
The products and services listed below are generally associated with your industry.
Please select the products or services that contributed to the sales, shipments, receipts, or revenue of this establishment. If a product or service is not listed, click the “Add
product/service not listed” button and search for the product or service.
For further clarification, click the "Additional Information" link above.

Description

Select

1. Wholesale sales of nonprescription drugs and over-the-counter medications

2. Wholesale sales of prescription cannabis-based pharmaceutical preparations (except pre-rolled or loose dried buds)

3. Wholesale sales of prescription drugs and antibiotics (except cannabis-based pharmaceutical preparations)

4. Wholesale sales of cannabis-based health supplements/vitamins

5. Wholesale sales of vitamins and nutritional and herbal supplements (except cannabis-based health supplements/vitamins)

6. Wholesale sales of cannabis-based topicals, including gels, creams, and balms
7. Wholesale sales of cosmetics, beauty supplies, perfumes and colognes, including hair preparations and hair brushes (except
cannabis-based topicals)

a. Wholesale sales of cosmetics and beauty supplies, including lotions and creams

b. Wholesale sales of beauty salon and barber supplies, including combs, curlers, and shampoos

Product Code

4001450000

4001430000

4001435000

4001480000

4001485000

4001560000

4001565000

4001565003

4001565006

4001565009

c. Wholesale sales of perfumes and colognes

8. Wholesale sales of health aids and household first aid supplies

a. Wholesale sales of household first aid kits, including nonsurgical bandages and gauze

4001555000

4001555003

4001555006

b. Wholesale sales of insect repellent

c. Wholesale sales of other health aids and household first aid supplies

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

4001555009

30

4001580000

9. Wholesale sales of sunblock
10. Wholesale sales of specialty pharmaceuticals, including vaccines, laboratory diagnostic reagents, and other specialty
pharmaceuticals

11. Wholesale sales of cannabis extracts and concentrates, including CBD oil

12. Wholesale sales of bath, facial, and hand soaps, including shampoos and hand sanitizers

13. Wholesale sales of other personal care supplies, including toothbrushes (except electric), razor blades, and razors (except electric)

4005125000

4003385000

4001600000

4001650000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Please do not combine product lines. If the information is not directly available from your records, reasonable estimates are acceptable.
Below are the products and services that you previously selected. If a product or service is not listed, click the “Add product/service not listed” button and search for the product or
service.
For further clarification, click the "Additional Information" link above.

Description

Value

Product Code

1. Wholesale sales of nonprescription drugs and over-the-counter medications

$

,000.00

4001450000

2. Wholesale sales of prescription cannabis-based pharmaceutical preparations (except pre-rolled or loose dried buds)

$

,000.00

4001430000

3. Wholesale sales of prescription drugs and antibiotics (except cannabis-based pharmaceutical preparations)

$

,000.00

4001435000

4. Wholesale sales of cannabis-based health supplements/vitamins

$

,000.00

4001480000

5. Wholesale sales of vitamins and nutritional and herbal supplements (except cannabis-based health
supplements/vitamins)

$

,000.00

4001485000

6. Wholesale sales of cannabis-based topicals, including gels, creams, and balms

$

,000.00

4001560000

a. Wholesale sales of cosmetics and beauty supplies, including lotions and creams

$

,000.00

4001565003

b. Wholesale sales of beauty salon and barber supplies, including combs, curlers, and shampoos

$

,000.00

4001565006

c. Wholesale sales of perfumes and colognes

$

,000.00

4001565009

Subtotal

$

,000.00

4001565000

a. Wholesale sales of household first aid kits, including nonsurgical bandages and gauze

$

,000.00

4001555003

b. Wholesale sales of insect repellent

$

,000.00

4001555006

$

,000.00

4001555009

7. Wholesale sales of cosmetics, beauty supplies, perfumes and colognes, including hair preparations and hair brushes
(except cannabis-based topicals)

8. Wholesale sales of health aids and household first aid supplies

c. Wholesale sales of other health aids and household first aid supplies

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

32

$

,000.00

4001555000

9. Wholesale sales of sunblock

$

,000.00

4001580000

10. Wholesale sales of specialty pharmaceuticals, including vaccines, laboratory diagnostic reagents, and other
specialty pharmaceuticals

$

,000.00

4005125000

11. Wholesale sales of cannabis extracts and concentrates, including CBD oil

$

,000.00

4003385000

12. Wholesale sales of bath, facial, and hand soaps, including shampoos and hand sanitizers

$

,000.00

4001600000

13. Wholesale sales of other personal care supplies, including toothbrushes (except electric), razor blades, and razors
(except electric)

$

,000.00

4001650000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Subtotal

Add product/service not listed

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33

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Employment by Primary Function Additional Information

ITEM 28: SPECIAL ITEMS - EMPLOYMENT BY PRIMARY FUNCTION
List the number of employees reported in Item 7, line A (), by the employee's primary function.
For further clarification, click the "Additional Information" link above.

2022 Paid
Employees
1. Selling

2. Sales support - including office, clerical, warehousing, customer service, maintenance employees, and drivers
3. General support of other establishments in your company - including central administrative, accounting, research, and other support
employees

4. Packaging
5. Production - including employees who manufacture products from raw materials or semi-finished products
(Report 'knockdown' assembly employees on line 6 below.)

6. 'Knockdown' assembly - assembling prefabricated components designed for a single application or reassembly of completed products

7. Other

Describe

8. TOTAL
(Sum of lines 1 through 7 should equal Item 7, line A.)

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

38

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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39

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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45

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

1000

characters remaining

46

Item 32: Establishment Information Additional Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

Type of operation at this location
(For further clarification, click the "Additional
Information" link above.)

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_WH-42542_su.pdf Generated 2022-02-23 18:34:41

,000.00

47

Attachment D-7
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 44-45

Attachment Sector

D-7

44-45

Instrument
Path
Instrument Path Title

44211
44512
44831
45111

Furniture Stores
Convenience Stores
Jewelry Stores
Sporting Goods Stores

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Furniture store, except custom

442110 501

Sleep/mattress shop

442110 301

Office and business furniture store

442110 503

Specialty furniture store, except custom, including recliners, outdoor furniture, baby and children's furniture, etc.

442110 504

Furniture warehouse showroom

442110 502

Home furnishings store, including china, glassware, metalware, lamps, lampshades, pictures, frames, mirrors, etc.

442299 001

Floor coverings store

442210 001

Household appliance store, including parts

443141 001

Custom upholstered furniture store

337121 002

Custom nonupholstered wood furniture store

337122 002

Custom wood cabinet shop, freestanding cabinetry

337122 003

Cabinet shop, including stock and custom kitchen and bath cabinets to be installed

444190 223

Interior decorator/designer

541410 004

Antique furniture store

453310 102

Antique store

453310 103

Secondhand store, except pawn shop

453310 20C

Furniture repair, refinishing, and reupholstery

811420 001

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total sales of merchandise and other operating receipts?
(Exclude sales taxes or other taxes collected.)

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
2022
%

1. Household consumers and individuals

2. Retailers for resale

%

3. Wholesalers/distributors for resale

%

%

4. Repair shops for use in repair work

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Restaurants, hotels, food services, and contract feeding

%

7. Businesses for end use in their own operation, not for resale or production

%

8. Building contractors, heavy construction, and special trade contractors

%

9. Farmers for use in farm production

%

10. Governmental bodies (Federal, state, and local)

%

11. Export sales

%

12. Other

%

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20

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

%

21

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Retail sales of indoor home furniture
(Report new and used office furniture on line 5, used furniture (non-office related) on line 12h, antique furniture on line 12a, and parts
and materials used in furniture repair or upholstery work on line 25.)

a. Retail sales of upholstered furniture (except dual-purpose pieces and infants' furniture)

b. Retail sales of sleep sofas, daybeds, futons, and other dual-purpose pieces

c. Retail sales of all other indoor furniture (except infants' furniture)
d. Retail sales of infants' furniture, including cribs, bassinets, high chairs, etc.
(Report playpens on line 22.)

Product Code

5000550000

5000550003

5000550006

5000550009

5000550012

5000680000

2. Retail sales of other home furnishings and accessories
a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware, vases, giftware,
mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom accessories, etc.)
(Report ceiling fans, light bulbs, and lighting fixtures on line 20.)

5000680003

5000680006

b. Retail sales of artificial/silk flowers, plants, and trees

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

3. Retail sales of mattresses, box springs, and air mattresses

5000680009

5000600000

5000575000

4. Retail sales of outdoor/patio furniture

5. Retail sales of new and used office equipment and furniture (exclude computers)

a. Retail sales of office equipment, new and used, including dictaphones, copying machines, calculating machines, etc.

b. Retail sales of office furniture, new and used, including computer-related furniture

6. Retail sales of major household appliances and related parts and accessories
a. Retail sales of kitchen appliances and related parts and accessories, including refrigerators, freezers, dishwashers, microwave
ovens, etc.

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

5001525000

5001525003

5001525006

5000700000

5000700003

23

b. Retail sales of laundry appliances and related parts and accessories, including clothes washers and dryers
c. Retail sales of other major household appliances and related parts and accessories, including room air-conditioners,
dehumidifiers, vacuum cleaners, sewing machines, etc.

5000700006

5000700009

7. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers; frypans; personal care
appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

5000725000

8. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware, and pots and
pans.)

5000750000

5001875000

9. Retail sales of flooring and floor coverings

a. Retail sales of soft-surface (textile) floor coverings to be installed

b. Retail sales of carpets and rugs not requiring installation

5001875003

5001875006

5001875009

c. Retail sales of hardwood flooring

5001875011

d. Retail sales of linoleum flooring

5001875013

e. Retail sales of ceramic flooring

f. Retail sales of other hard-surface floor coverings and accessories

10. Retail sales of domestics and other textile home furnishings (except carpet and rugs)
a. Retail sales of furniture coverings, including ready-made and custom-made (except parts and materials used in furniture repair or
upholstery work)

b. Retail sales of domestics, including towels, sheets, blankets, table linens and coverings, etc.

11. Retail sales of window treatments, including rods, poles, and fixtures

12. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

5001875015

5000650000

5000650003

5000650006

5000625000

5000850000

5000850003

a. Retail sales of antiques, items over 100 years old

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

c. Retail sales of art goods, including original pictures and sculptures

d. Retail sales of precious metals, coins, medals, and other numismatic items

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

5000850006

5000850009

5000850012

5000850015

24

5000850018

f. Retail sales of estate/antique jewelry

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products
h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and garden goods
(Report used office furniture on line 5b.)

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical instruments, etc.

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

k. Retail sales of used household and personal goods, not elsewhere classified

5000850021

5000850024

5000850027

5000850031

5000850033

5000875000

13. Retail sales of televisions, audio and video equipment

14. Retail sales of computers and peripheral equipment, communications equipment, and related products
15. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants (Include powered lawn and garden
tools, outdoor grills, pools, pool chemicals, and pool supplies, and outdoor nursery stock.)

16. Retail sales of fabrics, yarns, and other sewing materials and supplies

5001550000

5000805000

5001775000

5000925000

17. Retail sales of books

18. Retail sales of toys, games, and hobby and craft supplies

19. Retail sales of hardware, nonpower hand tools, and other building materials and supplies
20. Retail sales of plumbing, electrical, and HVAC supplies (Include heating stoves (wood, kerosene, and oil) and prefabricated
fireplaces, ceiling fans, light bulbs, and light fixtures.)

21. Retail sales of wallpaper and other flexible wallcoverings
22. Retail sales of miscellaneous household goods, not elsewhere classified (Include nonautomotive batteries and baby goods such as
swings, collapsible playpens, infant and booster car seats, etc.)

23. Local transportation and delivery of purchased or serviced items

24. Rental services for home furniture, furnishings, and accessories

5001125000

5001930000

5001900000

5001825000

5000860000

7011125000

7000700000

25. Off-site cleaning and repair services for home furniture, furnishings, and accessories, except curtain and drape cleaning services
(Include parts and materials used in repair. Include value of service contracts.)

7000770000

26. Maintenance and repair services for household and personal goods, not elsewhere classified (Include parts and materials used in
repair. Include value of service contracts.)

7000800000

Add product/service not listed

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25

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Retail sales of indoor home furniture
(Report new and used office furniture on line 5, used furniture (non-office related) on line 12h, antique furniture on line
12a, and parts and materials used in furniture repair or upholstery work on line 25.)

a. Retail sales of upholstered furniture (except dual-purpose pieces and infants' furniture)

$

,000.00

5000550003

b. Retail sales of sleep sofas, daybeds, futons, and other dual-purpose pieces

$

,000.00

5000550006

c. Retail sales of all other indoor furniture (except infants' furniture)

$

,000.00

5000550009

d. Retail sales of infants' furniture, including cribs, bassinets, high chairs, etc.
(Report playpens on line 22.)

$

,000.00

5000550012

Subtotal

$

,000.00

5000550000

a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware,
vases, giftware, mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom
accessories, etc.)
(Report ceiling fans, light bulbs, and lighting fixtures on line 20.)

$

,000.00

5000680003

b. Retail sales of artificial/silk flowers, plants, and trees

$

,000.00

5000680006

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

$

,000.00

5000680009

Subtotal

$

,000.00

5000680000

$

,000.00

5000600000

$

,000.00

5000575000

a. Retail sales of office equipment, new and used, including dictaphones, copying machines, calculating machines,
etc.

$

,000.00

5001525003

b. Retail sales of office furniture, new and used, including computer-related furniture

$

,000.00

5001525006

2. Retail sales of other home furnishings and accessories

3. Retail sales of mattresses, box springs, and air mattresses

4. Retail sales of outdoor/patio furniture
5. Retail sales of new and used office equipment and furniture (exclude computers)

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

27

$

,000.00

5001525000

a. Retail sales of kitchen appliances and related parts and accessories, including refrigerators, freezers, dishwashers,
microwave ovens, etc.

$

,000.00

5000700003

b. Retail sales of laundry appliances and related parts and accessories, including clothes washers and dryers

$

,000.00

5000700006

c. Retail sales of other major household appliances and related parts and accessories, including room airconditioners, dehumidifiers, vacuum cleaners, sewing machines, etc.

$

,000.00

5000700009

Subtotal

$

,000.00

5000700000

7. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers;
frypans; personal care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

$

,000.00

5000725000

8. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware,
and pots and pans.)

$

,000.00

5000750000

a. Retail sales of soft-surface (textile) floor coverings to be installed

$

,000.00

5001875003

b. Retail sales of carpets and rugs not requiring installation

$

,000.00

5001875006

c. Retail sales of hardwood flooring

$

,000.00

5001875009

d. Retail sales of linoleum flooring

$

,000.00

5001875011

e. Retail sales of ceramic flooring

$

,000.00

5001875013

f. Retail sales of other hard-surface floor coverings and accessories

$

,000.00

5001875015

Subtotal

$

,000.00

5001875000

a. Retail sales of furniture coverings, including ready-made and custom-made (except parts and materials used in
furniture repair or upholstery work)

$

,000.00

5000650003

b. Retail sales of domestics, including towels, sheets, blankets, table linens and coverings, etc.

$

,000.00

5000650006

Subtotal

$

,000.00

5000650000

$

,000.00

5000625000

Subtotal
6. Retail sales of major household appliances and related parts and accessories

9. Retail sales of flooring and floor coverings

10. Retail sales of domestics and other textile home furnishings (except carpet and rugs)

11. Retail sales of window treatments, including rods, poles, and fixtures

2022_RT-44211_su.pdf Generated 2022-02-23 16:22:27

28

12. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

a. Retail sales of antiques, items over 100 years old

$

,000.00

5000850003

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

$

,000.00

5000850006

$

,000.00

5000850009

d. Retail sales of precious metals, coins, medals, and other numismatic items

$

,000.00

5000850012

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

$

,000.00

5000850015

f. Retail sales of estate/antique jewelry

$

,000.00

5000850018

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products

$

,000.00

5000850021

h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and
garden goods
(Report used office furniture on line 5b.)

$

,000.00

5000850024

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical
instruments, etc.

$

,000.00

5000850027

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

$

,000.00

5000850031

k. Retail sales of used household and personal goods, not elsewhere classified

$

,000.00

5000850033

Subtotal

$

,000.00

5000850000

13. Retail sales of televisions, audio and video equipment

$

,000.00

5000875000

14. Retail sales of computers and peripheral equipment, communications equipment, and related products

$

,000.00

5001550000

15. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants (Include powered lawn
and garden tools, outdoor grills, pools, pool chemicals, and pool supplies, and outdoor nursery stock.)

$

,000.00

5000805000

16. Retail sales of fabrics, yarns, and other sewing materials and supplies

$

,000.00

5001775000

17. Retail sales of books

$

,000.00

5000925000

18. Retail sales of toys, games, and hobby and craft supplies

$

,000.00

5001125000

19. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

$

,000.00

5001930000

c. Retail sales of art goods, including original pictures and sculptures

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29

20. Retail sales of plumbing, electrical, and HVAC supplies (Include heating stoves (wood, kerosene, and oil) and
prefabricated fireplaces, ceiling fans, light bulbs, and light fixtures.)

$

,000.00

5001900000

21. Retail sales of wallpaper and other flexible wallcoverings

$

,000.00

5001825000

22. Retail sales of miscellaneous household goods, not elsewhere classified (Include nonautomotive batteries and baby
goods such as swings, collapsible playpens, infant and booster car seats, etc.)

$

,000.00

5000860000

23. Local transportation and delivery of purchased or serviced items

$

,000.00

7011125000

24. Rental services for home furniture, furnishings, and accessories

$

,000.00

7000700000

25. Off-site cleaning and repair services for home furniture, furnishings, and accessories, except curtain and drape
cleaning services (Include parts and materials used in repair. Include value of service contracts.)

$

,000.00

7000770000

26. Maintenance and repair services for household and personal goods, not elsewhere classified (Include parts and
materials used in repair. Include value of service contracts.)

$

,000.00

7000800000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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30

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Used Merchandise

ITEM 28: SPECIAL ITEMS - USED MERCHANDISE
Did the sale of used or secondhand merchandise, including antiques and collectibles, account for more than 75% of the total sales and receipts reported in Item 5?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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36

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

44

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

45

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Convenience food store

445120 001

Convenience store selling gasoline

447110 002

Grocery store

445110 001

Food supermarket

445110 003

Liquor store

445310 001

Beer, wine, liquor store

445310 002

Wine and/or beer store

445310 003

Cigarette, pipe, and tobacco store

453991 002

Meat market or ham store

445210 003

Delicatessen, primarily selling meats and a range of grocery items

445110 002

Delicatessen, primarily selling fresh and prepared meats

445210 001

Delicatessen, primarily preparing sandwiches and meals for immediate consumption

722513 004

Pizza take and bake store

445299 005

Ice cream/soft serve shop

722515 101

Candy, nut, confectionery store, little or no preparing on premises

445292 001

Coffee shop

722515 501

Fast food restaurant

722513 002

Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Bar with limited gaming operations (e.g., video poker, keno, pull tabs)

722410 002

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total sales of merchandise and other operating receipts?
(Include excise taxes. Exclude sales taxes or other taxes collected.)

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2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
2022
%

1. Household consumers and individuals

2. Retailers for resale

%

3. Wholesalers/distributors for resale

%

%

4. Repair shops for use in repair work

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Restaurants, hotels, food services, and contract feeding

%

7. Businesses for end use in their own operation, not for resale or production

%

8. Building contractors, heavy construction, and special trade contractors

%

9. Farmers for use in farm production

%

10. Governmental bodies (Federal, state, and local)

%

11. Export sales

%

12. Other

%

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20

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

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%

21

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

1. Retail sales of fresh meat and poultry
(Report deli meats on line 6a and meats sold in a frozen state on line 7a.)

5000025000

2. Retail sales of fresh fish and seafood
(Report fish and seafood sold in a frozen state on line 7a.)

5000050000

3. Retail sales of fresh fruit and vegetables
(Report frozen fruits and vegetables on line 7a.)

5000075000

4. Retail sales of eggs and dairy (except ice cream)
(Report deli cheeses on line 6a and ice cream and other frozen dairy products on line 7b.)

5000100000

5. Retail sales of baked goods packaged for future consumption (Include breads, doughnuts, pastries, and pies.)
(Report candy and prepackaged cookies on line 8 and frozen baked goods on line 7a.)

5000125000

6. Retail sales of perishable prepared foods packaged for future consumption
a. Retail sales of delicatessen items, including deli meats and other service delicatessen items (except prepared sandwiches,
dishes, and entrees)

5000150000

5000150003

5000150006

b. Retail sales of soup and salad bars

c. Retail sales of all other perishable prepared foods, including prepared sandwiches, dishes, and entrees
7. Retail sales of frozen foods
(Report hand-dipped ice cream and yogurt on line 11.)

5000150009

5000175000

a. Retail sales of frozen foods, excluding ice cream and other frozen dairy products

b. Retail sales of ice cream and other frozen dairy products

8. Retail sales of candy, prepackaged cookies, and snack foods
9. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy milk, and egg
and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and crackers.)

10. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

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5000175003

5000175006

5000200000

5000225000

5000250000

7000025000

23

12. Meals, snacks, other food items, and beverages prepared for catered events

13. Alcoholic beverages, prepared and served or dispensed for immediate consumption

7000060000

7000050000

5000300000

14. Retail sales of packaged alcoholic beverages

a. Retail sales of distilled spirits, including liquor, brandy, and liqueurs

5000300003

5000300006

b. Retail sales of wine

5000300009

c. Retail sales of beer and ale
15. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

a. Retail sales of tobacco products, electronic cigarettes, and other smoking supplies (excluding cannabis/marijuana)
b. Retail sales of cannabis/marijuana dried buds (pre-rolled or loose) and cannabis-based vapor cartridges and liquids, for medical
and non-medical use

5000325000

5000325003

5000325006

5000275000

16. Retail sales of ice

5000775000

17. Retail sales of household cleaning supplies

a. Retail sales of household soaps, detergents, and cleaners

b. Retail sales of household cleaning supplies, including mops, sponges, brooms, and brushes

5000775003

5000775006

18. Retail sales of household paper and plastic products, except tableware (Include paper towels, napkins, etc.)
(Report toilet paper, facial tissues, and sanitary napkins on line 22.)

5000825000

19. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware, and pots and
pans.)

5000750000

20. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements

5001350000

5001350003

a. Retail sales of prescriptions

5001350006

b. Retail sales of nonprescription medicines

c. Retail sales of vitamins, minerals, and other dietary supplements
21. Retail sales of cosmetics and fragrances (Include face cream, makeup, cologne, and perfume.)
(Report hair care products and nail polish on line 22.)

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

5001350009

5001450000

24

22. Retail sales of personal hygiene supplies (Include hand and foot care products, eye/contact lens care products, oral hygiene
products, deodorants, hair care products, nail polish, toilet paper, facial tissues, sanitary napkins, and disposable diapers.)

23. Retail sales of home health care equipment and supplies (Include first aid products and surgical and medical masks.)

5001425000

5001375000

5001250000

24. Retail sales of pet foods and supplies

25. Retail sales of books (Include audio books and e-books.)

26. Retail sales of magazines and newspapers, including issue format comic books

27. Retail sales of other publications, including greeting cards and calendars

5000925000

5000950000

5000975000

5001725000

28. Retail sales of automotive fuels

29. Retail sales of household fuels, including oil, LP gas, wood, coal

5001750000

5001950000

30. Retail sales of automotive parts and supplies

31. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

5001930000

5000375000

32. Retail sales of women's clothing

5000350000

33. Retail sales of men's clothing
34. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)
(Report costume jewelry on line 38.)

35. Retail sales of costumes, vestments, and unisex clothing

5000450000

5000425000

5000475000

36. Retail sales of footwear and footwear accessories

37. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including school uniforms

5000400000

5000455000

38. Retail sales of costume and novelty jewelry

39. Retail sales of toys, games, and hobby and craft supplies

5001125000

5001400000

40. Retail sales of glasses and contact lenses

41. Retail sales of hunting, fishing, hiking, and camping equipment

42. Retail sales of household goods, not elsewhere classified

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

5001075000

5000860000

25

5000860003

a. Retail sales of nonautomotive batteries

5000860006

b. Retail sales of religious goods (except books)

5000860009

c. Retail sales of souvenirs and novelty items
d. Retail sales of baby goods, not elsewhere classified, including bottles, monitors, carriers, swings, collapsible playpens, infant and
booster car seats, etc.

5000860012

5000860015

e. Retail sales of gift cards
43. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry and
miscellaneous materials and supplies

5001935000

5001935003

a. Retail sales of office, school, and packaging supplies

b. Retail sales of stationery products, including stationery, pads, looseleaf paper, and related products

c. Retail sales of office paper, including computer printer, copier, and fax paper

5001935006

5001935009

5001935012

d. Retail sales of artists' materials and supplies

5001935015

e. Retail sales of gift wrap, gift bags, and tissue paper

f. Retail sales of other general industry and miscellaneous materials and supplies

44. Document payment services, such as money order and check cashing services (Exclude traveler's check services.)

5001935018

7005543000

Add product/service not listed

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Retail sales of fresh meat and poultry
(Report deli meats on line 6a and meats sold in a frozen state on line 7a.)

$

,000.00

5000025000

2. Retail sales of fresh fish and seafood
(Report fish and seafood sold in a frozen state on line 7a.)

$

,000.00

5000050000

3. Retail sales of fresh fruit and vegetables
(Report frozen fruits and vegetables on line 7a.)

$

,000.00

5000075000

4. Retail sales of eggs and dairy (except ice cream)
(Report deli cheeses on line 6a and ice cream and other frozen dairy products on line 7b.)

$

,000.00

5000100000

5. Retail sales of baked goods packaged for future consumption (Include breads, doughnuts, pastries, and pies.)
(Report candy and prepackaged cookies on line 8 and frozen baked goods on line 7a.)

$

,000.00

5000125000

a. Retail sales of delicatessen items, including deli meats and other service delicatessen items (except prepared
sandwiches, dishes, and entrees)

$

,000.00

5000150003

b. Retail sales of soup and salad bars

$

,000.00

5000150006

c. Retail sales of all other perishable prepared foods, including prepared sandwiches, dishes, and entrees

$

,000.00

5000150009

Subtotal

$

,000.00

5000150000

a. Retail sales of frozen foods, excluding ice cream and other frozen dairy products

$

,000.00

5000175003

b. Retail sales of ice cream and other frozen dairy products

$

,000.00

5000175006

Subtotal

$

,000.00

5000175000

8. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

9. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy
milk, and egg and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and
crackers.)

$

,000.00

5000225000

$

,000.00

5000250000

6. Retail sales of perishable prepared foods packaged for future consumption

7. Retail sales of frozen foods
(Report hand-dipped ice cream and yogurt on line 11.)

10. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

27

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

12. Meals, snacks, other food items, and beverages prepared for catered events

$

,000.00

7000060000

13. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

a. Retail sales of distilled spirits, including liquor, brandy, and liqueurs

$

,000.00

5000300003

b. Retail sales of wine

$

,000.00

5000300006

$

,000.00

5000300009

$

,000.00

5000300000

a. Retail sales of tobacco products, electronic cigarettes, and other smoking supplies (excluding cannabis/marijuana)

$

,000.00

5000325003

b. Retail sales of cannabis/marijuana dried buds (pre-rolled or loose) and cannabis-based vapor cartridges and
liquids, for medical and non-medical use

$

,000.00

5000325006

Subtotal

$

,000.00

5000325000

$

,000.00

5000275000

a. Retail sales of household soaps, detergents, and cleaners

$

,000.00

5000775003

b. Retail sales of household cleaning supplies, including mops, sponges, brooms, and brushes

$

,000.00

5000775006

$

,000.00

5000775000

18. Retail sales of household paper and plastic products, except tableware (Include paper towels, napkins, etc.)
(Report toilet paper, facial tissues, and sanitary napkins on line 22.)

$

,000.00

5000825000

19. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware,
and pots and pans.)

$

,000.00

5000750000

$

,000.00

5001350003

14. Retail sales of packaged alcoholic beverages

c. Retail sales of beer and ale

Subtotal
15. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

16. Retail sales of ice
17. Retail sales of household cleaning supplies

Subtotal

20. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements

a. Retail sales of prescriptions

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

28

$

,000.00

5001350006

$

,000.00

5001350009

$

,000.00

5001350000

21. Retail sales of cosmetics and fragrances (Include face cream, makeup, cologne, and perfume.)
(Report hair care products and nail polish on line 22.)

$

,000.00

5001450000

22. Retail sales of personal hygiene supplies (Include hand and foot care products, eye/contact lens care products, oral
hygiene products, deodorants, hair care products, nail polish, toilet paper, facial tissues, sanitary napkins, and
disposable diapers.)

$

,000.00

5001425000

23. Retail sales of home health care equipment and supplies (Include first aid products and surgical and medical
masks.)

$

,000.00

5001375000

24. Retail sales of pet foods and supplies

$

,000.00

5001250000

25. Retail sales of books (Include audio books and e-books.)

$

,000.00

5000925000

$

,000.00

5000950000

27. Retail sales of other publications, including greeting cards and calendars

$

,000.00

5000975000

28. Retail sales of automotive fuels

$

,000.00

5001725000

29. Retail sales of household fuels, including oil, LP gas, wood, coal

$

,000.00

5001750000

30. Retail sales of automotive parts and supplies

$

,000.00

5001950000

31. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

$

,000.00

5001930000

32. Retail sales of women's clothing

$

,000.00

5000375000

33. Retail sales of men's clothing

$

,000.00

5000350000

34. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)
(Report costume jewelry on line 38.)

$

,000.00

5000450000

35. Retail sales of costumes, vestments, and unisex clothing

$

,000.00

5000425000

36. Retail sales of footwear and footwear accessories

$

,000.00

5000475000

37. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including
school uniforms

$

,000.00

5000400000

b. Retail sales of nonprescription medicines

c. Retail sales of vitamins, minerals, and other dietary supplements

Subtotal

26. Retail sales of magazines and newspapers, including issue format comic books

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

29

38. Retail sales of costume and novelty jewelry

$

,000.00

5000455000

39. Retail sales of toys, games, and hobby and craft supplies

$

,000.00

5001125000

$

,000.00

5001400000

$

,000.00

5001075000

a. Retail sales of nonautomotive batteries

$

,000.00

5000860003

b. Retail sales of religious goods (except books)

$

,000.00

5000860006

c. Retail sales of souvenirs and novelty items

$

,000.00

5000860009

d. Retail sales of baby goods, not elsewhere classified, including bottles, monitors, carriers, swings, collapsible
playpens, infant and booster car seats, etc.

$

,000.00

5000860012

e. Retail sales of gift cards

$

,000.00

5000860015

Subtotal

$

,000.00

5000860000

$

,000.00

5001935003

b. Retail sales of stationery products, including stationery, pads, looseleaf paper, and related products

$

,000.00

5001935006

c. Retail sales of office paper, including computer printer, copier, and fax paper

$

,000.00

5001935009

d. Retail sales of artists' materials and supplies

$

,000.00

5001935012

e. Retail sales of gift wrap, gift bags, and tissue paper

$

,000.00

5001935015

$

,000.00

5001935018

$

,000.00

5001935000

44. Document payment services, such as money order and check cashing services (Exclude traveler's check services.)

$

,000.00

7005543000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

40. Retail sales of glasses and contact lenses

41. Retail sales of hunting, fishing, hiking, and camping equipment
42. Retail sales of household goods, not elsewhere classified

43. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry
and miscellaneous materials and supplies

a. Retail sales of office, school, and packaging supplies

f. Retail sales of other general industry and miscellaneous materials and supplies

Subtotal

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

30

Add product/service not listed

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

31

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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32

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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33

Item 28: Special Items - Floor Space

ITEM 28: SPECIAL ITEMS - FLOOR SPACE
Include:
Only the floor space used/controlled by this company.
All space occupied by this establishment on every floor of multi-story buildings.

1. What was the total under-roof selling space?
(Enter the square footage of in-store selling space at the end of 2022. Include all store areas open to customers, including aisles,
elevators, etc. Exclude display windows fronting onto streets or walks, outdoor entrance ways, or other outdoor space.)

2. What was the total under-roof floor space?
(Enter the total square footage of all under-roof selling space plus all other space available at the end of 2022. Include dry storage,
refrigerated space, offices, workrooms, display windows, and enclosed entrance ways. Exclude outdoor space, even if covered.)

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

Square feet as of
December 31,
2022

Square feet as of
December 31,
2022

34

Item 28: Special Items - Self-Checkout

ITEM 28: SPECIAL ITEMS - SELF-CHECKOUT
Did this establishment offer a way for customers to self-checkout, with no or minimal assistance, in 2022?
Yes
No

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35

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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36

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

37

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

38

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

39

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

41

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

45

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

1000

characters remaining

46

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RT-44512_su.pdf Generated 2022-02-23 16:43:57

,000.00

47

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Jewelry store

448310 001

Costume jewelry/accessory store

448150 002

Watch store

448310 002

Clock store

448310 003

Jewelry, watch, and clock repair

811490 101

Collectors' items and supplies store, including philatelist, numismatist, etc.

453998 102

Gift, novelty, souvenir store, including crafts

453220 003

Pawn shop

522298 101

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total sales of merchandise and other operating receipts?
(Exclude sales taxes or other taxes collected.)

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RT-44831_su.pdf Generated 2022-02-23 16:27:04

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
2022
%

1. Household consumers and individuals

2. Retailers for resale

%

3. Wholesalers/distributors for resale

%

%

4. Repair shops for use in repair work

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Restaurants, hotels, food services, and contract feeding

%

7. Businesses for end use in their own operation, not for resale or production

%

8. Building contractors, heavy construction, and special trade contractors

%

9. Farmers for use in farm production

%

10. Governmental bodies (Federal, state, and local)

%

11. Export sales

%

12. Other

%

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20

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

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%

21

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Retail sales of fine jewelry and watches
(Report estate/antique jewelry on line 4f and receipts from watch, clock, and jewelry repair on line 10.)
a. Retail sales of diamond jewelry (except estate/ antique jewelry and watches)
(Report all watches on line 1g and loose diamonds on line 1f.)

b. Retail sales of pearl jewelry (except estate/ antique jewelry and watches)
c. Retail sales of other gemstone jewelry (except estate/ antique jewelry and watches)
(Report loose gemstones on line 1f.)

d. Retail sales of karat gold jewelry (except estate/antique jewelry and watches)

e. Retail sales of platinum jewelry (except estate/ antique jewelry and watches)

f. Retail sales of loose gemstones, including diamonds and colored gemstones

g. Retail sales of watches, watchbands, and parts (except batteries)

Product Code

5000500000

5000500003

5000500006

5000500009

5000500012

5000500015

5000500018

5000500021

2. Retail sales of costume and novelty jewelry (Include sterling silver jewelry.)
(Report used costume and novelty jewelry on line 4g.)

5000455000

3. Retail sales of luggage and leather goods, including briefcases
(Report men's and women's small leather apparel accessories on line 6.)

5001325000

4. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

5000850000

5000850003

a. Retail sales of antiques, items over 100 years old

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

c. Retail sales of art goods, including original pictures and sculptures

d. Retail sales of precious metals, coins, medals, and other numismatic items

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

5000850006

5000850009

5000850012

5000850015

5000850018

f. Retail sales of estate/antique jewelry

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23

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products

h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and garden goods

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical instruments, etc.

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

k. Retail sales of used household and personal goods, not elsewhere classified

5000850021

5000850024

5000850027

5000850031

5000850033

5000680000

5. Retail sales of other home furnishings and accessories
a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware, vases, giftware,
mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom accessories, etc.)

5000680003

5000680006

b. Retail sales of artificial/silk flowers, plants, and trees

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

6. Retail sales of men's and women's clothing accessories (except costume jewelry)

7. Retail sales of glasses and contact lenses (Include sunglasses.)

8. Retail sales of tableware, kitchenware, cookware, glassware

9. Retail sales of household goods, not elsewhere classified

10. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry

5000680009

5000450000

5001400000

5000750000

5000860000

7000200000

Add product/service not listed

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24

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Retail sales of fine jewelry and watches
(Report estate/antique jewelry on line 4f and receipts from watch, clock, and jewelry repair on line 10.)
a. Retail sales of diamond jewelry (except estate/ antique jewelry and watches)
(Report all watches on line 1g and loose diamonds on line 1f.)

$

,000.00

5000500003

b. Retail sales of pearl jewelry (except estate/ antique jewelry and watches)

$

,000.00

5000500006

c. Retail sales of other gemstone jewelry (except estate/ antique jewelry and watches)
(Report loose gemstones on line 1f.)

$

,000.00

5000500009

d. Retail sales of karat gold jewelry (except estate/antique jewelry and watches)

$

,000.00

5000500012

e. Retail sales of platinum jewelry (except estate/ antique jewelry and watches)

$

,000.00

5000500015

f. Retail sales of loose gemstones, including diamonds and colored gemstones

$

,000.00

5000500018

$

,000.00

5000500021

$

,000.00

5000500000

2. Retail sales of costume and novelty jewelry (Include sterling silver jewelry.)
(Report used costume and novelty jewelry on line 4g.)

$

,000.00

5000455000

3. Retail sales of luggage and leather goods, including briefcases
(Report men's and women's small leather apparel accessories on line 6.)

$

,000.00

5001325000

$

,000.00

5000850003

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

$

,000.00

5000850006

c. Retail sales of art goods, including original pictures and sculptures

$

,000.00

5000850009

d. Retail sales of precious metals, coins, medals, and other numismatic items

$

,000.00

5000850012

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

$

,000.00

5000850015

g. Retail sales of watches, watchbands, and parts (except batteries)

Subtotal

4. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

a. Retail sales of antiques, items over 100 years old

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25

f. Retail sales of estate/antique jewelry

$

,000.00

5000850018

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products

$

,000.00

5000850021

h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and
garden goods

$

,000.00

5000850024

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical
instruments, etc.

$

,000.00

5000850027

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

$

,000.00

5000850031

k. Retail sales of used household and personal goods, not elsewhere classified

$

,000.00

5000850033

Subtotal

$

,000.00

5000850000

$

,000.00

5000680003

b. Retail sales of artificial/silk flowers, plants, and trees

$

,000.00

5000680006

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

$

,000.00

5000680009

Subtotal

$

,000.00

5000680000

6. Retail sales of men's and women's clothing accessories (except costume jewelry)

$

,000.00

5000450000

7. Retail sales of glasses and contact lenses (Include sunglasses.)

$

,000.00

5001400000

8. Retail sales of tableware, kitchenware, cookware, glassware

$

,000.00

5000750000

9. Retail sales of household goods, not elsewhere classified

$

,000.00

5000860000

10. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry

$

,000.00

7000200000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

5. Retail sales of other home furnishings and accessories
a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware,
vases, giftware, mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom
accessories, etc.)

Add product/service not listed

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26

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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27

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Used Merchandise

ITEM 28: SPECIAL ITEMS - USED MERCHANDISE
Did the sale of used or secondhand merchandise, including antiques and collectibles, account for more than 75% of the total sales and receipts reported in Item 5?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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32

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

40

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

41

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Bicycle shop

451110 211

Golf specialty shop

451110 221

Gun shop

451110 231

Fishing tackle shop

451110 272

Ski and/or snowboard shop

451110 271

Fitness equipment specialty store

451110 273

Children's play equipment store, including swing sets, trampolines, etc.

451110 27A

Backpacking/camping/outfitter shop

451110 279

Scuba shop

451110 275

Surfing and/or skateboarding shop

451110 276

Pool/billiards store

451110 274

Tack store (saddlery)

451110 277

Tack store (feed)

444220 203

Other specialty sporting goods store, specializing in a maximum of four (4) lines, such as archery, bowling, tennis, swimming, hunting/fishing,
etc.

451110 278

General (full-line) sporting goods store

451110 102

Team athletic supply store, including equipment and uniforms

451110 104

Sports apparel store, including golf, tennis, riding, etc.

448190 301

Athletic footwear store

448210 501

Boat/marine dealer

441222 001

All-terrain vehicle (ATV) dealer, including motor bikes, motor scooters, and mopeds

441228 104

Other primary business or activity

779000 001

Select Sector

Describe

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total sales of merchandise and other operating receipts?
(Exclude sales taxes or other taxes collected.)

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER

A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
2022
%

1. Household consumers and individuals

2. Retailers for resale

%

3. Wholesalers/distributors for resale

%

%

4. Repair shops for use in repair work

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Restaurants, hotels, food services, and contract feeding

%

7. Businesses for end use in their own operation, not for resale or production

%

8. Building contractors, heavy construction, and special trade contractors

%

9. Farmers for use in farm production

%

10. Governmental bodies (Federal, state, and local)

%

11. Export sales

%

12. Other

%

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

20

Describe

13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

%

21

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Retail sales of hunting, fishing, hiking, and camping equipment
(Report used clothing on line 36g.)

a. Retail sales of firearms, hunting equipment, and supplies

Product Code

5001075000

5001075003

5001075006

b. Retail sales of fishing tackle, including bait

c. Retail sales of camping and backpacking equipment and supplies
2. Retail sales of golf equipment
(Report used golf equipment on line 36i.)

5001075009

5001050000

3. Retail sales of new and used exercise/fitness equipment

5001700000

4. Retail sales of bicycles and other cycles, all types, except children's sidewalk bikes, and parts and accessories
(Report used bicycles and other cycles on line 36i. Report maintenance and repair services and parts used in repair on line 38.)

5001025000

5. Retail sales of other sporting goods and equipment, excluding sport vehicles
(Report all other used sporting goods on line 36i and all sports vehicles under 12.)

5001105000

5001105003

a. Retail sales of tennis equipment

b. Retail sales of snow-skiing and snowboarding equipment

5001105006

5001105009

c. Retail sales of scuba and skin diving equipment

d. Retail sales of water skiing, surfing, and sail boarding equipment

5001105012

5001105015

e. Retail sales of billiards equipment and supplies

f. Retail sales of hockey equipment, except team hockey equipment

5001105018

5001105021

g. Retail sales of team sporting goods
h. Retail sales of all other sporting goods, including archery equipment, badminton sets, bowling equipment, ice skates,
skateboards, saddlery, cleated and other specialized athletic footwear, etc.
(Report men's athletic footwear (excluding cleats and other specialized athletic footwear) on line 6d and women's athletic footwear
(excluding cleats and other specialized athletic footwear) on line 6e.)

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

5001105024

23

6. Retail sales of footwear and footwear accessories
(Report used footwear on line 36g.)

5000475000

a. Retail sales of men's nonathletic footwear, including dress and casual footwear

b. Retail sales of women's nonathletic footwear, including dress and casual footwear

c. Retail sales of children's nonathletic footwear, including boys', girls', infants', and toddlers' dress and casual footwear

d. Retail sales of men's athletic footwear, including tennis shoes/sneakers

e. Retail sales of women's athletic footwear, including tennis shoes/sneakers

f. Retail sales of children's athletic footwear, including boys', girls', infants', and toddlers'

g. Retail sales of men's and women's outdoor hiking/sports boots

h. Retail sales of footwear accessories, including polishes, laces, trees, storage bags, etc.
7. Retail sales of men's clothing
(Report used clothing on line 36g.)

5000475003

5000475006

5000475009

5000475012

5000475015

5000475018

5000475021

5000475024

5000350000

a. Retail sales of men's outerwear coats, jackets, windbreakers, and similar

5000350003

5000350006

b. Retail sales of men's suits and formal wear

5000350009

c. Retail sales of men's sport coats and blazers

5000350012

d. Retail sales of men's tailored and dress slacks

e. Retail sales of men's casual slacks and jeans, walking shorts, etc.

5000350015

5000350018

f. Retail sales of men's dress shirts

g. Retail sales of men's sport shirts, including t-shirts, knit and woven shirts, etc.

5000350021

5000350024

h. Retail sales of men's sweaters

i. Retail sales of men's sweat tops, pants, and warm-ups

j. Retail sales of men's underwear, nightwear, and hosiery

5000350027

5000350031

5000350034

k. Retail sales of men's career and work uniforms

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

24

l. Retail sales of men's sports apparel, including tennis, golf, jogging, swimming, skiing, camping, fishing, hiking, and other rugged
outer and exercise apparel

5000350037

5000350041

m. Retail sales of other men's wear
8. Retail sales of women's clothing
(Report used clothing on line 36g.)

5000375000

a. Retail sales of women's, juniors', and misses' furs and fur garments

b. Retail sales of women's, juniors', and misses' dressy and tailored coats, outer jackets, and rainwear

c. Retail sales of women's, juniors', and misses' dresses, including all types

d. Retail sales of women's, juniors', and misses' suits, pantsuits, sport jackets, and blazers

e. Retail sales of women's, juniors', and misses' slacks/pants, jeans, walking shorts, and skirts

f. Retail sales of women's, juniors', and misses' tops, including t-shirts, knit and woven shirts, blouses, and sweaters

g. Retail sales of women's sweat tops, pants, and warm-ups

5000375003

5000375006

5000375009

5000375012

5000375015

5000375018

5000375021

5000375024

h. Retail sales of bras, girdles, and corsets

i. Retail sales of women's, juniors', and misses' lingerie, sleepwear, and loungewear

j. Retail sales of women's hosiery, including pantyhose, socks, and tights
k. Retail sales of women's sports apparel, including tennis, golf, jogging, swimming, skiing, camping, fishing, hiking, and other
rugged outer and exercise apparel

l. Retail sales of other women's apparel, including uniforms, smocks, and other apparel items
9. Retail sales of men's and women's clothing accessories (except costume jewelry)
(Report used accessories on line 36g.)

a. Retail sales of men's accessories, including hats, gloves, neckwear, handkerchiefs, belts, rain accessories, etc.

5000375027

5000375031

5000375034

5000375037

5000450000

5000450003

5000450006

b. Retail sales of women's hats, wigs, and hairpieces

c. Retail sales of women's accessories, including handbags, wallets, neckwear, gloves, belts, rain accessories, etc.
10. Retail sales of costumes, vestments, and unisex clothing
(Report used costumes, vestments, and unisex clothing on line 36g.)

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

5000450009

5000425000

25

11. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including school uniforms
(Report used clothing on line 36g.)

5000400000

5001175000

12. Retail sales of boats and other sports vehicles

a. Retail sales of new boats, canoes, kayaks, motors, and parts and accessories

b. Retail sales of used boats, canoes, kayaks, motors, and parts and accessories

c. Retail sales of utility trailers, including horse/livestock trailers

d. Retail sales of all-terrain vehicles (ATVs) and personal watercraft

e. Retail sales of other sports vehicles, including snowmobiles, golf cars, go-carts, parts and accessories, etc.

13. Retail sales of candy, prepackaged cookies, and snack foods
14. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy milk, and egg
and cheese substitutes

15. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

16. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption
17. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

5001175003

5001175006

5001175009

5001175012

5001175015

5000200000

5000225000

5000250000

7000025000

5000325000

5000300000

18. Retail sales of packaged alcoholic beverages
19. Retail sales of glasses and contact lenses (Include sunglasses.)
(Report binoculars on line 22.)

20. Retail sales of fine jewelry and watches (Include sport watches.)

21. Retail sales of luggage and leather goods, including briefcases

22. Retail sales of toys, games, and hobby and craft supplies

5001400000

5000500000

5001325000

5001125000

5000925000

23. Retail sales of books
24. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers; frypans; personal
care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

25. Retail sales of tableware, kitchenware, cookware, glassware

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

5000725000

5000750000

26

5000575000

26. Retail sales of outdoor/patio furniture
27. Retail sales of other home furnishings and accessories (Include decorative accessories and home furnishings; artificial/silk flowers,
plants, and trees; and seasonal decorations.)

28. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants

29. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

5000680000

5000805000

5001930000

5000900000

30. Retail sales of photographic equipment and supplies

31. Retail sales of computers and peripheral equipment, communications equipment, and related products

5001550000

5001250000

32. Retail sales of pet foods and supplies

5001710000

33. Retail sales of safes and vaults

5001110000

34. Retail sales of fireworks

35. Retail sales of household goods, not elsewhere classified

36. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

5000860000

5000850000

5000850003

a. Retail sales of antiques, items over 100 years old

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

c. Retail sales of art goods, including original pictures and sculptures

d. Retail sales of precious metals, coins, medals, and other numismatic items

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

5000850006

5000850009

5000850012

5000850015

5000850018

f. Retail sales of estate/antique jewelry

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products

h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and garden goods

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical instruments, etc.

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

5000850021

5000850024

5000850027

5000850031

27

k. Retail sales of used household and personal goods, not elsewhere classified

5000850033

37. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles, and musical
instruments)

7001800000

38. Maintenance and repair services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports
vehicles, and musical instruments)

7001825000

39. Leisure, recreational, and athletic instructional programs

7002500000

Add product/service not listed

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

28

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Retail sales of hunting, fishing, hiking, and camping equipment
(Report used clothing on line 36g.)

a. Retail sales of firearms, hunting equipment, and supplies

$

,000.00

5001075003

b. Retail sales of fishing tackle, including bait

$

,000.00

5001075006

c. Retail sales of camping and backpacking equipment and supplies

$

,000.00

5001075009

Subtotal

$

,000.00

5001075000

2. Retail sales of golf equipment
(Report used golf equipment on line 36i.)

$

,000.00

5001050000

3. Retail sales of new and used exercise/fitness equipment

$

,000.00

5001700000

4. Retail sales of bicycles and other cycles, all types, except children's sidewalk bikes, and parts and accessories
(Report used bicycles and other cycles on line 36i. Report maintenance and repair services and parts used in repair
on line 38.)

$

,000.00

5001025000

a. Retail sales of tennis equipment

$

,000.00

5001105003

b. Retail sales of snow-skiing and snowboarding equipment

$

,000.00

5001105006

c. Retail sales of scuba and skin diving equipment

$

,000.00

5001105009

d. Retail sales of water skiing, surfing, and sail boarding equipment

$

,000.00

5001105012

e. Retail sales of billiards equipment and supplies

$

,000.00

5001105015

f. Retail sales of hockey equipment, except team hockey equipment

$

,000.00

5001105018

g. Retail sales of team sporting goods

$

,000.00

5001105021

5. Retail sales of other sporting goods and equipment, excluding sport vehicles
(Report all other used sporting goods on line 36i and all sports vehicles under 12.)

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

29

h. Retail sales of all other sporting goods, including archery equipment, badminton sets, bowling equipment, ice
skates, skateboards, saddlery, cleated and other specialized athletic footwear, etc.
(Report men's athletic footwear (excluding cleats and other specialized athletic footwear) on line 6d and women's
athletic footwear (excluding cleats and other specialized athletic footwear) on line 6e.)

$

,000.00

5001105024

Subtotal

$

,000.00

5001105000

a. Retail sales of men's nonathletic footwear, including dress and casual footwear

$

,000.00

5000475003

b. Retail sales of women's nonathletic footwear, including dress and casual footwear

$

,000.00

5000475006

c. Retail sales of children's nonathletic footwear, including boys', girls', infants', and toddlers' dress and casual
footwear

$

,000.00

5000475009

d. Retail sales of men's athletic footwear, including tennis shoes/sneakers

$

,000.00

5000475012

e. Retail sales of women's athletic footwear, including tennis shoes/sneakers

$

,000.00

5000475015

f. Retail sales of children's athletic footwear, including boys', girls', infants', and toddlers'

$

,000.00

5000475018

g. Retail sales of men's and women's outdoor hiking/sports boots

$

,000.00

5000475021

h. Retail sales of footwear accessories, including polishes, laces, trees, storage bags, etc.

$

,000.00

5000475024

$

,000.00

5000475000

a. Retail sales of men's outerwear coats, jackets, windbreakers, and similar

$

,000.00

5000350003

b. Retail sales of men's suits and formal wear

$

,000.00

5000350006

$

,000.00

5000350009

d. Retail sales of men's tailored and dress slacks

$

,000.00

5000350012

e. Retail sales of men's casual slacks and jeans, walking shorts, etc.

$

,000.00

5000350015

f. Retail sales of men's dress shirts

$

,000.00

5000350018

g. Retail sales of men's sport shirts, including t-shirts, knit and woven shirts, etc.

$

,000.00

5000350021

6. Retail sales of footwear and footwear accessories
(Report used footwear on line 36g.)

Subtotal
7. Retail sales of men's clothing
(Report used clothing on line 36g.)

c. Retail sales of men's sport coats and blazers

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

30

h. Retail sales of men's sweaters

$

,000.00

5000350024

i. Retail sales of men's sweat tops, pants, and warm-ups

$

,000.00

5000350027

j. Retail sales of men's underwear, nightwear, and hosiery

$

,000.00

5000350031

$

,000.00

5000350034

l. Retail sales of men's sports apparel, including tennis, golf, jogging, swimming, skiing, camping, fishing, hiking, and
other rugged outer and exercise apparel

$

,000.00

5000350037

m. Retail sales of other men's wear

$

,000.00

5000350041

Subtotal

$

,000.00

5000350000

a. Retail sales of women's, juniors', and misses' furs and fur garments

$

,000.00

5000375003

b. Retail sales of women's, juniors', and misses' dressy and tailored coats, outer jackets, and rainwear

$

,000.00

5000375006

c. Retail sales of women's, juniors', and misses' dresses, including all types

$

,000.00

5000375009

$

,000.00

5000375012

e. Retail sales of women's, juniors', and misses' slacks/pants, jeans, walking shorts, and skirts

$

,000.00

5000375015

f. Retail sales of women's, juniors', and misses' tops, including t-shirts, knit and woven shirts, blouses, and sweaters

$

,000.00

5000375018

g. Retail sales of women's sweat tops, pants, and warm-ups

$

,000.00

5000375021

h. Retail sales of bras, girdles, and corsets

$

,000.00

5000375024

$

,000.00

5000375027

j. Retail sales of women's hosiery, including pantyhose, socks, and tights

$

,000.00

5000375031

k. Retail sales of women's sports apparel, including tennis, golf, jogging, swimming, skiing, camping, fishing, hiking,
and other rugged outer and exercise apparel

$

,000.00

5000375034

l. Retail sales of other women's apparel, including uniforms, smocks, and other apparel items

$

,000.00

5000375037

$

,000.00

5000375000

k. Retail sales of men's career and work uniforms

8. Retail sales of women's clothing
(Report used clothing on line 36g.)

d. Retail sales of women's, juniors', and misses' suits, pantsuits, sport jackets, and blazers

i. Retail sales of women's, juniors', and misses' lingerie, sleepwear, and loungewear

Subtotal

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

31

9. Retail sales of men's and women's clothing accessories (except costume jewelry)
(Report used accessories on line 36g.)

a. Retail sales of men's accessories, including hats, gloves, neckwear, handkerchiefs, belts, rain accessories, etc.

$

,000.00

5000450003

b. Retail sales of women's hats, wigs, and hairpieces

$

,000.00

5000450006

c. Retail sales of women's accessories, including handbags, wallets, neckwear, gloves, belts, rain accessories, etc.

$

,000.00

5000450009

Subtotal

$

,000.00

5000450000

10. Retail sales of costumes, vestments, and unisex clothing
(Report used costumes, vestments, and unisex clothing on line 36g.)

$

,000.00

5000425000

11. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including
school uniforms
(Report used clothing on line 36g.)

$

,000.00

5000400000

$

,000.00

5001175003

b. Retail sales of used boats, canoes, kayaks, motors, and parts and accessories

$

,000.00

5001175006

c. Retail sales of utility trailers, including horse/livestock trailers

$

,000.00

5001175009

d. Retail sales of all-terrain vehicles (ATVs) and personal watercraft

$

,000.00

5001175012

e. Retail sales of other sports vehicles, including snowmobiles, golf cars, go-carts, parts and accessories, etc.

$

,000.00

5001175015

Subtotal

$

,000.00

5001175000

13. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

14. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt,
nondairy milk, and egg and cheese substitutes

$

,000.00

5000225000

15. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

$

,000.00

5000250000

16. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

17. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

$

,000.00

5000325000

18. Retail sales of packaged alcoholic beverages

$

,000.00

5000300000

12. Retail sales of boats and other sports vehicles

a. Retail sales of new boats, canoes, kayaks, motors, and parts and accessories

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

32

19. Retail sales of glasses and contact lenses (Include sunglasses.)
(Report binoculars on line 22.)

$

,000.00

5001400000

20. Retail sales of fine jewelry and watches (Include sport watches.)

$

,000.00

5000500000

21. Retail sales of luggage and leather goods, including briefcases

$

,000.00

5001325000

22. Retail sales of toys, games, and hobby and craft supplies

$

,000.00

5001125000

23. Retail sales of books

$

,000.00

5000925000

24. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers;
frypans; personal care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

$

,000.00

5000725000

25. Retail sales of tableware, kitchenware, cookware, glassware

$

,000.00

5000750000

26. Retail sales of outdoor/patio furniture

$

,000.00

5000575000

27. Retail sales of other home furnishings and accessories (Include decorative accessories and home furnishings;
artificial/silk flowers, plants, and trees; and seasonal decorations.)

$

,000.00

5000680000

28. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants

$

,000.00

5000805000

29. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

$

,000.00

5001930000

30. Retail sales of photographic equipment and supplies

$

,000.00

5000900000

31. Retail sales of computers and peripheral equipment, communications equipment, and related products

$

,000.00

5001550000

32. Retail sales of pet foods and supplies

$

,000.00

5001250000

33. Retail sales of safes and vaults

$

,000.00

5001710000

34. Retail sales of fireworks

$

,000.00

5001110000

35. Retail sales of household goods, not elsewhere classified

$

,000.00

5000860000

$

,000.00

5000850003

$

,000.00

5000850006

$

,000.00

5000850009

36. Retail sales of antiques, collectibles, art works, and other used goods (except transportation and machinery goods)

a. Retail sales of antiques, items over 100 years old

b. Retail sales of collectibles, including items which are old, but less than 100 years old, and limited in supply

c. Retail sales of art goods, including original pictures and sculptures

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33

d. Retail sales of precious metals, coins, medals, and other numismatic items

$

,000.00

5000850012

e. Retail sales of stamps, autographs, and other philatelic materials and supplies

$

,000.00

5000850015

f. Retail sales of estate/antique jewelry

$

,000.00

5000850018

g. Retail sales of used clothing, footwear, personal accessories, jewelry, and related products

$

,000.00

5000850021

h. Retail sales of used home furniture, household appliances, kitchenware, home furnishings, and home lawn and
garden goods

$

,000.00

5000850024

i. Retail sales of used home entertainment, recreation, and culture products, including books, CDs, musical
instruments, etc.

$

,000.00

5000850027

j. Retail sales of used hardware, tools, plumbing and electrical supplies, and building materials

$

,000.00

5000850031

k. Retail sales of used household and personal goods, not elsewhere classified

$

,000.00

5000850033

Subtotal

$

,000.00

5000850000

37. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles,
and musical instruments)

$

,000.00

7001800000

38. Maintenance and repair services for recreational, sports, and fitness equipment (including boats, motorcycles, other
sports vehicles, and musical instruments)

$

,000.00

7001825000

39. Leisure, recreational, and athletic instructional programs

$

,000.00

7002500000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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34

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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35

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Used Merchandise

ITEM 28: SPECIAL ITEMS - USED MERCHANDISE
Did the sale of used or secondhand merchandise account for more than 75% of the total sales and receipts reported in Item 5?
Yes
No

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37

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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38

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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39

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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40

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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43

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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44

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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45

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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46

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

48

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RT-45111_su.pdf Generated 2022-02-23 15:52:18

,000.00

49

Attachment D-8
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 48-49

Attachment Sector

D-8

48-49

Instrument
Path
Instrument Path Title

48100
48400
48700
4930X

Air Transportation
Truck Transportation
Scenic and Sightseeing Transportation
Warehousing and Storage (Enterprise Support)

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Scheduled air transportation
Scheduled passenger carrier, including commuter

481111 001

Scheduled air freight carrier

481112 001

Courier service, including delivery of parcels weighing 100 pounds or less
Air courier service

492110 201

Courier service - local, except by air

492210 002

Courier service - intercity, except by air

492110 102

Nonscheduled air transportation - no regular routes or regular schedules
Nonscheduled passenger service, including air taxi and charters

481211 001

Nonscheduled freight service without passengers

481212 001

Sightseeing by airplane, helicopter, or hot air balloon

487990 003

Ambulance or emergency rescue services, air or ground

621910 003

Variety of specialized flying services - performing a variety of specialized flying services, e.g., crop dusting, aerial forest fire fighting, aerial
advertising and photography, aerial surveying - Describe

481219 001

Describe
Aviation clubs providing a variety of nonscheduled air transportation activities to the general public (except primarily operating public flying
fields)

481219 002

Aviation clubs, primary operating public flying fields

488119 003

Airport and aircraft services
Air traffic control, except military

488111 001

Airport operation and terminal services, including fixed base operators (FBOs), airfreight handling, hangar operations, runway maintenance,
airport terminal services, aircraft storage, baggage handling, airports and flying fields, etc.

488119 001

Aircraft maintenance and repair (except factory conversion, factory overhaul, factory rebuilding)

488190 001

Aircraft fueling service, except on contract basis

424720 006

Airplane cleaning and janitorial services

561720 005

Limousine or luxury sedan with drivers, except scheduled airport shuttle and taxi service

485320 001

Bus or motor vehicle transit system - with regular routes and schedules within a metropolitan area and its adjacent nonurban areas

485113 002

Taxi or ridesharing service by automobile or van

485310 001

Scheduled airport shuttle service

485999 101

Aircraft rental or leasing without crew and/or pilot

532411 901

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15

Other airport and aircraft transportation services - Describe

488190 002

Describe
Arrangement of transportation for passengers
Travel agency

561510 001

Tour operator - assembling tour packages and selling directly to travelers or through other travel agencies

561520 001

Arrangement of transportation for freight and cargo
Freight forwarding service

488510 101

Freight/shipping agent or broker, except freight forwarding

488510 203

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue?
For further clarification, click the "Additional Information" link above.

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Domestic, scheduled passenger transportation by air, first class and business class

2. Domestic, scheduled passenger transportation by air, coach class

3. International, scheduled passenger transportation by air, first class and business

4. International, scheduled passenger transportation by air, coach class

Product Code

7002975000

7003000000

7003025000

7003050000

7003075000

5. Domestic non-scheduled passenger transportation by air

6. International non-scheduled passenger transportation by air

7. Transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

a. Domestic, scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

b. International, scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

c. Domestic, non-scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

d. International, non-scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

8. Transportation of non-perishable/not climate-controlled boxed, palletized, and other packed goods, by air

a. Domestic, scheduled transportation of bundled postal mail by air

b. Domestic, scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other packed goods, by air

c. International, scheduled transportation of bundled postal mail by air

7003100000

7011425000

7011425003

7011425006

7011425009

7011425012

7011500000

7011500003

7011500006

7011500009

d. International, scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other packed general
freight, by air

7011500012

e. Domestic, non-scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other packed general
freight, by air

7011500015

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

21

f. International, non-scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other packed general
freight, by air

7011500018

7011300000

9. Transportation of bulk liquids and gases by air

7011675000

10. Transportation of automobiles and light trucks by air

7011850000

11. Transportation of other goods by air

12. Rental of air (Dry Leasing), rail, and water transportation equipment

13. Rental of aircraft with crew for air carrier use (Wet Leasing)

7009300000

7009325000

7015025000

14. Air traffic control services

7015050000

15. Fixed-base-operator (FBO) services

7015075000

16. Airport operation and administration services

7015075003

a. Parking services for aircraft

7015075006

b. Other airport operation and administration services

17. Other air transportation support services, not elsewhere classified

7015100000

7012375000

18. Leased display advertising media space

7012375003

a. Leased display advertising media space, large format

7012375006

b. Leased display advertising media space, transit

c. Leased display advertising media space, street furniture and other urban fixtures

7012375009

7012375012

d. Other leased display advertising media space

7017000000

19. Aerial support services, not elsewhere classified

7017000003

a. Aerial crop dusting services

7017000006

b. Other air specialty services, not elsewhere classified

7002025000

20. All other recreation, sports, and fitness services

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

22

7002025003

a. Air-based recreational services

b. All other recreation, sports, and fitness services, not elsewhere classified

7002025006

7004275000

21. Air ambulance emergency services

22. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

7000025000

7009400000

23. Maintenance and repair and related services for aircraft
24. Manufacturing of radio station equipment, including space-based (satellite) stations, airborne and marine-based stations, and earth
fixed-based and mobile-based systems (excluding transmission equipment)

25. Manufacturing of complete guided missiles and complete space vehicles (excluding propulsion systems, parts, and prototypes)
26. Manufacturing of complete missiles, space vehicle engines, propulsion units, and related parts and accessories (excluding
complete guided missiles and prototypes)

2011825000

2012380000

2012480000

Add product/service not listed

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

23

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Domestic, scheduled passenger transportation by air, first class and business class

$

,000.00

7002975000

2. Domestic, scheduled passenger transportation by air, coach class

$

,000.00

7003000000

3. International, scheduled passenger transportation by air, first class and business

$

,000.00

7003025000

4. International, scheduled passenger transportation by air, coach class

$

,000.00

7003050000

5. Domestic non-scheduled passenger transportation by air

$

,000.00

7003075000

6. International non-scheduled passenger transportation by air

$

,000.00

7003100000

a. Domestic, scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by
air

$

,000.00

7011425003

b. International, scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed goods,
by air

$

,000.00

7011425006

c. Domestic, non-scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed
goods, by air

$

,000.00

7011425009

d. International, non-scheduled transportation of perishable/climate-controlled boxed, palletized, and other packed
goods, by air

$

,000.00

7011425012

Subtotal

$

,000.00

7011425000

a. Domestic, scheduled transportation of bundled postal mail by air

$

,000.00

7011500003

b. Domestic, scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other packed
goods, by air

$

,000.00

7011500006

c. International, scheduled transportation of bundled postal mail by air

$

,000.00

7011500009

d. International, scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other
packed general freight, by air

$

,000.00

7011500012

7. Transportation of perishable/climate-controlled boxed, palletized, and other packed goods, by air

8. Transportation of non-perishable/not climate-controlled boxed, palletized, and other packed goods, by air

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

24

e. Domestic, non-scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other
packed general freight, by air

$

,000.00

7011500015

f. International, non-scheduled transportation of non-perishable/not climate-controlled boxed, palletized, and other
packed general freight, by air

$

,000.00

7011500018

Subtotal

$

,000.00

7011500000

9. Transportation of bulk liquids and gases by air

$

,000.00

7011300000

10. Transportation of automobiles and light trucks by air

$

,000.00

7011675000

11. Transportation of other goods by air

$

,000.00

7011850000

12. Rental of air (Dry Leasing), rail, and water transportation equipment

$

,000.00

7009300000

13. Rental of aircraft with crew for air carrier use (Wet Leasing)

$

,000.00

7009325000

14. Air traffic control services

$

,000.00

7015025000

15. Fixed-base-operator (FBO) services

$

,000.00

7015050000

$

,000.00

7015075003

$

,000.00

7015075006

$

,000.00

7015075000

$

,000.00

7015100000

a. Leased display advertising media space, large format

$

,000.00

7012375003

b. Leased display advertising media space, transit

$

,000.00

7012375006

c. Leased display advertising media space, street furniture and other urban fixtures

$

,000.00

7012375009

d. Other leased display advertising media space

$

,000.00

7012375012

Subtotal

$

,000.00

7012375000

16. Airport operation and administration services

a. Parking services for aircraft

b. Other airport operation and administration services

Subtotal

17. Other air transportation support services, not elsewhere classified
18. Leased display advertising media space

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

25

19. Aerial support services, not elsewhere classified

a. Aerial crop dusting services

$

,000.00

7017000003

b. Other air specialty services, not elsewhere classified

$

,000.00

7017000006

Subtotal

$

,000.00

7017000000

a. Air-based recreational services

$

,000.00

7002025003

b. All other recreation, sports, and fitness services, not elsewhere classified

$

,000.00

7002025006

$

,000.00

7002025000

21. Air ambulance emergency services

$

,000.00

7004275000

22. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

23. Maintenance and repair and related services for aircraft

$

,000.00

7009400000

24. Manufacturing of radio station equipment, including space-based (satellite) stations, airborne and marine-based
stations, and earth fixed-based and mobile-based systems (excluding transmission equipment)

$

,000.00

2011825000

25. Manufacturing of complete guided missiles and complete space vehicles (excluding propulsion systems, parts, and
prototypes)

$

,000.00

2012380000

26. Manufacturing of complete missiles, space vehicle engines, propulsion units, and related parts and accessories
(excluding complete guided missiles and prototypes)

$

,000.00

2012480000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

20. All other recreation, sports, and fitness services

Subtotal

Add product/service not listed

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26

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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27

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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28

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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29

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

30

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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31

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

35

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

37

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

1000

characters remaining

38

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_TW-48100_su.pdf Generated 2022-02-23 17:09:01

,000.00

39

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Local trucking - goods carried within a single metropolitan area and its adjacent nonurban areas; generally same-day return trips
Local used household goods moving (without storage)

484210 101

Local used household goods moving (with storage)

484210 301

Local general freight trucking, truckload (TL)

484110 501

Local general freight trucking, less than truckload (LTL)

484110 601

Dump trucking, including coal, gravel, and sand hauling

484220 301

Solid waste, recyclables, and yard waste (exclude hazardous waste) collection services, local

562111 001

Hazardous waste collection services

562112 001

Local hazardous materials trucking, except waste

484220 101

Local agricultural products trucking (without storage), including log hauling

484220 201

Local specialized trucking without storage, including auto transport, boat transport, manufactured (mobile) home transport, water transport,
and refrigerated transport - Describe

484220 401

Describe
484220 501

Local specialized trucking with storage - Describe
Describe
Long-distance trucking - goods carried between metropolitan areas
Long-distance used household goods moving

484210 201

Long-distance general freight, truckload (TL)

484121 001

Long-distance general freight, less-than-truckload (LTL)

484122 001

Long-distance hazardous materials trucking, except waste

484230 101

Long-distance agricultural products trucking, including log hauling

484230 201

Long-distance specialized trucking, including auto transport, boat transport, water transport, refrigerated transport, and coal hauling Describe

484230 301

Describe
Courier and messenger service, including delivery of parcels weighing 100 pounds or less, except by means of air transportation
Local messenger and delivery services, including bicycles

492210 001

Intercity courier and delivery services

492110 101

Warehousing and storage facilities
Cotton and linters storage

493130 001

Grain elevators, storage only

493130 002

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

15

Other farm products, except cold storage

493130 003

Refrigerated products, including fur storage

493120 002

Lessor of self-service storage or miniwarehouses

531130 001

Household goods storage

493190 101

General warehousing and storage, contract and public (except self-storage)

493110 002

Paper document warehousing and storage

493190 202

Distribution warehouse/center - Describe

493110 003

Describe
Specialized goods (except refrigerated), including bulk petroleum, chemicals, automobile dead storage, and other products requiring special
storage - Describe

493190 201

Describe
Other transportation-related activities
Physical distribution and logistics consulting services

541614 001

Freight/shipping agent or broker, except freight forwarding

488510 203

Freight forwarding service

488510 101

Motor freight terminal and joint terminal maintenance facility

488490 007

Truck rental, without drivers

532120 102

Truck leasing, without drivers, except finance leasing

532120 202

Driver leasing, without trucks

561330 003

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

What was the total operating revenue?
(Establishments which use purchased transportation and/or commissioned agents should include gross revenue
regardless of amount retained by this establishment. Exclude sales of used equipment.)

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

Check
if
None

2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7000450000

1. Household moving services

7011050000

2. Commercial moving

7011075000

3. Moving of other goods requiring special handling

4. Local transportation and delivery of purchased or serviced items

5. Transportation services for small packages, documents, and letters

a. Station-to-station transportation of documents and parcels

b. Other transportation services for small packages, documents, and letters

6. Transportation of bulk liquids and gases in intermodal tank containers by road

7. Transportation of bulk liquids and gases, except in intermodal tank containers, by road

8. Transportation of dry bulks, except in intermodal containers, by road

9. Transportation of climate-controlled boxed, palletized, and other packed goods, except in intermodal containers, by road

10. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal containers, by road

7011125000

7011100000

7011100003

7011100006

7011200000

7011225000

7011325000

7011375000

7011450000

a. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal containers, by road,
truckload service

7011450003

b. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal containers, by road,
less-than-truckload service

7011450006

11. Transportation of climate-controlled intermodal containers, not elsewhere classified, by road

12. Transportation of other intermodal containers, not climate-controlled, not elsewhere classified, by road

7011525000

7011575000

7011625000

13. Transportation of automobiles and light trucks by road

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

21

7011700000

14. Transportation of livestock by road

7011750000

15. Transportation of waste by road

7011750003

a. Transportation of non-hazardous waste by road

b. Transportation of non-hazardous recyclable material by road

7011750006

7011750009

c. Transportation of hazardous waste by road

7011800000

16. Transportation of other goods by road

7015325000

17. Drayage services

7011900000

18. Warehousing and storage services

7011975000

19. Handling services for goods

7012000000

20. Packing services for goods

21. Freight transportation arrangement and customs brokering services

7011925000

7015300000

22. Towing services

7009275000

23. Rental of heavy trucks, truck trailers, and buses

24. Operations and supply chain management consulting and implementation services

7014650000

Add product/service not listed

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Household moving services

$

,000.00

7000450000

2. Commercial moving

$

,000.00

7011050000

3. Moving of other goods requiring special handling

$

,000.00

7011075000

4. Local transportation and delivery of purchased or serviced items

$

,000.00

7011125000

a. Station-to-station transportation of documents and parcels

$

,000.00

7011100003

b. Other transportation services for small packages, documents, and letters

$

,000.00

7011100006

$

,000.00

7011100000

6. Transportation of bulk liquids and gases in intermodal tank containers by road

$

,000.00

7011200000

7. Transportation of bulk liquids and gases, except in intermodal tank containers, by road

$

,000.00

7011225000

8. Transportation of dry bulks, except in intermodal containers, by road

$

,000.00

7011325000

9. Transportation of climate-controlled boxed, palletized, and other packed goods, except in intermodal containers, by
road

$

,000.00

7011375000

a. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal
containers, by road, truckload service

$

,000.00

7011450003

b. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal
containers, by road, less-than-truckload service

$

,000.00

7011450006

Subtotal

$

,000.00

7011450000

$

,000.00

7011525000

5. Transportation services for small packages, documents, and letters

Subtotal

10. Transportation of boxed, palletized, and other packed goods, not climate-controlled and not in intermodal containers,
by road

11. Transportation of climate-controlled intermodal containers, not elsewhere classified, by road

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

23

$

,000.00

7011575000

$

,000.00

7011625000

$

,000.00

7011700000

a. Transportation of non-hazardous waste by road

$

,000.00

7011750003

b. Transportation of non-hazardous recyclable material by road

$

,000.00

7011750006

c. Transportation of hazardous waste by road

$

,000.00

7011750009

Subtotal

$

,000.00

7011750000

16. Transportation of other goods by road

$

,000.00

7011800000

17. Drayage services

$

,000.00

7015325000

18. Warehousing and storage services

$

,000.00

7011900000

19. Handling services for goods

$

,000.00

7011975000

20. Packing services for goods

$

,000.00

7012000000

21. Freight transportation arrangement and customs brokering services

$

,000.00

7011925000

22. Towing services

$

,000.00

7015300000

$

,000.00

7009275000

24. Operations and supply chain management consulting and implementation services

$

,000.00

7014650000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

12. Transportation of other intermodal containers, not climate-controlled, not elsewhere classified, by road

13. Transportation of automobiles and light trucks by road

14. Transportation of livestock by road
15. Transportation of waste by road

23. Rental of heavy trucks, truck trailers, and buses

Add product/service not listed

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24

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

25

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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26

Item 28: Special Items - Analysis of Operating (Trucking) Revenue

ITEM 28: SPECIAL ITEMS - ANALYSIS OF OPERATING (TRUCKING) REVENUE
What percentage of motor carrier revenue was from the following?
Check
if
None

2022 Percent

1. LOCAL (motor carrier service within a single metropolitan area and its adjacent nonurban areas, which may cross state
lines)

%

2. LONG-DISTANCE (motor carrier service between metropolitan areas which may cross North American borders)

%

3. TOTAL (Sum of lines 1 and 2 should equal 100%.)

%

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27

Item 28: Special Items - Purchased Transportation

ITEM 28: SPECIAL ITEMS - PURCHASED TRANSPORTATION
What was the cost of transportation purchased for each of the following uses?
Check
if
None

2022
$

,000.00

2. Lease and rental payments for trucks and other motor vehicles without drivers

$

,000.00

3. Purchased transportation from other motor carriers

$

,000.00

4. All other purchased transportation
(Include allowances to shippers less credits for equipment rents to others.)

$

,000.00

5. TOTAL (Add lines 1 through 4.)

$

,000.00

1. Lease and rental payments for trucks and other motor vehicles with drivers

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

28

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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29

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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30

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

31

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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32

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

33

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

34

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

36

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

38

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

1000

characters remaining

39

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_TW-48400_su.pdf Generated 2022-02-23 17:16:32

,000.00

40

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:10

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:10

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:10

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:10

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:10

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Scenic and sightseeing transportation
Sightseeing bus excursions

487110 004

Horse-drawn cabs or carriages, for hire

487110 003

Aerial tramway and cable lift, scenic or sightseeing

487990 002

Scenic railroad or steam train

487110 002

Sightseeing by airplane, helicopter, or hot air balloon

487990 003

Scenic and sightseeing transportation by water, including dinner cruises, excursions, and harbor tours

487210 103

Charter fishing boat

487210 202

Other scenic or sightseeing transportation - Describe

487990 004

Describe
Charter bus services
Bus charter services - local

485510 004

Bus charter services - interstate or interurban

485510 005

Other arrangement of passenger transportation NOT operated by a transportation company
Travel agency

561510 001

Tour operator - assembling tour packages and selling directly to travelers or through other travel agencies

561520 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What was the total operating revenue?
For further clarification, click the "Additional Information" link above.

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7003200000

1. Sightseeing services by air

7003135000

2. Sightseeing services by rail

7003150000

3. Sightseeing services by ground vehicles, except rail

4. Sightseeing services by water (Include dinner cruises, excursions, and harbor tours)

5. Short-term access to communications services (Internet cafe, cruise ship, conference, etc.)

7003175000

7014175000

7015350000

6. Vanpool and carpool coordination services
7. Other road transportation support services and road transportation intermediation services, including taxi dispatch services and
ridesharing arrangement services

8. Coastal and Great Lakes fixed-route, passenger transportation by water

7015375000

7003125000

7002850000

9. Local passenger transportation by water

7003250000

10. Cruises (Deep sea)

11. Long-distance, fixed-route passenger transportation by road

12. Local, fixed-route, passenger transportation by road and transit rail

13. Long-distance passenger transportation by road, except fixed-route

14. Local passenger transportation by road (except fixed-route)

15. Packaged tours with accommodation, except cruises and academic trips and tours

16. Customized tours with accommodation, except cruises and academic trips and tours

7002925000

7002800000

7002950000

7002825000

7003275000

7003285000

7001750000

17. Academic trips and tours

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

20

18. Retail sales of candy, prepackaged cookies, and snack foods

5000200000

5000250000

19. Retail sales of soft drinks and nonalcoholic beverages

20. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

7000025000

Add product/service not listed

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Sightseeing services by air

$

,000.00

7003200000

2. Sightseeing services by rail

$

,000.00

7003135000

3. Sightseeing services by ground vehicles, except rail

$

,000.00

7003150000

4. Sightseeing services by water (Include dinner cruises, excursions, and harbor tours)

$

,000.00

7003175000

5. Short-term access to communications services (Internet cafe, cruise ship, conference, etc.)

$

,000.00

7014175000

6. Vanpool and carpool coordination services

$

,000.00

7015350000

7. Other road transportation support services and road transportation intermediation services, including taxi dispatch
services and ridesharing arrangement services

$

,000.00

7015375000

8. Coastal and Great Lakes fixed-route, passenger transportation by water

$

,000.00

7003125000

9. Local passenger transportation by water

$

,000.00

7002850000

10. Cruises (Deep sea)

$

,000.00

7003250000

11. Long-distance, fixed-route passenger transportation by road

$

,000.00

7002925000

12. Local, fixed-route, passenger transportation by road and transit rail

$

,000.00

7002800000

13. Long-distance passenger transportation by road, except fixed-route

$

,000.00

7002950000

$

,000.00

7002825000

15. Packaged tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003275000

16. Customized tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003285000

17. Academic trips and tours

$

,000.00

7001750000

14. Local passenger transportation by road (except fixed-route)

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

22

$

,000.00

5000200000

19. Retail sales of soft drinks and nonalcoholic beverages

$

,000.00

5000250000

20. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

18. Retail sales of candy, prepackaged cookies, and snack foods

Add product/service not listed

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

23

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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24

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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25

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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26

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

27

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

28

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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29

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

32

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

33

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

34

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

1000

characters remaining

36

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_TW-48700_su.pdf Generated 2022-02-23 17:20:11

,000.00

37

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all selling and service
locations of a company and any other facilities such as warehouses, administrative offices, terminals, etc., that were in operation at any time during 2022. Permanent (or temporary)
locations with no paid employees (such as unmanned warehouses) are not considered separate establishments.
DEFINITION OF AN ENTERPRISE
An enterprise or company is a business, service, or membership organization consisting of one or more establishments within the United States under common ownership or control. It
includes all establishments of subsidiary companies, where there is more than 50 percent ownership, as well as establishments of firms which the enterprise has the power to direct or
cause the direction of management and policies.
DEFINITION OF AN ENTERPRISE SUPPORT ESTABLISHMENT
An enterprise support establishment is an establishment that is primarily engaged in performing management, supervision, general administrative functions, and supporting services
such as trucking and warehousing for other establishments of the same enterprise, rather than for the general public or other business firms.

PHYSICAL ADDRESS
Please update the location's physical address if needed.

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

4

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

5

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

6

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

7

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

8

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Warehousing and storage facilities
Cotton and linters storage

493130 001

Grain elevators, storage only

493130 002

Other farm products, except cold storage

493130 003

Refrigerated products, including fur storage

493120 002

Lessor of self-service storage or miniwarehouses

531130 001

Household goods storage

493190 101

General warehousing and storage, contract and public (except self-storage)

493110 002

Paper document warehousing and storage

493190 202

Distribution warehouse/center - Describe

493110 003

Describe
Specialized goods (except refrigerated), including bulk petroleum, chemicals, automobile dead storage, and other products requiring special
storage - Describe

493190 201

Describe
Other transportation-related activities
Physical distribution and logistics consulting services

541614 001

Freight/shipping agent or broker, except freight forwarding

488510 203

Freight forwarding service

488510 101

Motor freight terminal and joint terminal maintenance facility

488490 007

Truck rental, without drivers

532120 102

Truck leasing, without drivers, except finance leasing

532120 202

Driver leasing, without trucks

561330 003

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

9

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

%

10

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
For further clarification, click the "Additional Information" link above.

Check
if
None
What were the sales to, or receipts or revenue from, customers outside your enterprise?
(Exclude billings, sales, receipts, or revenue from establishments of your own enterprise.)

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

2022
$

,000.00

11

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

2022
$

,000.00

$

,000.00

12

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

13

Item 8: Support Services - Continued

ITEM 8: SUPPORT SERVICES - PRIMARY BUSINESS OR ACTIVITY OF THE OPERATING ESTABLISHMENTS SERVICED
What primary kind of business or activity is performed by the establishments of your enterprise that are managed or serviced by this establishment?
Example: If this establishment is a corporate, subsidiary, or regional managing office, data processing service center, or administrative/support office to a chain of clothing stores, please
describe "clothing stores" below.
Describe

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

14

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES
Report the payment of selected expenses allocated by category
Report payments for expenses directly incurred by this establishment in column 1.
Report payments made by this establishment for expenses incurred by other establishments of your enterprise in column 2 (where applicable).
Exclude:
Transfers made within the company
Capitalized expenses
Impairment
Interest
Bad debt
Income tax
Taxes collected from customers (e.g., sales and excise)
Cost of merchandise for resale
Personnel costs, except payroll

1. Employer's cost for employer paid insurance premiums,
pension plans, payroll taxes, and other employee
benefits More

Check
if
None

2022 Expenses of this
establishment ONLY
$

,000.00

$

,000.00

3. Expensed computer hardware and other equipment More

$

,000.00

4. Expensed purchases of other materials, parts, and
supplies More

$

,000.00

5. Purchased transportation More

$

,000.00

6. Expensed purchases of computer software More

$

,000.00

7. Purchased electricity More

$

,000.00

8. Purchased fuels for transportation More

$

,000.00

9. Purchased fuels (exclude motor fuels.) More

$

,000.00

2. Temporary staff and leased employee expense More
Expensed equipment and materials

Expensed purchased services

2022 Payments made by
this establishment on
behalf of other
establishments of your
enterprise

Check
if
None
10. Data processing and other purchased computer
services More

$

,000.00

$

,000.00

11. Purchased communication services More

$

,000.00

$

,000.00

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

15

12. Purchased repairs and maintenance to transportation
equipment More

$

,000.00

$

,000.00

13. Purchased repairs and maintenance to machinery and
equipment More

$

,000.00

$

,000.00

14. Purchased repairs and maintenance to buildings,
structures, and offices More

$

,000.00

$

,000.00

15. Water, sewer, refuse removal, and other utility
payments More

$

,000.00

$

,000.00

16. Purchased advertising and promotional services More

$

,000.00

$

,000.00

17. Purchased professional and technical services More

$

,000.00

$

,000.00

18. Lease and rental payments for machinery, equipment,
and other tangible items More

$

,000.00

$

,000.00

19. Lease and rental payments for land, buildings,
structures, store spaces, and offices More

$

,000.00

$

,000.00

20. Governmental taxes and license fees (Exclude sales,
excise, and income taxes.) More

$

,000.00

$

,000.00

21. Cost of insurance More

$

,000.00

22. Depreciation and amortization charges More

$

,000.00

23. All other selected expenses
(Describe - If more than 50% of TOTAL reported on line
24) More

$

,000.00

$

,000.00

Other selected expenses

Describe

24. TOTAL SELECTED EXPENSES of this establishment
ONLY, excluding payroll (Add lines 1 through 23.)

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

16

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7011900000

1. Warehousing and storage services

7011975000

2. Handling services for goods

7012000000

3. Packing services for goods

4. Freight transportation arrangement and customs brokering services

5. Operations and supply chain management consulting and implementation services

7011925000

7014650000

Add product/service not listed

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

17

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Warehousing and storage services

$

,000.00

7011900000

2. Handling services for goods

$

,000.00

7011975000

$

,000.00

7012000000

4. Freight transportation arrangement and customs brokering services

$

,000.00

7011925000

5. Operations and supply chain management consulting and implementation services

$

,000.00

7014650000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

3. Packing services for goods

Add product/service not listed

2022_TW-4930X_mu.pdf Generated 2022-02-23 17:29:53

18

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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22

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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characters remaining

27

Attachment D-9
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 51

Attachment Sector

D-9

51

Instrument
Path
Instrument Path Title

5160C
51213
51224
51314

Motion Picture and Video Production and Distribution and
Broadcasting Services (Classification)
Motion Picture and Video Exhibition
Sound Recording Studios and Other Sound Recording Industries
Directory and Mailing List Publishing

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State

99999-9999

EIN
99-9999999

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Motion picture, television, and video production, including distribution of productions by own company and distribution of productions by other companies
Producer of television shows, including commercials, infomercials, and music videos

512110 002

Producer of educational, training, corporate, religious, direct-to-home videos/DVDs, or other non-theatrical films and videos/DVDs

512110 003

Producer of motion pictures

512110 001

Producer of animated or computer animated films or videos/DVDs, including commercials and music videos

512110 004

Other film, video, or digital media productions

512110 005

Describe
Motion picture, television, and video distribution exclusively for other companies
Motion picture or television distributor - acquiring distribution rights and distributing film, video, or digital productions to theaters, television
networks and stations, and other exhibitors, including commercials, infomercials, and music videos

512120 001

Distributor of educational, training, corporate, religious, direct-to-home videos/DVDs, or other non-theatrical films and videos/DVDs

512120 002

Other film, video, or digital media distribution

512120 005

Describe
Services allied to film and video production and distribution
Author, writer, or composer

711510 004

Audio postproduction services

512240 003

Actor, actress, comedian, or other independent entertainer

711510 001

Independent film director or other motion picture artist or technician

711510 002

Postproduction services for film, video, or digital media

512191 002

Motion picture theater, excluding drive-in

512131 001

Radio broadcasting
Public radio broadcast station

515112 003

Independent radio station, except Internet only

515112 002

Radio network

515111 002

Radio network affiliated station, except Internet only

515112 001

Radio program syndication

515111 001

Television broadcasting
Television network affiliated station, except Internet only

515120 101

Television network, excluding cable programming network

515120 201

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Cable television network

515210 003

Independent television station, except Internet only

515120 102

Public access television producer

515210 002

Internet broadcasting and news syndicates
Internet broadcasting

519130 401

News syndicates

519110 002

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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characters remaining

8

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Motion picture theater, excluding drive-in

512131 001

Drive-in motion picture theater

512132 001

Film festival exhibitor

512131 002

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001575000

1. Admissions to film exhibitions

7001575003

a. Admissions to domestic films

7001575006

b. Admissions to foreign films

2. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption More

3. Retail sales of candy, prepackaged cookies, and snack foods

4. Alcoholic beverages, prepared and served or dispensed for immediate consumption

7000025000

5000200000

7000050000

7012410000

5. Other advertising space, time, and similar services More

7002325000

6. Video and other coin-operated games and rides More

7006375000

7. Rental and leasing of commercial space

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to film exhibitions

a. Admissions to domestic films

$

,000.00

7001575003

b. Admissions to foreign films

$

,000.00

7001575006

Subtotal

$

,000.00

7001575000

2. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption More

$

,000.00

7000025000

3. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

4. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

5. Other advertising space, time, and similar services More

$

,000.00

7012410000

6. Video and other coin-operated games and rides More

$

,000.00

7002325000

$

,000.00

7006375000

$

,000.00

9900000000

7. Rental and leasing of commercial space

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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27

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_IN-51213_su.pdf Generated 2022-02-24 06:42:30

29

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_IN-51213_su.pdf Generated 2022-02-24 06:42:30

32

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IN-51213_su.pdf Generated 2022-02-24 06:42:30

1000

characters remaining

33

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IN-51213_su.pdf Generated 2022-02-24 06:42:30

,000.00

34

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Sound recording industries
Sound recording studio, including independent establishments recording musical performances, but not engaged in production or distribution

512240 001

Audio postproduction services

512240 003

Music production for commercials

512240 002

Audio taping services, including meetings, conferences, etc.

512290 901

Producer of taped radio programs

512290 201

Record production - contracting with musical artists, arranging, and financing the production of original master recordings

512250 101

Stock music library

512290 902

Background recorded music provider

512290 903

Integrated record production/distribution (Primarily engaged in releasing, promoting, and distributing sound recordings, including audio tapes
and compact discs.)

512250 201

Music publishing, excluding sheet music and music books

512230 901

Other primary business or activity
Musical group or artist

711130 902

Songwriter

711510 006

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7013450000

1. Studio recording services for music clients More

a. Studio recording, excluding mixing of musical recordings More

b. Studio recording, including mixing of musical recordings More

7013450003

7013450006

7013450009

c. Mixing of musical recordings More

7013450012

d. Mastering of musical recordings More

7013450015

e. Mixing and mastering of musical recordings More

f. Remixing and remastering of musical recordings More
2. Studio recording services for spoken word clients that are primarily non-musical in nature, such as audio books and comedic
routines that are done inside a sound recording studio More

7013450018

7013475000

7013500000

3. Studio recording services for radio material More

7013500003

a. Radio spots More

7013500006

b. Radio programs More

4. Sound editing and design services for audiovisual works More

a. Original music produced under contract for audiovisual works More

7013525000

7013525003

7013525006

b. Orchestration More

7013525009

c. Foley stage More

7013525012

d. Additional dialogue recording (ADR) More

7013525015

e. Foreign language dubbing More

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

20

7013525018

f. Sound integration and synchronization More

7013525021

g. Other sound services for audiovisual works

7013550000

5. Live recording services

a. Audio recording of meetings, conferences, and seminars More

7013550003

7013550006

b. Audio recording of other events More
6. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

7006575000

7006575003

a. Rental and leasing of recording studio facilities More

b. Rental and leasing of motion picture and video production studios

c. Rental and leasing of other nonresidential space in buildings or other facilities, not elsewhere classified

7. Licensing of rights to use musical compositions protected by copyright More
8. Licensing of international rights to publish domestic musical compositions protected by copyright (i.e., international sub-publishing
rights)

9. Licensing of rights to use musical recordings protected by copyright

7006575006

7006575009

7009578000

7009579000

7009580000

7013575000

10. Support services for sound recording by others More

7013600000

11. Audio transfer services More
12. Other artistic and literary intellectual property protected by copyright produced under contract, except live performances and
audiovisual works More

7010125000

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Studio recording services for music clients More

a. Studio recording, excluding mixing of musical recordings More

$

,000.00

7013450003

b. Studio recording, including mixing of musical recordings More

$

,000.00

7013450006

c. Mixing of musical recordings More

$

,000.00

7013450009

d. Mastering of musical recordings More

$

,000.00

7013450012

e. Mixing and mastering of musical recordings More

$

,000.00

7013450015

$

,000.00

7013450018

$

,000.00

7013450000

$

,000.00

7013475000

a. Radio spots More

$

,000.00

7013500003

b. Radio programs More

$

,000.00

7013500006

$

,000.00

7013500000

$

,000.00

7013525003

b. Orchestration More

$

,000.00

7013525006

c. Foley stage More

$

,000.00

7013525009

d. Additional dialogue recording (ADR) More

$

,000.00

7013525012

f. Remixing and remastering of musical recordings More

Subtotal
2. Studio recording services for spoken word clients that are primarily non-musical in nature, such as audio books and
comedic routines that are done inside a sound recording studio More
3. Studio recording services for radio material More

Subtotal
4. Sound editing and design services for audiovisual works More

a. Original music produced under contract for audiovisual works More

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

22

$

,000.00

7013525015

f. Sound integration and synchronization More

$

,000.00

7013525018

g. Other sound services for audiovisual works

$

,000.00

7013525021

Subtotal

$

,000.00

7013525000

a. Audio recording of meetings, conferences, and seminars More

$

,000.00

7013550003

b. Audio recording of other events More

$

,000.00

7013550006

Subtotal

$

,000.00

7013550000

a. Rental and leasing of recording studio facilities More

$

,000.00

7006575003

b. Rental and leasing of motion picture and video production studios

$

,000.00

7006575006

$

,000.00

7006575009

$

,000.00

7006575000

7. Licensing of rights to use musical compositions protected by copyright More

$

,000.00

7009578000

8. Licensing of international rights to publish domestic musical compositions protected by copyright (i.e., international
sub-publishing rights)

$

,000.00

7009579000

$

,000.00

7009580000

10. Support services for sound recording by others More

$

,000.00

7013575000

11. Audio transfer services More

$

,000.00

7013600000

12. Other artistic and literary intellectual property protected by copyright produced under contract, except live
performances and audiovisual works More

$

,000.00

7010125000

$

,000.00

9900000000

e. Foreign language dubbing More

5. Live recording services

6. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service
gambling machines

c. Rental and leasing of other nonresidential space in buildings or other facilities, not elsewhere classified

Subtotal

9. Licensing of rights to use musical recordings protected by copyright

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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23

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

2022
$

,000.00

27

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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29

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

37

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IN-51224_su.pdf Generated 2022-02-24 06:44:40

,000.00

38

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Directory, database, and mailing list publishing, excluding Internet publishing
Advertising sales offices of directory and database publishing companies

511140 004

Directory and database publishers, including publishing and printing combined (Exclude publishing exclusively on the Internet.)

511140 002

Mailing list publishers, including publishing and printing combined (Exclude publishing exclusively on the Internet.)

511140 003

Other publishing and Internet publishing
Internet Directory and mailing list publishing, publishing exclusively on the Internet

519130 341

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included? Select ALL that apply.
Description

Select

Product Code

7014505000

1. Directories More

7014505003

a. Directories, online

7014505006

b. Directories, except online

7014515000

2. Databases and other collections of information More

7014515003

a. Databases and other collections of information, online

b. Databases and other collections of information, except online

7014515006

7002525000

3. Library and archive services

7012275000

4. Advertising space in printed publications

7012275003

a. Advertising space in printed general daily newspapers

b. Advertising space in printed newspapers other than general daily

7012275006

7012275009

c. Advertising space in printed specialized newspapers

d. Advertising space in printed arts, culture, leisure, and entertainment periodicals

e. Advertising space in printed home and living periodicals

f. Advertising space in printed political, social, and business news periodicals

g. Advertising space in other printed general interest periodicals

h. Advertising space in printed business (including farming), professional and academic periodicals

i. Advertising space in printed periodicals, not elsewhere classified

7012275012

7012275015

7012275018

7012275021

7012275024

7012275027

7012275031

j. Advertising space in printed telephone directories

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

20

7012275033

k. Advertising space in other printed directories

l. Advertising space in printed databases and other printed collections of information

7012275036

7012275039

m. Advertising space in books

7012350000

5. Internet advertising

7012350003

a. Advertising space in online general daily newspapers

b. Advertising space in online newspapers other than general daily

7012350006

7012350009

c. Advertising space in online specialized newspapers

d. Advertising space in online arts, culture, leisure, and entertainment periodicals

e. Advertising space in online home and living periodicals

f. Advertising space in online political, social, and business news periodicals

g. Advertising space in online general interest periodicals

h. Advertising space in online business (including farming), professional and academic periodicals

i. Advertising space in online periodicals, not elsewhere classified

7012350012

7012350015

7012350018

7012350021

7012350024

7012350027

7012350031

j. Advertising space in online directories

k. Advertising space in online databases and other online collections of information

6. Advertising space in publications on electronic and other media, except online

7012350033

7012400000

2052875000

7. Quick printing More

2052900000

8. Digital printing (excluding books) More

7012600000

9. Mailing list services
10. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings More

7009581000

Add product/service not listed

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Directories More

a. Directories, online

$

,000.00

7014505003

b. Directories, except online

$

,000.00

7014505006

Subtotal

$

,000.00

7014505000

a. Databases and other collections of information, online

$

,000.00

7014515003

b. Databases and other collections of information, except online

$

,000.00

7014515006

Subtotal

$

,000.00

7014515000

$

,000.00

7002525000

$

,000.00

7012275003

$

,000.00

7012275006

c. Advertising space in printed specialized newspapers

$

,000.00

7012275009

d. Advertising space in printed arts, culture, leisure, and entertainment periodicals

$

,000.00

7012275012

e. Advertising space in printed home and living periodicals

$

,000.00

7012275015

f. Advertising space in printed political, social, and business news periodicals

$

,000.00

7012275018

g. Advertising space in other printed general interest periodicals

$

,000.00

7012275021

h. Advertising space in printed business (including farming), professional and academic periodicals

$

,000.00

7012275024

2. Databases and other collections of information More

3. Library and archive services
4. Advertising space in printed publications

a. Advertising space in printed general daily newspapers

b. Advertising space in printed newspapers other than general daily

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

23

$

,000.00

7012275027

$

,000.00

7012275031

k. Advertising space in other printed directories

$

,000.00

7012275033

l. Advertising space in printed databases and other printed collections of information

$

,000.00

7012275036

m. Advertising space in books

$

,000.00

7012275039

Subtotal

$

,000.00

7012275000

a. Advertising space in online general daily newspapers

$

,000.00

7012350003

b. Advertising space in online newspapers other than general daily

$

,000.00

7012350006

c. Advertising space in online specialized newspapers

$

,000.00

7012350009

d. Advertising space in online arts, culture, leisure, and entertainment periodicals

$

,000.00

7012350012

e. Advertising space in online home and living periodicals

$

,000.00

7012350015

f. Advertising space in online political, social, and business news periodicals

$

,000.00

7012350018

g. Advertising space in online general interest periodicals

$

,000.00

7012350021

h. Advertising space in online business (including farming), professional and academic periodicals

$

,000.00

7012350024

$

,000.00

7012350027

j. Advertising space in online directories

$

,000.00

7012350031

k. Advertising space in online databases and other online collections of information

$

,000.00

7012350033

Subtotal

$

,000.00

7012350000

$

,000.00

7012400000

$

,000.00

2052875000

i. Advertising space in printed periodicals, not elsewhere classified

j. Advertising space in printed telephone directories

5. Internet advertising

i. Advertising space in online periodicals, not elsewhere classified

6. Advertising space in publications on electronic and other media, except online

7. Quick printing More

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

24

8. Digital printing (excluding books) More

$

,000.00

2052900000

9. Mailing list services

$

,000.00

7012600000

10. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings More

$

,000.00

7009581000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Media

ITEM 28: SPECIAL ITEMS - MEDIA
Estimate the percent of receipts from subscriptions and sales reported in Item 22 by type of dissemination media used to deliver product to client:
2022
%

1. Print

2. Internet

%

3. Other media, including CD-ROM/DVD-ROM, diskette or cassette, and
microform

%

4. TOTAL - Sum should equal 100%

%

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

2022
$

,000.00

29

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

36

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

38

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

1000

characters remaining

39

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IN-51314_su.pdf Generated 2022-02-24 06:37:02

,000.00

40

Attachment D-10
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 52

Attachment Sector

D-10

52

Instrument
Path
Instrument Path Title

52111
52230
52321
52410

Monetary Authorities - Central Bank
Financial Transactions Processing and Other Activities Related to
Credit Intermediation
Securities and Commodity Exchanges
Health and Medical Insurance Carriers

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Federal Reserve bank or branch

521110 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What was the total revenue?
For further clarification, click the "Additional Information" link above.

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Loans to financial businesses - include federal funds More

2. Trading securities and commodity contracts on own account - net gains (losses) More

Product Code

8000075000

8000150000

8000150003

a. Trading debt instruments on own account

b. Trading equities on own account, including private equity

8000150006

8000150009

c. Trading derivatives contracts on own account

8000150012

d. Trading foreign currency (wholesale) on own account

e. Trading other securities and commodity contracts on own account

8000150015

7005546000

3. Automated Clearing House (ACH) services More

4. Cash handling and management services for business More

5. Support services for financial and commodity markets More

7005542000

7005545000

7017475000

6. Regulation of credit markets
7. Other products supporting financial services, including electronic payment services and loan administration services (excluding credit
card, wire transfer, and automated clearing house (ACH) services)

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)
b. Other products supporting financial services, including loan administration services and ATM services to customers other than a
financial institution's own deposit holders More

7005547000

7005547003

7005547006

Add product/service not listed

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20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

$

,000.00

8000075000

a. Trading debt instruments on own account

$

,000.00

8000150003

b. Trading equities on own account, including private equity

$

,000.00

8000150006

c. Trading derivatives contracts on own account

$

,000.00

8000150009

$

,000.00

8000150012

e. Trading other securities and commodity contracts on own account

$

,000.00

8000150015

Subtotal

$

,000.00

8000150000

3. Automated Clearing House (ACH) services More

$

,000.00

7005546000

4. Cash handling and management services for business More

$

,000.00

7005542000

$

,000.00

7005545000

$

,000.00

7017475000

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)

$

,000.00

7005547003

b. Other products supporting financial services, including loan administration services and ATM services to
customers other than a financial institution's own deposit holders More

$

,000.00

7005547006

Subtotal

$

,000.00

7005547000

$

,000.00

9900000002

1. Loans to financial businesses - include federal funds More
2. Trading securities and commodity contracts on own account - net gains (losses) More

d. Trading foreign currency (wholesale) on own account

5. Support services for financial and commodity markets More

6. Regulation of credit markets
7. Other products supporting financial services, including electronic payment services and loan administration services
(excluding credit card, wire transfer, and automated clearing house (ACH) services)

TOTAL - Sum of lines should equal total Revenue reported in Item 5

Add product/service not listed

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

21

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

22

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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23

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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24

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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25

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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26

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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27

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

34

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_FI-52111_su.pdf Generated 2022-02-24 08:16:02

,000.00

35

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Financial transaction processing
Electronic funds transfer network

522320 201

Money transfer or wire transmission

522390 006

Electronic payment service

522320 202

Automated Teller Machine (ATM) or Automated Loan Machine (ALM) network

522320 203

Clearinghouse, bank or check

522320 204

Credit card service by business credit institutions

522320 301

Credit and/or debit card processing service

522320 902

Cryptocurrency financial payment services

522320 205

Other credit related services
Check cashing agency

522390 004

Payday loans

522390 005

Foreign currency exchange

523130 007

Mortgage broker

522310 002

Mortgage banker, mortgage company, or loan correspondent

522292 901

Mortgage and non-mortgage loan servicing

522390 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What was the total revenue?
For further clarification, click the "Additional Information" link above.

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7000300000

1. Residential mortgage loans More

7005425000

2. Unsecured loans to consumers More

7005526000

3. Credit card services More

a. Credit card services for cardholders, business and government

7005526003

7005526006

b. Credit card services for cardholders, consumer

7005526009

c. Credit card services for merchants More

7005526012

d. Credit card association products

4. Cash handling and management services for business More

7005542000

7005546000

5. Automated Clearing House (ACH) services More
6. Other products supporting financial services, including electronic payment services and loan administration services (excluding credit
card, wire transfer, and automated clearing house (ACH) services)

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)
b. Other products supporting financial services, including loan administration services and ATM services to customers other than a
financial institution's own deposit holders More

7005547000

7005547003

7005547006

Add product/service not listed

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Residential mortgage loans More

$

,000.00

7000300000

2. Unsecured loans to consumers More

$

,000.00

7005425000

a. Credit card services for cardholders, business and government

$

,000.00

7005526003

b. Credit card services for cardholders, consumer

$

,000.00

7005526006

$

,000.00

7005526009

d. Credit card association products

$

,000.00

7005526012

Subtotal

$

,000.00

7005526000

4. Cash handling and management services for business More

$

,000.00

7005542000

5. Automated Clearing House (ACH) services More

$

,000.00

7005546000

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)

$

,000.00

7005547003

b. Other products supporting financial services, including loan administration services and ATM services to
customers other than a financial institution's own deposit holders More

$

,000.00

7005547006

$

,000.00

7005547000

$

,000.00

9900000000

3. Credit card services More

c. Credit card services for merchants More

6. Other products supporting financial services, including electronic payment services and loan administration services
(excluding credit card, wire transfer, and automated clearing house (ACH) services)

Subtotal

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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21

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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22

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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23

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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24

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

2022
$

,000.00

25

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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26

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

27

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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28

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

35

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_FI-52230_su.pdf Generated 2022-02-24 08:22:35

,000.00

36

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Securities exchange

523210 001

Commodities exchange

523210 002

Securities/commodities exchange clearinghouse

523999 002

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What was the total revenue?
For further clarification, click the "Additional Information" link above.

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Support services for financial and commodity markets More

a. Payment clearing and settlement services for financial transactions, except trades of securities and commodity contracts
b. Trade execution, clearing, and settlement services for security and commodity contracts, excluding virtual
currency/cryptocurrency

c. Trading and clearing system services for security and commodity contracts, excluding virtual currency/cryptocurrency

d. Trading and clearing system services for virtual currency/cryptocurrency

Product Code

7005545000

7005545003

7005545006

7005545009

7005545011

7005545012

e. Listing services for security and commodity contracts

f. Support services for financial market and clearing products, not elsewhere classified

7005545016

7017450000

2. Regulation of securities markets
3. Other products supporting financial services, including electronic payment services and loan administration services (excluding credit
card, wire transfer, and automated clearing house (ACH) services)

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)
b. Other products supporting financial services, including loan administration services and ATM services to customers other than a
financial institution's own deposit holders More

7005547000

7005547003

7005547006

Add product/service not listed

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20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Support services for financial and commodity markets More
a. Payment clearing and settlement services for financial transactions, except trades of securities and commodity
contracts

$

,000.00

7005545003

b. Trade execution, clearing, and settlement services for security and commodity contracts, excluding virtual
currency/cryptocurrency

$

,000.00

7005545006

c. Trading and clearing system services for security and commodity contracts, excluding virtual
currency/cryptocurrency

$

,000.00

7005545009

d. Trading and clearing system services for virtual currency/cryptocurrency

$

,000.00

7005545011

$

,000.00

7005545012

f. Support services for financial market and clearing products, not elsewhere classified

$

,000.00

7005545016

Subtotal

$

,000.00

7005545000

$

,000.00

7017450000

a. Electronic payment services (excluding credit card, wire transfer, and automated clearing house (ACH) services)

$

,000.00

7005547003

b. Other products supporting financial services, including loan administration services and ATM services to
customers other than a financial institution's own deposit holders More

$

,000.00

7005547006

Subtotal

$

,000.00

7005547000

$

,000.00

9900000000

e. Listing services for security and commodity contracts

2. Regulation of securities markets
3. Other products supporting financial services, including electronic payment services and loan administration services
(excluding credit card, wire transfer, and automated clearing house (ACH) services)

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

21

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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22

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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23

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

2022
$

,000.00

24

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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25

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:55

26

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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27

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

34

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_FI-52321_su.pdf Generated 2022-02-24 08:25:56

,000.00

35

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Health insurance carrier

524114 005

Accident and disability income insurance carrier

524113 003

Dental and/or vision insurance carrier

524114 001

Health maintenance organization office - NOT providing hospital, medical, and/or dental services

524114 002

Preferred provider organization office - NOT providing hospital, medical, and/or dental services

524114 003

Dental insurance plan office - NOT providing hospital, medical, and/or dental services

524114 004

Property and casualty insurance carrier

524126 101

Life insurance carrier

524113 001

Reinsurance carrier including life, accident and health, property and casualty, surety, fidelity and liability, title or other reinsurance carrier

524130 005

Insurance agent or broker

524210 006

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_FI-52410_su.pdf Generated 2022-02-24 08:28:09

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What was the total revenue?
For further clarification, click the "Additional Information" link above.

2022_FI-52410_su.pdf Generated 2022-02-24 08:28:09

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_FI-52410_su.pdf Generated 2022-02-24 08:28:09

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Heath and accident insurance underwriting services - net premiums earned

a. Dental service plans for groups and individuals - underwriting services

b. Individual medical service plans - underwriting services

c. Supplemental Medicare insurance plans - underwriting services

d. Supplemental CHAMPUS/TRICARE insurance plans - underwriting services

e. Group managed care medical service plans - underwriting services

f. Group fee-for-service medical service plans - underwriting services

g. Accidental death and dismemberment, and disability income insurance plans - underwriting services

h. Other health and medical insurance - underwriting services

2. Life insurance underwriting services - net premiums earned

3. Reinsurance services for life and health insurance and annuities - premiums assumed

Product Code

7005000000

7005000003

7005000006

7005000009

7005000012

7005000015

7005000018

7005000021

7005000024

7004975000

7005555000

7005561000

4. Claims adjustment services More

5. Insurance support services, not elsewhere classified, including third party administration

6. Trading securities and commodity contracts on own account - net gains (losses) More

7005563000

8000150000

Add product/service not listed

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20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Heath and accident insurance underwriting services - net premiums earned

a. Dental service plans for groups and individuals - underwriting services

$

,000.00

7005000003

b. Individual medical service plans - underwriting services

$

,000.00

7005000006

c. Supplemental Medicare insurance plans - underwriting services

$

,000.00

7005000009

d. Supplemental CHAMPUS/TRICARE insurance plans - underwriting services

$

,000.00

7005000012

$

,000.00

7005000015

f. Group fee-for-service medical service plans - underwriting services

$

,000.00

7005000018

g. Accidental death and dismemberment, and disability income insurance plans - underwriting services

$

,000.00

7005000021

h. Other health and medical insurance - underwriting services

$

,000.00

7005000024

Subtotal

$

,000.00

7005000000

$

,000.00

7004975000

3. Reinsurance services for life and health insurance and annuities - premiums assumed

$

,000.00

7005555000

4. Claims adjustment services More

$

,000.00

7005561000

5. Insurance support services, not elsewhere classified, including third party administration

$

,000.00

7005563000

6. Trading securities and commodity contracts on own account - net gains (losses) More

$

,000.00

8000150000

TOTAL - Sum of lines should equal total Revenue reported in Item 5

$

,000.00

9900000002

e. Group managed care medical service plans - underwriting services

2. Life insurance underwriting services - net premiums earned

Add product/service not listed

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21

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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22

Item 28: Special Items - Administrative Expenses and Benefits Paid (Losses)

ITEM 28: SPECIAL ITEMS - ADMINISTRATIVE EXPENSES AND BENEFITS PAID (LOSSES)
What were the benefits paid to policy holders (losses) and administrative expenses from providing insurance by this establishment in 2022?
INSTRUCTIONS FOR ADMINISTRATIVE EXPENSES
Include:
Commissions paid to salespersons on premiums and annuity considerations, including commissions and expense allowances on reinsurance assumed (net of commissions
received on reinsurance ceded)
Wages, salaries, and other compensation
Insurance taxes, licenses, and fees
Increase in loading on, and cost of collection in excess of loading on, deferred and uncollected premiums
Aggregate write-ins for deductions
Investment expenses, including investment taxes, licenses, and fees, depreciation on real estate and other invested assets. Assign real estate investment expenses to line 8 (all
other activities); assign all other investment expenses according to the distribution of reserves.
Other general insurance expenses
Exclude:
Federal income taxes
Activity
Benefits Paid (Losses)

Administrative Expenses

$

,000.00

$

,000.00

2. Health and medical reinsurance

$

,000.00

$

,000.00

3. Life insurance and annuities

$

,000.00

$

,000.00

4. Life reinsurance

$

,000.00

$

,000.00

5. Accident insurance

$

,000.00

$

,000.00

6. Accident reinsurance

$

,000.00

$

,000.00

$

,000.00

1. Health insurance and hospital and medical service plans

7. Providing claims processing and other administrative services for other parties

8. All other activities (i.e., property and casualty, including reinsurance, etc.)

$

,000.00

$

,000.00

9. TOTAL (Add lines 1 through 8.)

$

,000.00

$

,000.00

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23

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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24

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_FI-52410_su.pdf Generated 2022-02-24 08:28:09

25

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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26

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

34

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

35

Attachment D-11
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 53

Attachment Sector

D-11

53

Instrument
Path
Instrument Path Title

53100
53110
53210
53300

Offices of Real Estate Agents and Brokers and Activities Related to
Real Estate
Real Estate Lessors
Automotive Equipment Rental and Leasing (Without Drivers)
Lessors of Nonfinancial Intangible Assets (except Copyrighted
Works)

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Individual rental properties in which a permanent leasing or property management office is not maintained

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Real estate agents/brokers
Agent or broker - residential real estate

531210 101

Agent or broker - nonresidential real estate

531210 901

Time share sales or resales by agent or broker

531210 102

Resort/vacation property rental and leasing by agent or broker

531210 103

Real estate property management (primarily engaged in managing property for others)
Property manager - residential real estate

531311 005

Property manager - nonresidential real estate

531312 002

Property owners' association, including home owners', condominium owners', and cooperative owners' associations (Not strictly providing
property management.)

813990 401

Resort/vacation property management

531311 003

Time share property management

531311 002

Activities related to real estate
Appraiser - real estate

531320 002

Listing service - real estate (excluding agents and brokers)

531390 001

Real estate consultant (excluding agents and brokers)

531390 004

Escrow agent - real estate

531390 003

Real estate relocation services

531390 006

Mortgage broker

522310 002

Landman, right of way leasing

531390 005

Lessors of real estate (property owned by you)
Lessor of apartment buildings with 5 or more housing units per building

531110 101

Lessor of residential space, excluding apartments with 5 or more housing units per building

531110 905

Lessor of office/professional space

531120 101

Lessor of shopping centers, retail shops

531120 303

Lessor of industrial buildings

531120 201

Other primary business or activity
Hotel management services (providing management and operating staff to run hotel)

721110 004

Vacation time share exchange services (except by offices of real estate agents)

561599 605

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779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_RE-53100_su.pdf Generated 2022-02-24 08:16:18

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Include:
Commissions and fees for managing, listing, selling, or renting property owned by others - not gross rents or gross sale price
Commissions and fees received on behalf of, and paid to, sales agents and to other brokers
Commissions and fees received from other brokers (co-brokerage fees)
Gross rents from properties owned by this establishment and leased to others
Reimbursements from property owners for miscellaneous expenditures
For further clarification, click the "Additional Information" link above.
Check
if
None

2022
$

What was the total revenue?

2022_RE-53100_su.pdf Generated 2022-02-24 08:16:18

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RE-53100_su.pdf Generated 2022-02-24 08:16:18

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Agent and brokerage services for the sale and rental of residential real estate - including real estate auction, relocation, and online
residential intermediary services More

a. Agent and brokerage services for the sale of residential real estate

b. Agent and brokerage services for the rental of residential real estate

2. Agent and brokerage services for the sale and rental of nonresidential real estate - includes real estate auction services More

a. Agent and brokerage services for the sale of nonresidential real estate

b. Agent and brokerage services for the rental of nonresidential real estate

3. Agent and brokerage services for the sale and rental of land - includes real estate auction services More

Product Code

7000250000

7000250003

7000250006

7007300000

7007300003

7007300006

7008200000

7008200003

a. Agent and brokerage services for the sale of land

7008200006

b. Agent and brokerage services for the rental of land

4. Real estate consulting services - includes real estate escrow, landman, and real estate asset management services

7008225000

7008250000

5. Real estate appraisal services

7008250003

a. Urban real estate appraisal services

7008250006

b. Rural real estate appraisal services

6. Property management services - includes payroll and repair reimbursements More

7008550000

7008550003

a. Residential building property management

7008550006

b. Nonresidential building property management

7008550009

c. Land property management

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21

7008275000

7. Real estate listing services

7012850000

8. Marketing research services

9. Home, apartment, rooming house, and other residential space rental and leasing More

10. Rental and leasing of office and professional space More

7000275000

7006325000

7006375000

11. Rental and leasing of commercial space More

12. Rental and leasing of industrial and manufacturing space More

7006400000

7003825000

13. Room or unit accommodation for travelers

14. Insurance brokerage and agency services - commissions and related fees

7005560000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Agent and brokerage services for the sale and rental of residential real estate - including real estate auction,
relocation, and online residential intermediary services More

a. Agent and brokerage services for the sale of residential real estate

$

,000.00

7000250003

b. Agent and brokerage services for the rental of residential real estate

$

,000.00

7000250006

Subtotal

$

,000.00

7000250000

a. Agent and brokerage services for the sale of nonresidential real estate

$

,000.00

7007300003

b. Agent and brokerage services for the rental of nonresidential real estate

$

,000.00

7007300006

Subtotal

$

,000.00

7007300000

a. Agent and brokerage services for the sale of land

$

,000.00

7008200003

b. Agent and brokerage services for the rental of land

$

,000.00

7008200006

Subtotal

$

,000.00

7008200000

$

,000.00

7008225000

a. Urban real estate appraisal services

$

,000.00

7008250003

b. Rural real estate appraisal services

$

,000.00

7008250006

Subtotal

$

,000.00

7008250000

2. Agent and brokerage services for the sale and rental of nonresidential real estate - includes real estate auction
services More

3. Agent and brokerage services for the sale and rental of land - includes real estate auction services More

4. Real estate consulting services - includes real estate escrow, landman, and real estate asset management services
5. Real estate appraisal services

6. Property management services - includes payroll and repair reimbursements More

2022_RE-53100_su.pdf Generated 2022-02-24 08:16:18

23

$

,000.00

7008550003

$

,000.00

7008550006

c. Land property management

$

,000.00

7008550009

Subtotal

$

,000.00

7008550000

7. Real estate listing services

$

,000.00

7008275000

8. Marketing research services

$

,000.00

7012850000

$

,000.00

7000275000

10. Rental and leasing of office and professional space More

$

,000.00

7006325000

11. Rental and leasing of commercial space More

$

,000.00

7006375000

12. Rental and leasing of industrial and manufacturing space More

$

,000.00

7006400000

13. Room or unit accommodation for travelers

$

,000.00

7003825000

14. Insurance brokerage and agency services - commissions and related fees

$

,000.00

7005560000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

a. Residential building property management

b. Nonresidential building property management

9. Home, apartment, rooming house, and other residential space rental and leasing More

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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29

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

37

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

38

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS
Exclude:
Individual rental properties in which a permanent leasing or property management office is not maintained

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Lessors of residential properties (property owned by you)
Lessor of apartment buildings with 5 or more housing units per building

531110 101

Lessor of retirement housing with 5 or more housing units per building (without nursing care)

531110 102

Lessor of apartment buildings with 2 to 4 housing units per building

531110 901

Lessor of single-family houses, including townhouses

531110 902

Lessor of manufactured and/or mobile homes, on site

531110 904

Lessor of home sites for manufactured and/or mobile homes - land only

531190 101

Real estate investment trust - equity REIT - apartment buildings with 5 or more housing units per building

531110 103

Real estate investment trust - equity REIT - manufactured (mobile) home sites

531190 103

Real estate investment trust - equity REIT - dwellings other than apartment buildings

531110 903

Operator of trailer park or recreational vehicle park, overnight or short-term site rentals

721211 002

Nursing care facility, providing nursing and rehabilitative services, including inpatient hospice facility

623110 004

Lessors of nonresidential properties (property owned by you)
Lessor of self-service storage or miniwarehouses

531130 001

Lessor of office/professional buildings

531120 102

Lessor of shopping centers, retail shops - property operation only

531120 301

Lessor of industrial buildings

531120 201

Lessor of flea market spaces - under roof

531120 903

Lessor of flea market spaces, excluding under roof

531190 901

Lessor of hotel or motel buildings - property ownership and leasing

531120 902

Lessor of piers, docks, and associated buildings and facilities

531120 901

Real estate investment trust - equity REIT - miniwarehouses and self-storage units

531130 003

Real estate investment trust - equity REIT - shopping centers and retail stores

531120 302

Real estate investment trust - equity REIT - professional and office buildings

531120 103

Real estate investment trust - equity REIT - manufacturing and industrial buildings

531120 202

Real estate investment trust - equity REIT - other nonresidential buildings and facilities

531120 904

Real estate investment trust - equity REIT - other real property

531190 902

Other real estate activities
Property manager (primarily engaged in managing property for others) - residential real estate

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

531311 001

15

Property manager (primarily engaged in managing property for others) - nonresidential real estate

531312 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Other primary business or activity
Hotel management services (providing management and operating staff to run hotel)

721110 004

Vacation time share exchange services (except by offices of real estate agents)

561599 605

Other primary business or activity

779000 001

Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Include:
Gross rents from properties owned by this establishment and leased to others
Gross sales of real property subdivided or buildings built for sale by this establishment
Commissions and fees for managing, listing, selling, or renting property owned by others - not gross rents or gross sale price
Commissions and fees received on behalf of, and paid to, sales agents and to other brokers
Commissions and fees received from other brokers (co-brokerage fees)
Net gains (losses) on sale of investment or rental property owned by this establishment
Other investment income
For further clarification, click the "Additional Information" link above.
Check
if
None

2022
$

What was the total revenue?

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Home, apartment, rooming house, and other residential space rental and leasing More

a. Rental and leasing of residential space in houses for principal residence

b. Rental and leasing of residential space in apartments for principal residence

c. Rental and leasing of other residential space for principal use

Product Code

7000275000

7000275006

7000275009

7000275012

7000275003

d. Rental and leasing of land for residential use

7006300000

2. Rental and leasing of land for nonresidential use More

3. Rental and leasing of office and professional space More

7006325000

7006375000

4. Rental and leasing of commercial space More

7006375003

a. Rental and leasing of retail space in shopping malls

b. Rental and leasing of food service space in shopping malls

c. Rental and leasing of retail space in free-standing locations

d. Rental and leasing of food service space in free-standing locations

e. Rental and leasing of booths and chairs in beauty and personal care establishments

7006375006

7006375009

7006375012

7006375015

7006375018

f. Rental and leasing of other commercial space

5. Rental and leasing of industrial and manufacturing space More

7006400000

7006400003

a. Rental and leasing of space in industrial parks

b. Rental and leasing of industrial space, except in industrial parks

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

7006400006

21

6. Rental of space for meetings, conventions, and similar short-term business uses More

7. Rental of mini-warehouses and self-storage units space More

8. Rental of space for weddings, banquets, parties, and similar short-term social uses More

9. Rental of space for sporting, entertainment, and other events More
10. Rental and leasing of nonresidential space in buildings or other facilities, not elsewhere specified, excluding hosting of coinoperated self-service gambling machines More

11. Property management services - includes payroll and repair reimbursements More

7006425000

7006450000

7006475000

7006500000

7006575000

7008550000

7008550003

a. Residential building property management

7008550006

b. Nonresidential building property management

7008550009

c. Land property management

7003825000

12. Room or unit accommodation for travelers

a. Room or unit accommodation for travelers, with maid service

b. Room or unit accommodation for travelers, without maid service

7003825003

7003825006

7003825009

c. Shared-room accommodation for travelers

13. Trading securities and commodity contracts on own account - includes interest income and other investment income - net

8000150000

8000175000

14. Gains (losses) from non-financial assets sold More

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Home, apartment, rooming house, and other residential space rental and leasing More

a. Rental and leasing of residential space in houses for principal residence

$

,000.00

7000275006

b. Rental and leasing of residential space in apartments for principal residence

$

,000.00

7000275009

c. Rental and leasing of other residential space for principal use

$

,000.00

7000275012

d. Rental and leasing of land for residential use

$

,000.00

7000275003

Subtotal

$

,000.00

7000275000

$

,000.00

7006300000

$

,000.00

7006325000

$

,000.00

7006375003

b. Rental and leasing of food service space in shopping malls

$

,000.00

7006375006

c. Rental and leasing of retail space in free-standing locations

$

,000.00

7006375009

d. Rental and leasing of food service space in free-standing locations

$

,000.00

7006375012

e. Rental and leasing of booths and chairs in beauty and personal care establishments

$

,000.00

7006375015

f. Rental and leasing of other commercial space

$

,000.00

7006375018

Subtotal

$

,000.00

7006375000

$

,000.00

7006400003

2. Rental and leasing of land for nonresidential use More

3. Rental and leasing of office and professional space More
4. Rental and leasing of commercial space More

a. Rental and leasing of retail space in shopping malls

5. Rental and leasing of industrial and manufacturing space More

a. Rental and leasing of space in industrial parks

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23

$

,000.00

7006400006

$

,000.00

7006400000

6. Rental of space for meetings, conventions, and similar short-term business uses More

$

,000.00

7006425000

7. Rental of mini-warehouses and self-storage units space More

$

,000.00

7006450000

8. Rental of space for weddings, banquets, parties, and similar short-term social uses More

$

,000.00

7006475000

9. Rental of space for sporting, entertainment, and other events More

$

,000.00

7006500000

10. Rental and leasing of nonresidential space in buildings or other facilities, not elsewhere specified, excluding hosting
of coin-operated self-service gambling machines More

$

,000.00

7006575000

a. Residential building property management

$

,000.00

7008550003

b. Nonresidential building property management

$

,000.00

7008550006

c. Land property management

$

,000.00

7008550009

Subtotal

$

,000.00

7008550000

a. Room or unit accommodation for travelers, with maid service

$

,000.00

7003825003

b. Room or unit accommodation for travelers, without maid service

$

,000.00

7003825006

c. Shared-room accommodation for travelers

$

,000.00

7003825009

Subtotal

$

,000.00

7003825000

13. Trading securities and commodity contracts on own account - includes interest income and other investment income
- net

$

,000.00

8000150000

14. Gains (losses) from non-financial assets sold More

$

,000.00

8000175000

TOTAL - Sum of lines should equal total Revenue reported in Item 5

$

,000.00

9900000002

b. Rental and leasing of industrial space, except in industrial parks

Subtotal

11. Property management services - includes payroll and repair reimbursements More

12. Room or unit accommodation for travelers

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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29

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

37

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RE-53110_su.pdf Generated 2022-02-24 08:17:30

,000.00

38

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

If more than one establishment:
Separate automotive rental offices or concessions (for example, airport locations) in the same metropolitan area, for which a common fleet is maintained, should not be considered
separate locations for the purpose of this report. Data for offices that share a common fleet should be included with the controlling main or branch location for that metropolitan area.

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Passenger car rental and leasing
Renting passenger cars, passenger vans, and sport utility vehicles without drivers on a short-term basis

532111 001

Leasing passenger cars, passenger vans, and sport utility vehicles without drivers

532112 001

Third party financing of passenger car, passenger van, and sport utility vehicle leases

522220 903

Truck rental and leasing
Renting trucks, including nonpassenger vans, buses, truck tractors, truck trailers, semitrailers, and storage semitrailers without drivers on a
short-term basis

532120 101

Leasing trucks, including nonpassenger vans, buses, truck tractors, truck trailers, semitrailers, and storage semitrailers without drivers

532120 201

Renting or leasing trucks with drivers (truckload) - local

484110 502

Renting or leasing trucks with drivers (truckload) - excluding local

484121 002

Third party financing of trucks, including nonpassenger van, truck tractor, truck trailer, semitrailer, and storage semitrailer leases

522220 904

Other automotive rental and leasing
Renting and/or leasing utility trailers

532120 901

Renting motor homes, travel trailers, and RV's

532120 902

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Include:
Revenue derived from rentals and operating leases
If you hold the leases, interest from capital, finance, and full-payout leases
If you do not hold the leases, the fair sales value of merchandise marketed by your firm under capital, finance, or full-payout leases
Exclude:
Revenue from sales of used equipment previously rented or leased to customers
For further clarification, click the "Additional Information" link above.
Check
if
None

2022
$

What was the total revenue?

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,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RE-53210_su.pdf Generated 2022-02-24 08:15:10

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total revenue (reported in Item 5) by class of customer?
2022
%

1. Individuals

2. Federal, state, and local governments

%

3. Businesses and all other

%

%

4. TOTAL - Sum should equal 100%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7003800000

1. Rental of automobiles and light-duty trucks

a. Rental of automobiles and light-duty trucks, nonelectric

b. Rental of automobiles and light-duty trucks, electric and hybrid

7003800003

7003800006

7005528000

2. Automobile and light-duty truck leasing services

a. Automobile and light-duty truck leasing services, nonelectric

b. Automobile and light-duty truck leasing services, electric and hybrid

3. Rental and leasing, excluding financial, of heavy trucks, truck trailers, and buses More

a. Rental, excluding leasing, of heavy trucks, truck trailers, and buses

b. Leasing, excluding financial, of heavy trucks, truck trailers, and buses

4. Rental and leasing services, excluding financial, for motor homes, travel trailers, campers, and utility trailers More

5. Finance leasing services, except automobile and light-duty truck leasing services

6. Protection plans, damage waivers, warranty programs, and liability insurance - Insurance brokerage and agency services

7. Maintenance and repair services for automobiles and light-duty trucks

8. Maintenance and repair and related services for motor homes, travel trailers, and campers

9. Maintenance and repair services for heavy trucks and buses

7005528003

7005528006

7009275000

7009275003

7009275006

7002875000

7005529000

7005560000

7002625000

7002900000

7009375000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Rental of automobiles and light-duty trucks

a. Rental of automobiles and light-duty trucks, nonelectric

$

,000.00

7003800003

b. Rental of automobiles and light-duty trucks, electric and hybrid

$

,000.00

7003800006

Subtotal

$

,000.00

7003800000

a. Automobile and light-duty truck leasing services, nonelectric

$

,000.00

7005528003

b. Automobile and light-duty truck leasing services, electric and hybrid

$

,000.00

7005528006

Subtotal

$

,000.00

7005528000

$

,000.00

7009275003

$

,000.00

7009275006

$

,000.00

7009275000

4. Rental and leasing services, excluding financial, for motor homes, travel trailers, campers, and utility trailers More

$

,000.00

7002875000

5. Finance leasing services, except automobile and light-duty truck leasing services

$

,000.00

7005529000

6. Protection plans, damage waivers, warranty programs, and liability insurance - Insurance brokerage and agency
services

$

,000.00

7005560000

7. Maintenance and repair services for automobiles and light-duty trucks

$

,000.00

7002625000

8. Maintenance and repair and related services for motor homes, travel trailers, and campers

$

,000.00

7002900000

9. Maintenance and repair services for heavy trucks and buses

$

,000.00

7009375000

2. Automobile and light-duty truck leasing services

3. Rental and leasing, excluding financial, of heavy trucks, truck trailers, and buses More

a. Rental, excluding leasing, of heavy trucks, truck trailers, and buses

b. Leasing, excluding financial, of heavy trucks, truck trailers, and buses

Subtotal

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TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

36

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RE-53210_su.pdf Generated 2022-02-24 08:15:10

,000.00

37

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Franchise leasing/licensing, without primarily selling products to the franchisee

533110 901

Patent leasing/licensing of products designed or invented by other companies

533110 902

Trademark leasing/licensing of products designed or invented by other companies

533110 903

Music publishing, excluding sheet music and music books

512230 901

Other copyright leasing/licensing - Describe type of works copyrighted

777530 005

Describe
Patent leasing/licensing of products designed or invented by this company - Describe products

777530 003

Describe
Oil royalty company

533110 101

Other primary business or activity

779000 001

Select Sector

Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What was the total revenue?
For further clarification, click the "Additional Information" link above.

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Licensing of rights to use intellectual property protected by patent

2. Licensing of rights to use intellectual property protected by trademark

3. Licensing of rights to use intellectual property protected as industrial property, not elsewhere classified

4. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright
5. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings

6. Leasing of rights to explore for and exploit natural resources

7. Leasing of other rights related to intellectual property, not elsewhere classified

Product Code

7009600000

7009625000

7009650000

7009576000

7009581000

7010200000

7010250000

7010260000

8. Franchising agreements

9. Trading securities and commodity contracts on own account - includes interest income and other investment income - net

8000150000

Add product/service not listed

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20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Licensing of rights to use intellectual property protected by patent

$

,000.00

7009600000

2. Licensing of rights to use intellectual property protected by trademark

$

,000.00

7009625000

3. Licensing of rights to use intellectual property protected as industrial property, not elsewhere classified

$

,000.00

7009650000

4. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright

$

,000.00

7009576000

5. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings

$

,000.00

7009581000

6. Leasing of rights to explore for and exploit natural resources

$

,000.00

7010200000

7. Leasing of other rights related to intellectual property, not elsewhere classified

$

,000.00

7010250000

8. Franchising agreements

$

,000.00

7010260000

9. Trading securities and commodity contracts on own account - includes interest income and other investment income net

$

,000.00

8000150000

TOTAL - Sum of lines should equal total Revenue reported in Item 5

$

,000.00

9900000002

Add product/service not listed

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

21

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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22

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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23

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

2022
$

,000.00

24

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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25

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

26

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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27

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

28

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

29

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

30

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

31

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

1000

characters remaining

34

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RE-53300_su.pdf Generated 2022-02-24 08:21:23

,000.00

35

Attachment D-12
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 54

Attachment Sector

Instrument
Path
Instrument Path Title

D-12

5403X

54

54140
5415C
54162

Architectural and Landscape Architectural Services (Enterprise
Support)
Specialized Design Services
Computer Systems Design and Related Services and Management,
Scientific, and Technical Consulting Services (Classification)
Environmental Consulting and Other Scientific and Technical
Consulting Services

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all locations of a company or
organization, including administrative offices, warehouses, etc., that were in operation at any time during 2022. Report activity for each establishment on a separate form.
DEFINITION OF AN ENTERPRISE
An enterprise or company is a business, service, or membership organization consisting of one or more establishments within the United States under common ownership or control. It
includes all establishments of subsidiary companies, where there is more than 50 percent ownership, as well as establishments of firms which the enterprise has the power to direct or
cause the direction of management and policies.
DEFINITION OF AN ENTERPRISE SUPPORT ESTABLISHMENT
An enterprise support establishment is an establishment that is primarily engaged in performing management, supervision, general administrative functions, and supporting services for
other establishments of the same enterprise, rather than for the general public or other business firms.

PHYSICAL ADDRESS
Please update the location's physical address if needed.

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

4

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

5

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

6

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

7

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

8

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Architectural and engineering services
Architectural services, excluding landscape architectural services

541310 003

Landscape architectural services, excluding landscaping and landscape construction

541320 005

Engineering services, including construction engineering services

541330 00B

Design services
Interior design services

541410 001

Graphic design services

541430 001

Administrative services
Corporate, subsidiary, or regional managing office engaged in management of, or providing more than one centralized administrative support
functions to, other establishments of the company (Offices engaged in only one type of specific activity should select another kind of
business or activity.)

551114 001

Other primary business or activity
Urban/city/regional planning and design services

541320 00A

Landscape maintenance and installation services

561730 003

Drafting services, including CAD (Computer Aided Design) drafting and steel detailing

541340 006

Other primary business or activity

779000 001

Select Sector

Describe

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

9

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

%

10

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Sales, Receipts, or Revenue
Include:
Sales, receipts, or revenue from customers outside your enterprise originating from this location.
Exclude:
Sales, receipts, or revenue from other establishments within your own enterprise.
For further clarification, click "Additional Information" link above.
Check
if
None
What were the sales, receipts, or revenue (exclude billings) from customers outside your enterprise originating from
this location?

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

2022
$

,000.00

11

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

12

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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13

Item 8: Support Services - Continued

ITEM 8: SUPPORT SERVICES - PRIMARY BUSINESS OR ACTIVITY OF THE OPERATING ESTABLISHMENTS SERVICED
What primary kind of business or activity is performed by the establishments of your enterprise that are managed or serviced by this establishment?
Example: If this establishment is a corporate, subsidiary, or regional managing office, data processing service center, or administrative/support office to a chain of clothing stores, please
describe "clothing stores" below.
Describe

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

14

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES
Report the payment of selected expenses allocated by category
Report payments for expenses directly incurred by this establishment in column 1.
Report payments made by this establishment for expenses incurred by other establishments of your enterprise in column 2 (where applicable).
Exclude:
Transfers made within the company
Capitalized expenses
Impairment
Interest
Bad debt
Income tax
Taxes collected from customers (e.g., sales and excise)
Cost of merchandise for resale
Personnel costs, except payroll

1. Employer's cost for employer paid insurance premiums,
pension plans, payroll taxes, and other employee
benefits More

Check
if
None

2022 Expenses of this
establishment ONLY
$

,000.00

$

,000.00

3. Expensed computer hardware and other equipment More

$

,000.00

4. Expensed purchases of other materials, parts, and
supplies More

$

,000.00

5. Expensed purchases of software More

$

,000.00

6. Purchased electricity More

$

,000.00

7. Purchased fuels (Exclude motor fuels.) More

$

,000.00

2. Temporary staff and leased employee expense More
Expensed equipment and materials

Expensed purchased services

2022 Payments made by
this establishment on
behalf of other
establishments of your
enterprise

Check
if
None
8. Data processing and other purchased computer
services More

$

,000.00

$

,000.00

9. Purchased communication services More

$

,000.00

$

,000.00

10. Purchased repairs and maintenance to machinery,
vehicles, and equipment More

$

,000.00

$

,000.00

11. Purchased repairs and maintenance to buildings,
structures, and offices More

$

,000.00

$

,000.00

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

15

12. Water, sewer, refuse removal, and other utility
payments More

$

,000.00

$

,000.00

13. Purchased advertising and promotional services More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

15. Lease and rental payments for machinery, equipment,
and other tangible items More

$

,000.00

$

,000.00

16. Lease and rental payments for land, buildings,
structures, store spaces, and offices More

$

,000.00

$

,000.00

17. Governmental taxes and license fees (Exclude sales,
excise, and income taxes.) More

$

,000.00

$

,000.00

18. Depreciation and amortization charges More

$

,000.00

19. All other selected expenses
(Describe - If more than 50% of TOTAL reported on line
20.) More

$

,000.00

$

,000.00

14. Purchased professional and technical services More
Other selected expenses

Describe

20. TOTAL SELECTED EXPENSES of this establishment
ONLY, excluding payroll (Add lines 1 through 19.)

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16

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the estimated percentage of receipts (reported in Item 5) from services provided to clients outside your enterprise by class of customer?
2022
%

1. Federal government

%

2. State and local governments, including public authorities

3. Construction firms

%

4. Architectural firms

%

5. Engineering firms

%

6. All other business firms and organizations
(Manufacturing, utilities, mining, shopping centers, office buildings, etc.)

%

7. Not-for-profit organizations
(Include religious organizations.)

%

8. Household consumers and individuals
(Report fees from individually owned businesses on lines 3, 4, 5, or 6 as appropriate.)

%

9. TOTAL (Sum of lines 1 through 8 should equal 100%.)

%

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17

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Architectural services for apartment building and other nonresidential building projects More

2. Architectural services for residential building projects, excluding apartment building projects More

3. Architectural services for historical restoration projects More

Product Code

7006775000

7000625000

7006800000

7007525000

4. Architectural consulting services More

5. Landscape architectural services for residential building projects, excluding apartment building projects More

6. Landscape architectural services for nonresidential building projects, including apartment building projects More

7. Landscape architectural services for recreational and open space projects More

8. Landscape architectural services, specific elements More

7000650000

7006825000

7006850000

7007550000

7007575000

9. Landscape architectural consulting services More

7006925000

10. Development of comprehensive urban plans More

7006950000

11. Development of community urban plans More

7006975000

12. Development of urban plan elements

7007000000

13. Urban planning consulting services More

7007600000

14. Project site master planning services More

15. Construction project management services, excluding at-risk More

16. Project management services, except construction More

3004800000

7014925000

7000645000

17. Residential landscaping services More

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18

7006750000

18. Exterior commercial landscaping services More

7008000000

19. Full-service interior design services More

7008025000

20. Interior design services, excluding full-service More

21. Engineering services for residential building projects, excluding apartment building projects More

22. Engineering services for commercial, public and institutional building projects, including apartment building projects More

7000640000

7007025000

Add product/service not listed

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Architectural services for apartment building and other nonresidential building projects More

$

,000.00

7006775000

2. Architectural services for residential building projects, excluding apartment building projects More

$

,000.00

7000625000

3. Architectural services for historical restoration projects More

$

,000.00

7006800000

4. Architectural consulting services More

$

,000.00

7007525000

$

,000.00

7000650000

6. Landscape architectural services for nonresidential building projects, including apartment building projects More

$

,000.00

7006825000

7. Landscape architectural services for recreational and open space projects More

$

,000.00

7006850000

8. Landscape architectural services, specific elements More

$

,000.00

7007550000

9. Landscape architectural consulting services More

$

,000.00

7007575000

10. Development of comprehensive urban plans More

$

,000.00

7006925000

$

,000.00

7006950000

12. Development of urban plan elements

$

,000.00

7006975000

13. Urban planning consulting services More

$

,000.00

7007000000

14. Project site master planning services More

$

,000.00

7007600000

15. Construction project management services, excluding at-risk More

$

,000.00

3004800000

16. Project management services, except construction More

$

,000.00

7014925000

17. Residential landscaping services More

$

,000.00

7000645000

18. Exterior commercial landscaping services More

$

,000.00

7006750000

5. Landscape architectural services for residential building projects, excluding apartment building projects More

11. Development of community urban plans More

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

20

19. Full-service interior design services More

$

,000.00

7008000000

20. Interior design services, excluding full-service More

$

,000.00

7008025000

21. Engineering services for residential building projects, excluding apartment building projects More

$

,000.00

7000640000

22. Engineering services for commercial, public and institutional building projects, including apartment building
projects More

$

,000.00

7007025000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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21

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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22

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

2022
$

,000.00

23

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

24

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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25

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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26

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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27

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

29

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_PS-5403X_mu.pdf Generated 2022-02-24 06:25:40

31

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

32

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Design services
Graphic design services

541430 001

Communication design services

541430 005

Interior design services - planning, designing, and administering projects in interior spaces to meet the physical and aesthetic needs of
people using the spaces

541410 002

Interior decorating consultant - advising on interior decorating

541410 003

Advertising agency - creating advertising campaigns and placing advertising with media

541810 001

Industrial design services - developing designs that optimize the use, value, and appearance of products

541420 001

Engineering design services - applying principles of engineering in the design and development of machines and products

541330 00C

Fashion design services

541490 001

Commercial art services

541430 002

Display advertising

541850 004

Architectural services, excluding landscape

541310 001

Furniture store, except custom

442110 501

Other primary business or activity
Commercial photography services

541922 001

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

2022
$

,000.00

$

,000.00

19

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating receipts (reported in Item 5) by class of customer?
2022
%

1. Business firms and farms

2. Not-for-profit organizations (Include religious organizations.)

%

%

3. Federal government

4. State and local governments

%

5. Household consumers and individuals (Report receipts from individually owned businesses on line 1.)

%

6. TOTAL (Sum of lines 1 through 5 should equal 100%.)

%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7008000000

1. Full-service interior design services More

a. Full-service interior design services for residential buildings, except historical restoration

b. Full-service interior design services for nonresidential buildings, except historical restoration

c. Full-service interior design services for restoration of historic buildings

7008000003

7008000006

7008000009

7008025000

2. Interior design services, except full-service More

7000630000

3. Interior decorating services More

7012050000

4. Industrial design services More

7012050003

a. Industrial design services for products

7012050006

b. Model design and fabrication services More

c. Consulting services for industrial design and other industrial design services
5. Developing and making prototypes of other goods (excluding aircraft, aircraft engines and parts, guided missiles, space vehicles,
space vehicle engines, propulsion units, and missile and space vehicle parts and components)

6. Graphic design services, except advertising graphic design

7012050009

2019365000

7012075000

7012075003

a. Graphic design services for corporate identity More

7012075009

b. Graphic design services for publications

7012075012

c. Graphic design services for commercial illustrations

d. Graphic interface and interaction design services More

7012075015

7012075018

e. Graphic design services, not elsewhere classified

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

22

7012028000

7. Integrated website design and development services

8. Advertising creative services, including advertising and promotional graphic design services

7012475000

7014500000

9. Information and document transformation services

7014500003

a. Imaging and other data capture services

b. Data plotting, printing, conversion, and migration services

10. Other printing and related contract manufacturing services, performed using materials owned by others (i.e., the customer)

11. Clothing and other specialized design services, not elsewhere classified

7014500006

2053415000

7012100000

7012100003

a. Clothing design services

b. Other specialized design services, not elsewhere classified

7012100006

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Full-service interior design services More

a. Full-service interior design services for residential buildings, except historical restoration

$

,000.00

7008000003

b. Full-service interior design services for nonresidential buildings, except historical restoration

$

,000.00

7008000006

c. Full-service interior design services for restoration of historic buildings

$

,000.00

7008000009

Subtotal

$

,000.00

7008000000

2. Interior design services, except full-service More

$

,000.00

7008025000

3. Interior decorating services More

$

,000.00

7000630000

a. Industrial design services for products

$

,000.00

7012050003

b. Model design and fabrication services More

$

,000.00

7012050006

$

,000.00

7012050009

$

,000.00

7012050000

$

,000.00

2019365000

a. Graphic design services for corporate identity More

$

,000.00

7012075003

b. Graphic design services for publications

$

,000.00

7012075009

c. Graphic design services for commercial illustrations

$

,000.00

7012075012

d. Graphic interface and interaction design services More

$

,000.00

7012075015

4. Industrial design services More

c. Consulting services for industrial design and other industrial design services

Subtotal
5. Developing and making prototypes of other goods (excluding aircraft, aircraft engines and parts, guided missiles,
space vehicles, space vehicle engines, propulsion units, and missile and space vehicle parts and components)
6. Graphic design services, except advertising graphic design

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

24

e. Graphic design services, not elsewhere classified

$

,000.00

7012075018

Subtotal

$

,000.00

7012075000

$

,000.00

7012028000

$

,000.00

7012475000

a. Imaging and other data capture services

$

,000.00

7014500003

b. Data plotting, printing, conversion, and migration services

$

,000.00

7014500006

Subtotal

$

,000.00

7014500000

$

,000.00

2053415000

$

,000.00

7012100003

b. Other specialized design services, not elsewhere classified

$

,000.00

7012100006

Subtotal

$

,000.00

7012100000

$

,000.00

9900000000

7. Integrated website design and development services

8. Advertising creative services, including advertising and promotional graphic design services
9. Information and document transformation services

10. Other printing and related contract manufacturing services, performed using materials owned by others (i.e., the
customer)
11. Clothing and other specialized design services, not elsewhere classified

a. Clothing design services

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_PS-54140_su.pdf Generated 2022-02-24 06:59:49

2022
$

,000.00

29

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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characters remaining

39

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

40

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Management and consulting services
Administrative and general management consulting services, including strategic planning and organizational change

541611 002

Marketing consulting services, including sales management, customer service, and marketing planning/strategy

541613 001

Management and administrative services - providing day-to-day administrative services such as personnel management, bookkeeping,
billing, etc., for a client's business or operation (Exclude administrative activities provided for own company.)

561110 001

Environmental consulting services, excluding engineering

541620 005

Human resources and personnel management consulting services

541612 301

Financial management consulting services, excluding investment advice

541611 003

Manufacturing operations management consulting services

541614 004

Physical distribution and logistics consulting services

541614 001

Actuarial consulting services

541612 101

Employee benefit consulting services

541612 302

Transportation management consulting services

541614 006

Outplacement consulting services

561312 002

Agricultural consulting services

541690 902

Other management consulting services

541618 001

Computer services
Data processing service center - providing data entry, image processing, database management, record conversion, and other computer
processing services from central processing centers and cloud services

518210 009

Data storage services, including remote backup and storage of computer data

518210 002

Cloud computing and cloud storage

518210 00B

Custom computer programming services - writing, modifying, testing, and supporting software to meet the needs of a particular customer,
including web design and network software

541511 001

Custom software development services

541511 002

Computer systems integrator services - analyzing a client's computer needs and bundling software and hardware to deliver an integrated
system to meet those specialized needs

541512 101

Computer systems design services, excluding software development

541512 203

Computer systems facilities support services - on-site management and operation of a client's computer systems

541513 003

Computer-related consulting, including domain registration and software/hardware installation services (exclude computer systems
consulting or design services)

541519 001

Software publishers, including developing and publishing or publishing only, packaged software, including cloud-based

511210 001

Computer software/hardware consulting services

541512 206

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Other primary business or activity
Executive search services

561312 001

Engineering services, including construction engineering services

541330 00B

Certified public accountant (CPA)

541211 001

Accountant, excluding CPA

541219 001

Other primary business or activity

779000 001

Select Sector

Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

8

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Scientific and technical consulting services
Environmental consulting services, excluding engineering

541620 005

Consulting engineering services, including environmental engineering

541330 00D

Safety or security consulting services

541690 901

Scientific consulting services, such as geological, chemical, and biological (except economic, meteorological, environmental, and
engineering consulting services)

541690 905

Computer systems design services

541512 205

Economic consulting services

541690 101

Pharmaceutical or clinical consulting services

541690 906

Energy management consulting services

541690 904

Educational consulting services, excluding management consulting

611710 104

Industrial design consulting services

541420 002

Other primary business or activity
Management consulting services

541611 004

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

2022
$

,000.00

$

,000.00

19

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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20

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating receipts (reported in Item 5) by class of customer?
2022
%

1. Business firms and farms

2. Not-for-profit organizations (Include religious organizations.)

%

%

3. Federal government

4. State and local governments

%

5. Household consumers and individuals (Report receipts from individually owned businesses on line 1.)

%

6. TOTAL (Sum of lines 1 through 5 should equal 100%.)

%

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

6000800000

1. Environmental assessment services More

6000800003

a. Environmental assessment services, integrated More

6000800006

b. Environmental assessment services, air

6000800009

c. Environmental assessment services, water

6000800012

d. Environmental assessment services, soil

6000800015

e. Environmental assessment services, noise

6000850000

2. Site remediation planning services More

6000850003

a. Site remediation planning services, integrated More

6000850006

b. Site remediation planning services, air

6000850009

c. Site remediation planning services, water

6000850012

d. Site remediation planning services, soil

6000850015

e. Site remediation planning services, noise

6000825000

3. Environmental audit services More

6000825003

a. Environmental audit services, integrated More

6000825006

b. Environmental audit services, air

6000825009

c. Environmental audit services, water

6000825012

d. Environmental audit services, soil

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

22

6000825015

e. Environmental audit services, noise

6000875000

4. Evaluation of environmental studies

6000900000

5. Natural resource management consulting services More

6000925000

6. Waste management consulting services

6000925003

a. Hazardous waste management consulting services

b. Non-hazardous waste management consulting services

6000925006

6000950000

7. Environmental policy development consulting services

8. Environmental consulting services, except environmental litigation support

6000980000

6001000000

9. Environmental licensing and permitting services

7012265000

10. Economic consulting services

11. Information technology (IT) technical consulting services

12. Scientific and technical consulting services, not elsewhere classified

a. Agricultural, fisheries, and biological consulting services

7014225000

7012270000

7012270003

7012270006

b. Occupational health and safety consulting services

7012270009

c. Public safety and security consulting services

7012270012

d. Energy, mining, and geological consulting services

7012270015

e. Geophysical consulting services

7012270018

f. Consulting services for research and development

g. Other scientific and technical consulting services, not elsewhere classified

13. Strategic management consulting and implementation services

14. Marketing management consulting and implementation services

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

7012270021

7014550000

7014600000

23

15. Human resources management consulting and implementation services

16. Operations and supply chain management consulting and implementation services

17. Construction project management services, excluding at-risk

7014625000

7014650000

3004800000

7014675000

18. Other facility support services

Add product/service not listed

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24

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Environmental assessment services More

a. Environmental assessment services, integrated More

$

,000.00

6000800003

b. Environmental assessment services, air

$

,000.00

6000800006

c. Environmental assessment services, water

$

,000.00

6000800009

d. Environmental assessment services, soil

$

,000.00

6000800012

e. Environmental assessment services, noise

$

,000.00

6000800015

Subtotal

$

,000.00

6000800000

a. Site remediation planning services, integrated More

$

,000.00

6000850003

b. Site remediation planning services, air

$

,000.00

6000850006

c. Site remediation planning services, water

$

,000.00

6000850009

$

,000.00

6000850012

e. Site remediation planning services, noise

$

,000.00

6000850015

Subtotal

$

,000.00

6000850000

a. Environmental audit services, integrated More

$

,000.00

6000825003

b. Environmental audit services, air

$

,000.00

6000825006

c. Environmental audit services, water

$

,000.00

6000825009

2. Site remediation planning services More

d. Site remediation planning services, soil

3. Environmental audit services More

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

25

d. Environmental audit services, soil

$

,000.00

6000825012

e. Environmental audit services, noise

$

,000.00

6000825015

Subtotal

$

,000.00

6000825000

$

,000.00

6000875000

$

,000.00

6000900000

a. Hazardous waste management consulting services

$

,000.00

6000925003

b. Non-hazardous waste management consulting services

$

,000.00

6000925006

Subtotal

$

,000.00

6000925000

7. Environmental policy development consulting services

$

,000.00

6000950000

8. Environmental consulting services, except environmental litigation support

$

,000.00

6000980000

9. Environmental licensing and permitting services

$

,000.00

6001000000

10. Economic consulting services

$

,000.00

7012265000

11. Information technology (IT) technical consulting services

$

,000.00

7014225000

a. Agricultural, fisheries, and biological consulting services

$

,000.00

7012270003

b. Occupational health and safety consulting services

$

,000.00

7012270006

c. Public safety and security consulting services

$

,000.00

7012270009

d. Energy, mining, and geological consulting services

$

,000.00

7012270012

$

,000.00

7012270015

$

,000.00

7012270018

4. Evaluation of environmental studies

5. Natural resource management consulting services More
6. Waste management consulting services

12. Scientific and technical consulting services, not elsewhere classified

e. Geophysical consulting services

f. Consulting services for research and development

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26

g. Other scientific and technical consulting services, not elsewhere classified

$

,000.00

7012270021

Subtotal

$

,000.00

7012270000

13. Strategic management consulting and implementation services

$

,000.00

7014550000

14. Marketing management consulting and implementation services

$

,000.00

7014600000

$

,000.00

7014625000

16. Operations and supply chain management consulting and implementation services

$

,000.00

7014650000

17. Construction project management services, excluding at-risk

$

,000.00

3004800000

18. Other facility support services

$

,000.00

7014675000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

15. Human resources management consulting and implementation services

Add product/service not listed

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27

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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28

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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29

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

2022
$

,000.00

30

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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31

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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32

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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33

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

1000

characters remaining

40

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_PS-54162_su.pdf Generated 2022-02-24 06:55:24

,000.00

41

Attachment D-13
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 55

Attachment Sector

Instrument
Path
Instrument Path Title

D-13

5511X

55

55111

Corporate, Subsidiary, and Regional Managing Offices (Enterprise
Support)
Holding Companies

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all locations of a company or
organization, including administrative offices, warehouses, etc., that were in operation at any time during 2022. Report activity for each establishment on a separate form.
DEFINITION OF AN ENTERPRISE
An enterprise or company is a business, service, or membership organization consisting of one or more establishments within the United States under common ownership or control. It
includes all establishments of subsidiary companies, where there is more than 50 percent ownership, as well as establishments of firms which the enterprise has the power to direct or
cause the direction of management and policies.
DEFINITION OF AN ENTERPRISE SUPPORT ESTABLISHMENT
An enterprise support establishment is an establishment that is primarily engaged in performing management, supervision, general administrative functions, and supporting services for
other establishments of the same enterprise, rather than for the general public or other business firms.

PHYSICAL ADDRESS
Please update the location's physical address if needed.

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

5

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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6

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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7

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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8

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Corporate, subsidiary, or regional managing offices
Corporate, subsidiary, or regional managing office engaged in management of, or providing more than one centralized administrative support
functions to, other establishments of the company (Offices engaged in only one type of specific activity should select another kind of
business or activity.)

551114 001

Holding companies, excluding bank and financial holding companies
Holding company NOT engaged in direct management of held company(ies)

551112 001

Holding company engaged in direct management of held company(ies)

551114 003

Bank and financial holding companies (Registered with the Board of Governors of the Federal Reserve.)
Bank holding company

551111 001

Financial holding company

551112 002

Other kind of support service or activity
Data processing center or facility

518210 008

Other primary business or activity

779000 001

Select Sector

Describe

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

9

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

%

10

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Sales, Receipts, or Revenue
Include:
Sales, receipts, or revenue from customers outside your enterprise originating from this location.
Exclude:
Sales, receipts, or revenue from other establishments within your own enterprise.
For further clarification, click "Additional Information" link above.
Check
if
None
What were the sales, receipts, or revenue (exclude billings) from customers outside your enterprise originating from
this location?

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

2022
$

,000.00

11

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

2022
$

,000.00

$

,000.00

12

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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13

Item 8: Support Services - Continued

ITEM 8: SUPPORT SERVICES - PRIMARY BUSINESS OR ACTIVITY OF THE OPERATING ESTABLISHMENTS SERVICED
What primary kind of business or activity is performed by the establishments of your enterprise that are managed or serviced by this establishment?
Example: If this establishment is a corporate, subsidiary, or regional managing office, data processing service center, or administrative/support office to a chain of clothing stores, please
describe "clothing stores" below.
Describe

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

14

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES
Report the payment of selected expenses allocated by category
Report payments for expenses directly incurred by this establishment in column 1.
Report payments made by this establishment for expenses incurred by other establishments of your enterprise in column 2 (where applicable).
Exclude:
Transfers made within the company
Capitalized expenses
Impairment
Interest
Bad debt
Income tax
Taxes collected from customers (e.g., sales and excise)
Cost of merchandise for resale
Personnel costs, except payroll

1. Employer's cost for employer paid insurance premiums,
pension plans, payroll taxes, and other employee
benefits More

Check
if
None

2022 Expenses of this
establishment ONLY
$

,000.00

$

,000.00

3. Expensed computer hardware and other equipment More

$

,000.00

4. Expensed purchases of other materials, parts, and
supplies More

$

,000.00

5. Expensed purchases of software More

$

,000.00

6. Purchased electricity More

$

,000.00

7. Purchased fuels (Exclude motor fuels.) More

$

,000.00

2. Temporary staff and leased employee expense More
Expensed equipment and materials

Expensed purchased services

2022 Payments made by
this establishment on
behalf of other
establishments of your
enterprise

Check
if
None
8. Data processing and other purchased computer
services More

$

,000.00

$

,000.00

9. Purchased communication services More

$

,000.00

$

,000.00

10. Purchased repairs and maintenance to machinery,
vehicles, and equipment More

$

,000.00

$

,000.00

11. Purchased repairs and maintenance to buildings,
structures, and offices More

$

,000.00

$

,000.00

2022_MN-5511X_mu.pdf Generated 2022-02-18 07:36:31

15

12. Water, sewer, refuse removal, and other utility
payments More

$

,000.00

$

,000.00

13. Purchased advertising and promotional services More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

15. Lease and rental payments for machinery, equipment,
and other tangible items More

$

,000.00

$

,000.00

16. Lease and rental payments for land, buildings,
structures, store spaces, and offices More

$

,000.00

$

,000.00

17. Governmental taxes and license fees (Exclude sales,
excise, and income taxes.) More

$

,000.00

$

,000.00

18. Depreciation and amortization charges More

$

,000.00

19. All other selected expenses
(Describe - If more than 50% of TOTAL reported on line
20.) More

$

,000.00

$

,000.00

14. Purchased professional and technical services More
Other selected expenses

Describe

20. TOTAL SELECTED EXPENSES of this establishment
ONLY, excluding payroll (Add lines 1 through 19.)

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16

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Trading securities and commodity contracts on own account (Include interest and dividends.) More

Product Code

8000150000

8000175000

2. Gains (losses) from non-financial assets sold More

8000075000

3. Loans to financial businesses More

8000100000

4. Loans to non-financial businesses

8000125000

5. Loans to governments

7014900000

6. Bundled head-office services to the enterprise More

7. Financial management consulting and implementation services for businesses and government

8. Leasing of rights to explore for and exploit natural resources

7014575000

7010200000

7010260000

9. Franchising agreements More

10. Licensing of rights to use intellectual property protected by patent More

11. Licensing of rights to use intellectual property protected by trademark More
12. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings

7009600000

7009625000

7009581000

8000025000

13. Government contributions, gifts, and grants

8000050000

14. Private contributions, gifts, and grants
15. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

16. Basic and applied research in engineering and technology More

7006575000

7009700000

Add product/service not listed

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17

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Trading securities and commodity contracts on own account (Include interest and dividends.) More

$

,000.00

8000150000

2. Gains (losses) from non-financial assets sold More

$

,000.00

8000175000

$

,000.00

8000075000

4. Loans to non-financial businesses

$

,000.00

8000100000

5. Loans to governments

$

,000.00

8000125000

6. Bundled head-office services to the enterprise More

$

,000.00

7014900000

7. Financial management consulting and implementation services for businesses and government

$

,000.00

7014575000

$

,000.00

7010200000

$

,000.00

7010260000

10. Licensing of rights to use intellectual property protected by patent More

$

,000.00

7009600000

11. Licensing of rights to use intellectual property protected by trademark More

$

,000.00

7009625000

12. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings

$

,000.00

7009581000

$

,000.00

8000025000

14. Private contributions, gifts, and grants

$

,000.00

8000050000

15. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated selfservice gambling machines

$

,000.00

7006575000

$

,000.00

7009700000

3. Loans to financial businesses More

8. Leasing of rights to explore for and exploit natural resources

9. Franchising agreements More

13. Government contributions, gifts, and grants

16. Basic and applied research in engineering and technology More
17. All other nonoperating or tax-exempt revenue

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18

a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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19

Item 28: Special Items - Merchandise Sales

ITEM 28: SPECIAL ITEMS - MERCHANDISE SALES
NOTE - "Manufacturing" is transforming or otherwise processing materials or components into new products, including assembling of component parts, prototype development, blending,
and jobbing. Excludes packaging and minor assembly of manufactured goods incidental to distribution or sale.
Estimate the percent of merchandise sales, shipments, receipts, or revenues reported in Item 22 from:
2022
%

1. Products manufactured or assembled at this establishment
2. Products manufactured or assembled for this establishment by other domestic establishments of your company (i.e., within the 50
States and District of Columbia)

%

3. Products manufactured for this establishment by other companies on a contract basis OR manufactured by your company's foreign
plants

%

4. Product resales (products purchased by this establishment from others and sold without further processing or transformation; or sold on
a commission basis)

%

5. TOTAL (Sum of lines 1 through 4 should equal 100%.)

%

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20

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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21

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

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2022
$

,000.00

22

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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23

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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24

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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25

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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26

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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27

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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28

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

31

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all locations of a company or
organization, including administrative offices, warehouses, etc., that were in operation at any time during 2022. Report activity for each establishment on a separate form.
DEFINITION OF HOLDING COMPANY
A holding company is a company primarily engaged in holding securities of (or other equity interests in) companies and enterprises for the purpose of owning a controlling interest or
influencing the management decisions of these firms. They do not administer, oversee, or manage other establishments of the company or enterprise whose securities they hold.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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3

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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8

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Holding companies, excluding bank and financial holding companies
Holding company NOT engaged in direct management of held company(ies)

551112 001

Bank and financial holding companies (Registered with the Board of Governors of the Federal Reserve.)
Bank holding company

551111 001

Financial holding company

551112 002

Corporate managing offices and other kind of business activity
Franchise leasing/licensing, without primarily selling products to the franchisee

533110 901

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
What was the income, earnings, or revenue of this establishment only?
For further clarification, click the "Additional Information" link above.
Check
if
None

2022
$

Income, earnings, or revenue

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Trading securities and commodity contracts on own account (Include interest and dividends.) More

Product Code

8000150000

8000175000

2. Gains (losses) from non-financial assets sold More

8000075000

3. Loans to financial businesses More

8000100000

4. Loans to non-financial businesses

8000125000

5. Loans to governments

7014900000

6. Bundled head-office services to the enterprise More

7. Financial management consulting and implementation services for businesses and government

8. Leasing of rights to explore for and exploit natural resources

7014575000

7010200000

7010260000

9. Franchising agreements More

10. Licensing of rights to use intellectual property protected by patent More

11. Licensing of rights to use intellectual property protected by trademark More
12. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings

7009600000

7009625000

7009581000

8000025000

13. Government contributions, gifts, and grants

8000050000

14. Private contributions, gifts, and grants
15. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

16. Basic and applied research in engineering and technology More

7006575000

7009700000

Add product/service not listed

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Trading securities and commodity contracts on own account (Include interest and dividends.) More

$

,000.00

8000150000

2. Gains (losses) from non-financial assets sold More

$

,000.00

8000175000

3. Loans to financial businesses More

$

,000.00

8000075000

4. Loans to non-financial businesses

$

,000.00

8000100000

5. Loans to governments

$

,000.00

8000125000

6. Bundled head-office services to the enterprise More

$

,000.00

7014900000

7. Financial management consulting and implementation services for businesses and government

$

,000.00

7014575000

8. Leasing of rights to explore for and exploit natural resources

$

,000.00

7010200000

9. Franchising agreements More

$

,000.00

7010260000

$

,000.00

7009600000

11. Licensing of rights to use intellectual property protected by trademark More

$

,000.00

7009625000

12. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings

$

,000.00

7009581000

13. Government contributions, gifts, and grants

$

,000.00

8000025000

$

,000.00

8000050000

15. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated selfservice gambling machines

$

,000.00

7006575000

16. Basic and applied research in engineering and technology More

$

,000.00

7009700000

10. Licensing of rights to use intellectual property protected by patent More

14. Private contributions, gifts, and grants

17. All other nonoperating or tax-exempt revenue

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

22

a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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27

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

35

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_MN-55111_su.pdf Generated 2022-02-18 07:35:53

,000.00

36

Attachment D-14
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 56

Attachment Sector

D-14

56

Instrument
Path
Instrument Path Title

5611C
56120
56150
5622X

Office Administrative Services (Classification)
Facilities Support Services
Travel Arrangement and Reservation Services
Waste Treatment and Disposal (Enterprise Support)

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Management services - providing management staff to direct or coordinate a client's business operation, but not providing staff for complete operation of the client's
business (Exclude management services provided to own establishments.)
Management and administrative services - providing day-to-day administrative services such as personnel management, bookkeeping,
billing, etc., for a client's business or operation (Exclude administrative activities provided for own company.)

561110 001

Hotel and restaurant management

561110 004

Medical office management

561110 005

Corrections management

561210 006

Facilities support services
Facilities support management (exclude computer facilities) - providing operating staff to perform a range of services to support operations
within the client's facilities, but not involved with or responsible for the core activities of the client's business operations

561210 001

Military base management

561210 005

Correctional facilities management and operation

561210 004

Computer systems facilities management and operation services

541513 002

Management consulting - providing advice and counsel to clients on various aspects of operating a business or other type of organization, but not providing
management services for day-to-day operations
Administrative and general management consulting services, including strategic planning and organizational change

541611 002

Human resources and personnel management consulting services

541612 301

Marketing consulting services, including sales management, customer service, and marketing planning/strategy

541613 001

Physical distribution and logistics consulting services

541614 001

Other primary business or activity
Medical case management - assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's
health care needs to provide quality and cost-effective outcomes

621999 101

Other primary business or activity

779000 001

Select Sector

Describe

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Item 28: Special Items - Merchandise Sales

ITEM 28: SPECIAL ITEMS - MERCHANDISE SALES
Did the sale of merchandise account for more than half of the total receipts of this establishment in 2022?
Yes - Describe merchandise sold
Describe
No

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

8

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Facilities support services
Facilities support management (exclude computer facilities) - providing operating staff to perform a range of services to support operations
within the client's facilities, but not involved with or responsible for the core activities of the client's business operations

561210 001

Military base management

561210 005

Correctional facilities management and operation

561210 004

Computer systems facilities management and operation services

541513 002

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

2022
$

,000.00

$

,000.00

19

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating receipts (reported in Item 5) by class of customer?
2022
%

1. Business firms and farms

2. Not-for-profit organizations (Include religious organizations.)

%

%

3. Federal government

4. State and local governments

%

5. Household consumers and individuals (Report receipts from individually owned businesses on line 1.)

%

6. TOTAL (Sum of lines 1 through 5 should equal 100%.)

%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Facilities support services (Exclude correctional facilities.)

Product Code

7014675000

7014670000

2. Correctional facilities contract operation services

3. Construction project management services, excluding at-risk

3004800000

7014925000

4. Project management services, except construction

7014450000

5. IT infrastructure and network management services

7014450003

a. Network management services

7014450006

b. Computer systems management services
6. Head office services to the enterprise including administering, overseeing, and managing other establishments for own company or
enterprise (e.g., corporate offices, head offices, regional managing offices, holding companies that manage)

7014900000

7012265000

7. Economic consulting services

7014225000

8. Information technology (IT) technical consulting services

9. Scientific and technical consulting services, not elsewhere classified

10. Operations and supply chain management consulting and implementation services

7012270000

7014650000

Add product/service not listed

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Facilities support services (Exclude correctional facilities.)

$

,000.00

7014675000

2. Correctional facilities contract operation services

$

,000.00

7014670000

3. Construction project management services, excluding at-risk

$

,000.00

3004800000

4. Project management services, except construction

$

,000.00

7014925000

a. Network management services

$

,000.00

7014450003

b. Computer systems management services

$

,000.00

7014450006

$

,000.00

7014450000

6. Head office services to the enterprise including administering, overseeing, and managing other establishments for
own company or enterprise (e.g., corporate offices, head offices, regional managing offices, holding companies that
manage)

$

,000.00

7014900000

7. Economic consulting services

$

,000.00

7012265000

8. Information technology (IT) technical consulting services

$

,000.00

7014225000

9. Scientific and technical consulting services, not elsewhere classified

$

,000.00

7012270000

10. Operations and supply chain management consulting and implementation services

$

,000.00

7014650000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

5. IT infrastructure and network management services

Subtotal

Add product/service not listed

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

23

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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24

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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25

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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26

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

2022
$

,000.00

27

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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28

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

29

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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30

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

37

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_AS-56120_su.pdf Generated 2022-02-23 17:10:30

,000.00

38

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Travel agency and tour operator
Travel agency

561510 001

Tour operator - assembling tour packages and selling directly to travelers or through other travel agencies

561520 001

Other travel arrangement and reservation services
Ticket, reservation, and other travel arrangement services

561599 601

Ticket agency, including airline, railroad, bus, theatrical, sports, cruise ships, amusement, and recreation

561599 602

Automobile club, road and travel services

561599 201

Reservation system, including airlines, hotels, automobiles, and restaurants

561599 603

Convention and visitor/tourist information bureau

561591 001

Vacation time share exchange services

561599 604

Automobile travel clubs

561599 202

Transportation services
Limousine or luxury sedan with drivers, except scheduled airport shuttle and taxi service

485320 001

Bus charter services - local

485510 004

Bus charter services - interstate or interurban

485510 005

Sightseeing bus, trolley, or steam train excursions

487110 005

Scenic and sightseeing boat, including dinner cruises, excursions, and harbor tours

487210 102

Sightseeing airplane or helicopter

487990 001

Aerial tramway and cable lift, scenic or sightseeing

487990 002

Shipping agents or brokers

488510 202

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Report operating receipts of this establishment
Travel agents, ticket offices/agencies, and reservation systems should include commissions or fees, not gross sales.
Tour operators should include the difference between the selling price of their tours and the amount paid to suppliers.
Convention, visitor, and tourist information bureaus should report total revenue, including contributions, gifts, and grants.
For further clarification, click the "Additional Information" link above.
Check
if
None

2022
$

What were the total operating receipts?

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

2022
$

,000.00

$

,000.00

19

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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20

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating receipts (reported in Item 5) by class of customer?
2022 Whole
percent of
receipts
1. Household consumers and individuals
(Report receipts from individually owned businesses on lines 2 and 3 as appropriate.)

%

2. Travel agencies and other resellers

%

3. All other business firms and farms

%

4. Not-for-profit organizations
(Include religious organizations.)

%

5. Federal government

%

6. State and local governments

%

7. TOTAL (Sum of lines 1 through 6 should equal 100%)

%

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7003575000

1. Trip planning services More

2. Packaged tours with accommodation, except cruises and academic trips and tours More

a. Domestic packaged tours with accommodation, except cruises and academic trips and tours

b. International packaged tours with accommodation, except cruises and academic trips and tours

7003275000

7003275003

7003275006

7003275009

c. Pre-packaged tour reselling services More

3. Customized tours with accommodation, except cruises and academic trips and tours More

a. Domestic customized tours with accommodation, except cruises and academic trips and tours

b. International customized tours with accommodation, except cruises and academic trips and tours

7003285000

7003285003

7003285006

7013050000

4. Public relations event management services More

a. Convention and trade show organization services More

b. Sports and performing arts event organization and management services

7013050003

7013050006

7013050009

c. All other public relations event management services

5. Visitor information and sightseeing tour information services More

7003903000

7003906000

6. Automobile club services More

7003900000

7. Condominium time-share exchange services More

7003909000

8. Travel document services

7003912000

9. Emergency travel services More

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22

7003915000

10. Traveler's check services

11. Insurance brokerage and agency services for travel insurance

7003775000

7003325000

12. Reservation service for airline seats

7003325006

a. Reservation service for airline seats, domestic travel

b. Reservation service for airline seats, international travel

7003325003

7003425000

13. Reservation service for vehicle rental

7003450000

14. Reservation service for cruises

7003450003

a. Reservation service for cruises of one day or less

7003450006

b. Reservation service for cruises of more than one day

15. Reservation service for passenger transportation, not elsewhere classified

a. Reservation service for bus seats and airport shuttle services

7003465000

7003465003

7003465006

b. Reservation service for rail seats

7003465009

c. Reservation service for ferry transportation

7003475000

16. Lodging reservation service

7003475006

a. Lodging reservation service, domestic travel

7003475003

b. Lodging reservation service, international travel

7003500000

17. Reservation service for packaged tours More

a. Reservation service for packaged tours, domestic travel

b. Reservation service for packaged tours, international travel

7003500006

7003500003

7003550000

18. Event ticket sales and reservation services

7014275000

19. Application service provisioning

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23

a. Computerized reservation system application provisioning

b. Application service provisioning with integration services

c. Application service provisioning without integration services

7014275003

7014275006

7014275009

Add product/service not listed

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

24

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

$

,000.00

7003575000

a. Domestic packaged tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003275003

b. International packaged tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003275006

c. Pre-packaged tour reselling services More

$

,000.00

7003275009

Subtotal

$

,000.00

7003275000

a. Domestic customized tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003285003

b. International customized tours with accommodation, except cruises and academic trips and tours

$

,000.00

7003285006

Subtotal

$

,000.00

7003285000

a. Convention and trade show organization services More

$

,000.00

7013050003

b. Sports and performing arts event organization and management services

$

,000.00

7013050006

c. All other public relations event management services

$

,000.00

7013050009

Subtotal

$

,000.00

7013050000

5. Visitor information and sightseeing tour information services More

$

,000.00

7003903000

6. Automobile club services More

$

,000.00

7003906000

7. Condominium time-share exchange services More

$

,000.00

7003900000

1. Trip planning services More
2. Packaged tours with accommodation, except cruises and academic trips and tours More

3. Customized tours with accommodation, except cruises and academic trips and tours More

4. Public relations event management services More

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

25

8. Travel document services

$

,000.00

7003909000

9. Emergency travel services More

$

,000.00

7003912000

10. Traveler's check services

$

,000.00

7003915000

$

,000.00

7003775000

$

,000.00

7003325006

b. Reservation service for airline seats, international travel

$

,000.00

7003325003

Subtotal

$

,000.00

7003325000

$

,000.00

7003425000

a. Reservation service for cruises of one day or less

$

,000.00

7003450003

b. Reservation service for cruises of more than one day

$

,000.00

7003450006

Subtotal

$

,000.00

7003450000

a. Reservation service for bus seats and airport shuttle services

$

,000.00

7003465003

b. Reservation service for rail seats

$

,000.00

7003465006

$

,000.00

7003465009

$

,000.00

7003465000

a. Lodging reservation service, domestic travel

$

,000.00

7003475006

b. Lodging reservation service, international travel

$

,000.00

7003475003

Subtotal

$

,000.00

7003475000

11. Insurance brokerage and agency services for travel insurance
12. Reservation service for airline seats

a. Reservation service for airline seats, domestic travel

13. Reservation service for vehicle rental
14. Reservation service for cruises

15. Reservation service for passenger transportation, not elsewhere classified

c. Reservation service for ferry transportation

Subtotal
16. Lodging reservation service

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

26

17. Reservation service for packaged tours More

$

,000.00

7003500006

b. Reservation service for packaged tours, international travel

$

,000.00

7003500003

Subtotal

$

,000.00

7003500000

$

,000.00

7003550000

a. Computerized reservation system application provisioning

$

,000.00

7014275003

b. Application service provisioning with integration services

$

,000.00

7014275006

c. Application service provisioning without integration services

$

,000.00

7014275009

Subtotal

$

,000.00

7014275000

$

,000.00

9900000000

a. Reservation service for packaged tours, domestic travel

18. Event ticket sales and reservation services
19. Application service provisioning

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

27

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

28

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

29

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

30

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

2022
$

,000.00

31

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

32

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

33

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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34

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

35

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

36

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

37

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

38

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

39

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

40

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

1000

characters remaining

41

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_AS-56150_su.pdf Generated 2022-02-23 17:16:30

,000.00

42

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all locations of a company or
organization, including administrative offices, warehouses, etc., that were in operation at any time during 2022. Report activity for each establishment on a separate form.
DEFINITION OF AN ENTERPRISE
An enterprise or company is a business, service, or membership organization consisting of one or more establishments within the United States under common ownership or control. It
includes all establishments of subsidiary companies, where there is more than 50 percent ownership, as well as establishments of firms which the enterprise has the power to direct or
cause the direction of management and policies.
DEFINITION OF AN ENTERPRISE SUPPORT ESTABLISHMENT
An enterprise support establishment is an establishment that is primarily engaged in performing management, supervision, general administrative functions, and supporting services for
other establishments of the same enterprise, rather than for the general public or other business firms.

PHYSICAL ADDRESS
Please update the location's physical address if needed.

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

4

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

5

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

6

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

7

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

8

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Waste treatment and disposal services, including combined collection and disposal
Solid waste landfill

562212 001

Hazardous waste

562211 003

Medical waste

562211 001

Solid waste combustor and incinerator

562213 001

Septic tank cleaning services

562991 102

Waste collection services, without treatment or disposal
Solid waste, recyclables, and yard waste (exclude hazardous waste) collection services, local

562111 001

Solid waste transfer station

562111 002

Hazardous waste collection services

562112 001

Hazardous waste transfer station

562112 002

Other primary business or activity
Remediation services - remediating/cleaning up contaminated buildings, mine sites, soil, or ground water (excluding asbestos abatement
and/or lead removal)

562910 101

Other primary business or activity

779000 001

Select Sector

Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

9

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

%

10

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Sales, Receipts, or Revenue
Include:
Sales, receipts, or revenue from customers outside your enterprise originating from this location.
Exclude:
Sales, receipts, or revenue from other establishments within your own enterprise.
For further clarification, click "Additional Information" link above.
Check
if
None
What were the sales, receipts, or revenue (exclude billings) from customers outside your enterprise originating from
this location?

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

2022
$

,000.00

11

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

2022
$

,000.00

$

,000.00

12

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

13

Item 8: Support Services - Continued

ITEM 8: SUPPORT SERVICES - PRIMARY BUSINESS OR ACTIVITY OF THE OPERATING ESTABLISHMENTS SERVICED
What primary kind of business or activity is performed by the establishments of your enterprise that are managed or serviced by this establishment?
Example: If this establishment is a corporate, subsidiary, or regional managing office, data processing service center, or administrative/support office to a chain of clothing stores, please
describe "clothing stores" below.
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

14

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES
Report the payment of selected expenses allocated by category
Report payments for expenses directly incurred by this establishment in column 1.
Report payments made by this establishment for expenses incurred by other establishments of your enterprise in column 2 (where applicable).
Exclude:
Transfers made within the company
Capitalized expenses
Impairment
Interest
Bad debt
Income tax
Taxes collected from customers (e.g., sales and excise)
Cost of merchandise for resale
Personnel costs, except payroll

1. Employer's cost for employer paid insurance premiums,
pension plans, payroll taxes, and other employee
benefits More

Check
if
None

2022 Expenses of this
establishment ONLY
$

,000.00

$

,000.00

3. Expensed computer hardware and other equipment More

$

,000.00

4. Expensed purchases of other materials, parts, and
supplies More

$

,000.00

5. Expensed purchases of software More

$

,000.00

6. Purchased electricity More

$

,000.00

7. Purchased fuels (Exclude motor fuels.) More

$

,000.00

2. Temporary staff and leased employee expense More
Expensed equipment and materials

Expensed purchased services

2022 Payments made by
this establishment on
behalf of other
establishments of your
enterprise

Check
if
None
8. Data processing and other purchased computer
services More

$

,000.00

$

,000.00

9. Purchased communication services More

$

,000.00

$

,000.00

10. Purchased repairs and maintenance to machinery,
vehicles, and equipment More

$

,000.00

$

,000.00

11. Purchased repairs and maintenance to buildings,
structures, and offices More

$

,000.00

$

,000.00

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

15

12. Water, sewer, refuse removal, and other utility
payments More

$

,000.00

$

,000.00

13. Purchased advertising and promotional services More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

15. Lease and rental payments for machinery, equipment,
and other tangible items More

$

,000.00

$

,000.00

16. Lease and rental payments for land, buildings,
structures, store spaces, and offices More

$

,000.00

$

,000.00

17. Governmental taxes and license fees (Exclude sales,
excise, and income taxes.) More

$

,000.00

$

,000.00

18. Depreciation and amortization charges More

$

,000.00

19. All other selected expenses
(Describe - If more than 50% of TOTAL reported on line
20.) More

$

,000.00

$

,000.00

14. Purchased professional and technical services More
Other selected expenses

Describe

20. TOTAL SELECTED EXPENSES of this establishment
ONLY, excluding payroll (Add lines 1 through 19.)

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

16

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
What was the percentage of this establishment's total operating receipts (reported in Item 5) from services provided to clients outside your enterprise by class of customer?
2022 Whole
percent of
receipts
1. Household consumers and individuals
(Report receipts from individually owned businesses on lines 2, 3, 4, 5, or 6 as appropriate.)

%

2. Retailers

%

3. Banks, insurance companies, and other financial institutions

%

4. Hospitals and other health care services

%

5. Travel agencies and other resellers

%

6. All other business firms and farms

%

7. Not-for-profit organizations
(Include religious organizations.)

%

8. Federal government

%

%

9. State and local governments

%

10. TOTAL (Sum of lines 1 through 9 should equal 100%.)

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

17

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

6000350000

1. Disposal services for non-hazardous waste

6000350003

a. Landfilling services for non-hazardous waste

b. Incineration disposal services for non-hazardous waste

6000350006

6000350009

c. Other disposal services for non-hazardous waste

6000525000

2. Disposal services for hazardous waste

a. Disposal services for hazardous waste, by controlled confinement by landfilling

b. Disposal services for hazardous waste, by controlled confinement other than landfilling

6000525003

6000525006

6000525009

c. Other disposal services for hazardous waste

6000575000

3. Hazardous waste brokerage services

6000500000

4. Treatment services for hazardous waste

a. Treatment services for hazardous waste (biological-infectious waste)

b. Treatment services for hazardous waste (radioactive waste)

c. Treatment services for other hazardous waste (except waste water)

5. Residential collection services for non-hazardous waste and recyclable material More

a. Residential collection services for non-hazardous waste

b. Residential collection services for non-hazardous recyclable material

6. Nonresidential collection services for non-hazardous waste and recyclable material More

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

6000500003

6000500006

6000500009

6000200000

6000200003

6000200006

6000225000

18

a. Nonresidential collection services for non-hazardous industrial waste

b. Nonresidential collection services for non-hazardous non-industrial waste

c. Nonresidential collection services for non-hazardous recyclable material

7. Collection services for non-hazardous construction and demolition waste

8. Consolidation, storage, and preparation services for non-hazardous waste and recyclable material

a. Transfer facility services for non-hazardous waste More

b. Recovery and preparation services for non-hazardous recyclable material More

6000225003

6000225006

6000225009

6000250000

6000325000

6000325003

6000325006

6000075000

9. Electricity generation

a. Electricity generation (except waste energy generation)

6000075003

6000075006

b. Non-hazardous waste energy generation services

6000075009

c. Hazardous waste energy generation services More

10. Other non-hazardous waste management services, not elsewhere classified

6000425000

6000450000

11. Collection services for hazardous waste More

6000450003

a. Residential collection services for hazardous waste

b. Nonresidential collection services for hazardous waste

c. Cleaning and removal services for hazardous waste holding facilities

12. Consolidation, storage, and preparation services for hazardous waste and recyclable material More

6000450006

6000450009

6000475000

7011750000

13. Transportation of waste by road

7011750003

a. Transportation of non-hazardous waste by road

b. Transportation of non-hazardous recyclable material by road

7011750006

7011750009

c. Transportation of hazardous waste by road

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

19

7011775000

14. Transportation of waste by water

6000400000

15. Non-hazardous waste brokerage services

16. Hazardous waste management services, not elsewhere classified

6000600000

2019625000

17. Manufacturing of other fuels, not elsewhere classified

Add product/service not listed

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Disposal services for non-hazardous waste

a. Landfilling services for non-hazardous waste

$

,000.00

6000350003

b. Incineration disposal services for non-hazardous waste

$

,000.00

6000350006

c. Other disposal services for non-hazardous waste

$

,000.00

6000350009

Subtotal

$

,000.00

6000350000

$

,000.00

6000525003

$

,000.00

6000525006

c. Other disposal services for hazardous waste

$

,000.00

6000525009

Subtotal

$

,000.00

6000525000

$

,000.00

6000575000

a. Treatment services for hazardous waste (biological-infectious waste)

$

,000.00

6000500003

b. Treatment services for hazardous waste (radioactive waste)

$

,000.00

6000500006

c. Treatment services for other hazardous waste (except waste water)

$

,000.00

6000500009

Subtotal

$

,000.00

6000500000

a. Residential collection services for non-hazardous waste

$

,000.00

6000200003

b. Residential collection services for non-hazardous recyclable material

$

,000.00

6000200006

2. Disposal services for hazardous waste

a. Disposal services for hazardous waste, by controlled confinement by landfilling

b. Disposal services for hazardous waste, by controlled confinement other than landfilling

3. Hazardous waste brokerage services
4. Treatment services for hazardous waste

5. Residential collection services for non-hazardous waste and recyclable material More

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

21

$

,000.00

6000200000

a. Nonresidential collection services for non-hazardous industrial waste

$

,000.00

6000225003

b. Nonresidential collection services for non-hazardous non-industrial waste

$

,000.00

6000225006

c. Nonresidential collection services for non-hazardous recyclable material

$

,000.00

6000225009

Subtotal

$

,000.00

6000225000

$

,000.00

6000250000

a. Transfer facility services for non-hazardous waste More

$

,000.00

6000325003

b. Recovery and preparation services for non-hazardous recyclable material More

$

,000.00

6000325006

Subtotal

$

,000.00

6000325000

a. Electricity generation (except waste energy generation)

$

,000.00

6000075003

b. Non-hazardous waste energy generation services

$

,000.00

6000075006

c. Hazardous waste energy generation services More

$

,000.00

6000075009

Subtotal

$

,000.00

6000075000

$

,000.00

6000425000

$

,000.00

6000450003

$

,000.00

6000450006

c. Cleaning and removal services for hazardous waste holding facilities

$

,000.00

6000450009

Subtotal

$

,000.00

6000450000

Subtotal
6. Nonresidential collection services for non-hazardous waste and recyclable material More

7. Collection services for non-hazardous construction and demolition waste
8. Consolidation, storage, and preparation services for non-hazardous waste and recyclable material

9. Electricity generation

10. Other non-hazardous waste management services, not elsewhere classified
11. Collection services for hazardous waste More

a. Residential collection services for hazardous waste

b. Nonresidential collection services for hazardous waste

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

22

$

,000.00

6000475000

$

,000.00

7011750003

b. Transportation of non-hazardous recyclable material by road

$

,000.00

7011750006

c. Transportation of hazardous waste by road

$

,000.00

7011750009

Subtotal

$

,000.00

7011750000

14. Transportation of waste by water

$

,000.00

7011775000

15. Non-hazardous waste brokerage services

$

,000.00

6000400000

16. Hazardous waste management services, not elsewhere classified

$

,000.00

6000600000

17. Manufacturing of other fuels, not elsewhere classified

$

,000.00

2019625000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

12. Consolidation, storage, and preparation services for hazardous waste and recyclable material More
13. Transportation of waste by road

a. Transportation of non-hazardous waste by road

Add product/service not listed

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

2022
$

,000.00

25

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

26

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

29

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

31

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

32

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_AS-5622X_mu.pdf Generated 2022-02-23 17:29:31

33

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

34

Attachment D-15
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 61

Attachment Sector

D-15

61

Instrument
Path
Instrument Path Title

6100C
61140
61150
61170

Educational Services (Classification)
Business Schools and Computer and Management Training
Technical and Trade Schools
Educational Support Services

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

2

Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Management, clerical, and computer training services, excluding degree-granting colleges and universities
Business leadership, entrepreneurial training, and skills development, including provision of seminars or instruction to improve professional
and management skills
(Exclude degree-granting colleges and universities.)

611430 003

Vocational school for certification to work in health fields
(Exclude degree-granting colleges and universities.)

611519 008

Medical technician and nursing continuing education and recertification services

611430 002

Teacher and staff professional development training and continuing education services

611430 004

Clerical, secretarial, or court reporting school
(Include business schools or colleges not offering academic degrees.)

611410 002

Computer and information technology (IT) training services, including computer programming, gaining proficiency with software packages
and systems, IT security, and local area network (LAN) management
(Exclude computer repair training and software development.)

611420 001

Technical and trade schools
Cosmetology or beauty school, including skin and nail care

611511 002

Barber or hairdresser college or school

611511 001

Beauty shop, spa, or hair salon
(Exclude beauty schools.)

812112 005

Massage therapy school

611519 007

Modeling or acting school

611519 006

Apprenticeship training programs, including HVAC, electrical, mechanical, plumbing, welding, and carpentry

611513 002

Vocational school, including HVAC, electrical, mechanical, plumbing, welding, and carpentry
(Exclude apprenticeships.)

611519 004

Truck, bus, or heavy equipment driving school
(Exclude automobile and motorcycle driving schools.)

611519 00A

Commercial art, photography, or graphic arts school

611519 005

Culinary or bartending school

611519 009

Real estate, stock trading, or insurance school
(Exclude degree-granting institutions.)

611519 003

Training of instructors for yoga, personal trainers, and other fitness certifications

611519 002

Flight/Pilot training school
(Include flight simulation training. Exclude air crew training.)

611512 001

Vocational rehabilitation facility, including sheltered workshops, Job Corps, and no-cost technical and trade education and training programs
(Exclude schools.)

624310 003

All other miscellaneous schools and instruction e.g., first aid, CPR, life guard, military combat, and survival skills training
(Exclude security guard training.)

611699 001

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Other schools and instruction
Dance schools, children's and/or professionals', except fitness classes

611610 101

Sports and recreation instruction, including swimming, gymnastics, horseback riding, martial arts, etc.
(Include day and/or overnight instructional sports camps. Exclude clubs, teams, or leagues.)

611620 001

Sports and recreation clubs, teams, or leagues that may also include instruction
(Exclude day and/or overnight sports camps.)

713990 80C

Day camp, excluding overnight and instructional camps

713990 80A

Yoga or pilates studio

713940 909

Art, drama, music, or other fine arts school
(Exclude training for commercial or graphic artists.)

611610 201

Automobile and motorcycle driving school, including driver education
(Exclude truck driving schools.)

611692 001

Basic academic skills learning center and adult literacy groups
(Exclude social services and English as a second language (ESL).)

611691 002

Community remedial education or learning center, social services for the elderly or disabled
(Exclude schools.)

624120 00C

Tutoring and exam preparation services, including college board preparation

611691 003

Youth scholars and leadership programs
(Exclude social services.)

611430 005

Child early intervention center or services - providing services to children with disabilities, special needs, or delays

624120 00B

Youth mentoring or guidance program, social services

624110 00A

Language school
(Include sign language. Exclude elementary or secondary schools.)

611630 001

Elementary or secondary school

611110 001

Junior college or community college - granting associate degrees or certificates

611210 001

College, university, or professional school - granting academic degrees

611310 001

Child care services, including those with preschool and/or Head Start programs
(Include services for children with or without disabilities.)

624410 001

Educational support services
Libraries

519120 003

Educational guidance services - evaluating and advising students and families on recommended course of study, choice of schools or
colleges, financial aid, international exchange and education, study abroad, etc.

611710 101

Educational test development and evaluation services, including testing services

611710 202

Educational research and curriculum development services

611710 102

Administrative and general management consulting services

541611 001

Scientific and technical consulting services provided to businesses and other organizations

541690 907

Multi-service organization providing a range of social assistance services to families and individuals, excluding services primarily to children,
the elderly, the disabled, the intellectually and developmentally disabled, or the mentally ill

624190 003

Other social advocacy organizations addressing issues such as antipoverty, peace and international understanding, drug abuse awareness,
firearms safety, public safety, social change, and taxpayer advocacy

813319 004

Grantmaking foundations

813211 004

Book publishers

511130 404

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_ED-6100C_su.pdf Generated 2022-02-23 17:03:50

1000

characters remaining

9

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Management, clerical, and computer training services, excluding degree-granting colleges and universities
Business leadership, entrepreneurial training, and skills development, including provision of seminars or instruction to improve professional
and management skills
(Exclude degree-granting colleges and universities.)

611430 003

Provision of continuing education seminars or conferences, including continuing education for recertification of health professionals and
medical technicians, nurses, legal, and financial workers
(Exclude vocational training programs and schools with specialized training for job-specific certification.)

611430 006

Computer and information technology (IT) training services, including computer programming, gaining proficiency with software packages
and systems, IT security, and local area network (LAN) management
(Exclude computer repair training and software development.)

611420 001

Clerical, secretarial, or court reporting school
(Include business schools or colleges not offering academic degrees.)

611410 002

Technical and trade schools
Apprenticeship training programs, including HVAC, electrical, mechanical, plumbing, welding, and carpentry

611513 002

Vocational school, including HVAC, electrical, mechanical, plumbing, welding, and carpentry
(Exclude apprenticeships.)

611519 004

Vocational rehabilitation facility, including sheltered workshops, Job Corps, and no-cost technical and trade education and training programs
(Exclude schools.)

624310 003

Other schools and instruction
Language school
(Include sign language. Exclude elementary or secondary schools.)

611630 001

Elementary or secondary school

611110 001

Junior college or community college - granting associate degrees or certificates

611210 001

College, university, or professional school - granting academic degrees

611310 001

Educational support services
Teacher and staff professional development training and continuing education services

611430 004

Basic academic skills learning center and adult literacy groups
(Exclude social services and English as a second language (ESL).)

611691 002

Tutoring and exam preparation services, including college board preparation

611691 003

Educational test development and evaluation services, including testing services

611710 202

Educational research and curriculum development services

611710 102

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

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2022
$

,000.00

$

,000.00

21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second Language (ESL)
programs, and special educational programs for children.) More

2. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

Product Code

7003925000

7003950000

7003950003

7003950015

b. Business, management, and public administration

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

7003950021

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

7003950036

h. Certification training for operating machinery and equipment

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and courses
(Include instruction in culinary arts.)

7003950061

3. Higher career, technical, academic, and advanced research qualification programs More

7003975000

7004075000

4. Educational support and consulting services

7004000000

5. Exam preparation courses

6. Rental of space for meetings, conventions, and similar short-term business uses

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7006425000

23

7. Retail sales of audio and video recordings of educational courses/lectures, including purchased downloads

8. Published applications software, including publishing educational software

5001000000

7009000000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

1. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second
Language (ESL) programs, and special educational programs for children.) More

Product Code

$

,000.00

7003925000

a. Education
(Include continuing education and recertification for instructors.)

$

,000.00

7003950003

b. Business, management, and public administration

$

,000.00

7003950015

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

$

,000.00

7003950021

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

$

,000.00

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

$

,000.00

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

$

,000.00

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

$

,000.00

7003950036

h. Certification training for operating machinery and equipment

$

,000.00

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

$

,000.00

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and
courses
(Include instruction in culinary arts.)

$

,000.00

7003950061

Subtotal

$

,000.00

7003950000

3. Higher career, technical, academic, and advanced research qualification programs More

$

,000.00

7003975000

4. Educational support and consulting services

$

,000.00

7004075000

5. Exam preparation courses

$

,000.00

7004000000

2. Trade, career, technical and professional development training programs

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25

6. Rental of space for meetings, conventions, and similar short-term business uses

$

,000.00

7006425000

7. Retail sales of audio and video recordings of educational courses/lectures, including purchased downloads

$

,000.00

5001000000

8. Published applications software, including publishing educational software

$

,000.00

7009000000

$

,000.00

9900000000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second Language (ESL)
programs, and special educational programs for children.) More

2. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

Product Code

7003925000

7003950000

7003950003

7003950015

b. Business, management, and public administration

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

7003950021

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

7003950036

h. Certification training for operating machinery and equipment

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and courses
(Include instruction in culinary arts.)

7003950061

3. Higher career, technical, academic, and advanced research qualification programs More

7003975000

7004075000

4. Educational support and consulting services

7004000000

5. Exam preparation courses

6. Rental of space for meetings, conventions, and similar short-term business uses

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7006425000

27

7. Retail sales of audio and video recordings of educational courses/lectures, including purchased downloads

8. Published applications software, including publishing educational software

9. Program service revenue including government fees and contracts More

5001000000

7009000000

8000200000

8000025000

10. Government contributions, gifts, and grants
11. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include
commissioned fundraising.)

8000050000

12. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

8000150000

13. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

1. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second
Language (ESL) programs, and special educational programs for children.) More

Product Code

$

,000.00

7003925000

a. Education
(Include continuing education and recertification for instructors.)

$

,000.00

7003950003

b. Business, management, and public administration

$

,000.00

7003950015

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

$

,000.00

7003950021

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

$

,000.00

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

$

,000.00

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

$

,000.00

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

$

,000.00

7003950036

h. Certification training for operating machinery and equipment

$

,000.00

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

$

,000.00

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and
courses
(Include instruction in culinary arts.)

$

,000.00

7003950061

Subtotal

$

,000.00

7003950000

3. Higher career, technical, academic, and advanced research qualification programs More

$

,000.00

7003975000

4. Educational support and consulting services

$

,000.00

7004075000

5. Exam preparation courses

$

,000.00

7004000000

2. Trade, career, technical and professional development training programs

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29

6. Rental of space for meetings, conventions, and similar short-term business uses

$

,000.00

7006425000

7. Retail sales of audio and video recordings of educational courses/lectures, including purchased downloads

$

,000.00

5001000000

8. Published applications software, including publishing educational software

$

,000.00

7009000000

9. Program service revenue including government fees and contracts More

$

,000.00

8000200000

10. Government contributions, gifts, and grants

$

,000.00

8000025000

11. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc.
Include commissioned fundraising.)

$

,000.00

8000050000

12. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

$

,000.00

8000150000

13. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

$

,000.00

8000175000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

14. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

43

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_ED-61140_su.pdf Generated 2022-02-23 17:04:53

,000.00

44

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Technical and trade schools
Vocational school, including HVAC, electrical, mechanical, plumbing, welding, and carpentry
(Exclude apprenticeships.)

611519 004

Vocational rehabilitation facility, including sheltered workshops, Job Corps, and no-cost technical and trade education and training programs
(Exclude schools.)

624310 003

Apprenticeship training programs, including HVAC, electrical, mechanical, plumbing, welding, and carpentry

611513 002

Commercial art, photography, or graphic arts school

611519 005

Cosmetology or beauty school, including skin and nail care

611511 002

Barber or hairdresser college or school

611511 001

Modeling or acting school

611519 006

Massage therapy school

611519 007

Vocational school for certification to work in health fields
(Exclude degree-granting colleges and universities.)

611519 008

Provision of continuing education seminars or conferences, including continuing education for recertification of health professionals and
medical technicians, nurses, legal, and financial workers
(Exclude vocational training programs and schools with specialized training for job-specific certification.)

611430 006

Flight/Pilot training school
(Include flight simulation training. Exclude air crew training.)

611512 001

Truck, bus, or heavy equipment driving school
(Exclude automobile and motorcycle driving schools.)

611519 00A

Automobile and motorcycle driving school, including driver education
(Exclude truck driving schools.)

611692 001

Real estate, stock trading, or insurance school
(Exclude degree-granting institutions.)

611519 003

Culinary or bartending school

611519 009

Schools for training police, firefighters, security guards, and occupational safety workers

611519 00B

All other miscellaneous schools and instruction e.g., first aid, CPR, life guard, military combat, and survival skills training
(Exclude security guard training.)

611699 001

Management and computer training services, excluding colleges and universities
Computer and information technology (IT) training services, including computer programming, gaining proficiency with software packages
and systems, IT security, and local area network (LAN) management
(Exclude computer repair training and software development.)

611420 001

Business leadership, entrepreneurial training, and skills development, including provision of seminars or instruction to improve professional
and management skills
(Exclude degree-granting colleges and universities.)

611430 003

Other schools and instruction

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

15

Elementary or secondary school

611110 001

Junior college or community college - granting associate degrees or certificates

611210 001

College, university, or professional school - granting academic degrees

611310 001

Other primary business or activity
Beauty shop, spa, or hair salon
(Exclude beauty schools.)

812112 005

Other primary business or activity

779000 001

Select Sector

Describe

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

2022
$

,000.00

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

2022
$

,000.00

$

,000.00

21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

2022
$

,000.00

$

,000.00

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

Product Code

7003950000

7003950003

7003950015

b. Business, management, and public administration

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

7003950021

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

7003950036

h. Certification training for operating machinery and equipment

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and courses
(Include instruction in culinary arts.)

7003950061

2. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second Language (ESL)
programs, and special educational programs for children.) More

3. Higher career, technical, academic, and advanced research qualification programs More

7003925000

7003975000

4. Hair care services
(Exclude training programs in beauty and personal care.)

7005025000

5. Nail care services
(Exclude training programs in beauty and personal care.)

7005050000

6. Skin care services
(Exclude training programs in beauty and personal care.)

7005075000

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23

7009300000

7. Rental of air, rail, and water transportation equipment

Add product/service not listed

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

$

,000.00

7003950003

b. Business, management, and public administration

$

,000.00

7003950015

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

$

,000.00

7003950021

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

$

,000.00

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

$

,000.00

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

$

,000.00

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

$

,000.00

7003950036

$

,000.00

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

$

,000.00

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and
courses
(Include instruction in culinary arts.)

$

,000.00

7003950061

$

,000.00

7003950000

2. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second
Language (ESL) programs, and special educational programs for children.) More

$

,000.00

7003925000

3. Higher career, technical, academic, and advanced research qualification programs More

$

,000.00

7003975000

4. Hair care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005025000

5. Nail care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005050000

h. Certification training for operating machinery and equipment

Subtotal

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

25

6. Skin care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005075000

7. Rental of air, rail, and water transportation equipment

$

,000.00

7009300000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

Product Code

7003950000

7003950003

7003950015

b. Business, management, and public administration

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

7003950021

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

7003950036

h. Certification training for operating machinery and equipment

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and courses
(Include instruction in culinary arts.)

7003950061

2. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second Language (ESL)
programs, and special educational programs for children.) More

3. Higher career, technical, academic, and advanced research qualification programs More

7003925000

7003975000

4. Hair care services
(Exclude training programs in beauty and personal care.)

7005025000

5. Nail care services
(Exclude training programs in beauty and personal care.)

7005050000

6. Skin care services
(Exclude training programs in beauty and personal care.)

7005075000

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27

7009300000

7. Rental of air, rail, and water transportation equipment

8. Program service revenue including government fees and contracts More

8000200000

8000025000

9. Government contributions, gifts, and grants
10. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include
commissioned fundraising.)

8000050000

11. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

8000150000

12. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Trade, career, technical and professional development training programs
a. Education
(Include continuing education and recertification for instructors.)

$

,000.00

7003950003

b. Business, management, and public administration

$

,000.00

7003950015

c. Computer and information sciences, mathematics, architecture, engineering, and related technologies

$

,000.00

7003950021

d. Heating, ventilation, and air conditioning (HVAC); electrical; mechanical; plumbing; and carpentry

$

,000.00

7003950057

e. Parks, recreation, fitness, and public health
(Include instruction in first aid, CPR, lifeguarding, and survival skills.)

$

,000.00

7003950031

f. Professional development and management training programs and courses
(Include continuing education and recertification services for health professionals and technicians.)

$

,000.00

7003950033

g. Beauty and personal care
(Include instruction in massage therapy.)

$

,000.00

7003950036

h. Certification training for operating machinery and equipment

$

,000.00

7003950039

i. All other personal, protective, and transportation services
(Include pilot/flight training and commercial driver's license (CDL) training.)

$

,000.00

7003950042

j. All other occupational, technical and trade; professional development; and management training programs and
courses
(Include instruction in culinary arts.)

$

,000.00

7003950061

Subtotal

$

,000.00

7003950000

2. Basic education and skills programs
(Include tuition receipts for literacy and numeracy programs, GED, foreign language and English as a Second
Language (ESL) programs, and special educational programs for children.) More

$

,000.00

7003925000

3. Higher career, technical, academic, and advanced research qualification programs More

$

,000.00

7003975000

4. Hair care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005025000

5. Nail care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005050000

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29

6. Skin care services
(Exclude training programs in beauty and personal care.)

$

,000.00

7005075000

7. Rental of air, rail, and water transportation equipment

$

,000.00

7009300000

8. Program service revenue including government fees and contracts More

$

,000.00

8000200000

9. Government contributions, gifts, and grants

$

,000.00

8000025000

10. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc.
Include commissioned fundraising.)

$

,000.00

8000050000

11. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

$

,000.00

8000150000

12. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

$

,000.00

8000175000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

13. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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35

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

1000

characters remaining

43

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_ED-61150_su.pdf Generated 2022-02-23 17:05:16

,000.00

44

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Educational support services
Educational guidance services - evaluating and advising students and families on recommended course of study, choice of schools or
colleges, financial aid, international exchange and education, study abroad, etc.

611710 101

Educational research and curriculum development services

611710 102

Educational test development and evaluation services, including testing services

611710 202

Tutoring and exam preparation services, including college board preparation

611691 003

Teacher and staff professional development training and continuing education services

611430 004

Youth mentoring or guidance program, social services

624110 00A

Youth scholars and leadership programs
(Exclude social services.)

611430 005

Child care services, including those with preschool and/or Head Start programs
(Include services for children with or without disabilities.)

624410 001

Child early intervention center or services - providing services to children with disabilities, special needs, or delays

624120 00B

Management and computer training services, excluding colleges and universities
Business leadership, entrepreneurial training, and skills development, including provision of seminars or instruction to improve professional
and management skills
(Exclude degree-granting colleges and universities.)

611430 003

Computer and information technology (IT) training services, including computer programming, gaining proficiency with software packages
and systems, IT security, and local area network (LAN) management
(Exclude computer repair training and software development.)

611420 001

Other schools and instruction
Elementary or secondary school

611110 001

Junior college or community college - granting associate degrees or certificates

611210 001

College, university, or professional school - granting academic degrees

611310 001

Language school
(Include sign language. Exclude elementary or secondary schools.)

611630 001

Other primary business or activity
Administrative and general management consulting services

541611 001

Scientific, technical, and safety or security consulting services

541690 908

Educational consulting services
(Exclude management, scientific, technical consulting)

611710 103

Other social advocacy organizations addressing issues such as antipoverty, peace and international understanding, drug abuse awareness,
firearms safety, public safety, social change, and taxpayer advocacy

813319 004

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779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

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2022
$

,000.00

$

,000.00

21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_ED-61170_su.pdf Generated 2022-02-23 17:05:56

2022
$

,000.00

$

,000.00

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7004075000

1. Educational support and consulting services

7004075003

a. Educational testing services

7004075006

b. Educational consulting services More
c. Other educational support services
(Include student exchange program services. Report continuing education and recertification for instructors on line 3.) More

7004075009

7004050000

2. Student services More

3. Trade, career, technical and professional development training programs

7003950000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Educational support and consulting services

a. Educational testing services

$

,000.00

7004075003

b. Educational consulting services More

$

,000.00

7004075006

$

,000.00

7004075009

$

,000.00

7004075000

2. Student services More

$

,000.00

7004050000

3. Trade, career, technical and professional development training programs

$

,000.00

7003950000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

c. Other educational support services
(Include student exchange program services. Report continuing education and recertification for instructors on line
3.) More

Subtotal

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7004075000

1. Educational support and consulting services

7004075003

a. Educational testing services

7004075006

b. Educational consulting services More
c. Other educational support services
(Include student exchange program services. Report continuing education and recertification for instructors on line 3.) More

7004075009

7004050000

2. Student services More

3. Trade, career, technical and professional development training programs

4. Program service revenue including government fees and contracts More

7003950000

8000200000

8000025000

5. Government contributions, gifts, and grants
6. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include commissioned
fundraising.)

8000050000

7. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

8000150000

8. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Educational support and consulting services

a. Educational testing services

$

,000.00

7004075003

b. Educational consulting services More

$

,000.00

7004075006

c. Other educational support services
(Include student exchange program services. Report continuing education and recertification for instructors on line
3.) More

$

,000.00

7004075009

$

,000.00

7004075000

2. Student services More

$

,000.00

7004050000

3. Trade, career, technical and professional development training programs

$

,000.00

7003950000

4. Program service revenue including government fees and contracts More

$

,000.00

8000200000

5. Government contributions, gifts, and grants

$

,000.00

8000025000

6. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include
commissioned fundraising.)

$

,000.00

8000050000

7. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

$

,000.00

8000150000

8. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

$

,000.00

8000175000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

Subtotal

9. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

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9900000002

26

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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32

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

40

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_ED-61170_su.pdf Generated 2022-02-23 17:05:56

,000.00

41

Attachment D-16
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 62

Attachment Sector

D-16

62

Instrument
Path
Instrument Path Title

6210C
6230C
62412
62441

Ambulatory Health Care Services (Classification)
Nursing and Residential Care Facilities (Classification)
Services for the Elderly, Disables, and Intellectually and
Developmentally Disabled
Child Day Care Services

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

2

Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

3

Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

4

Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

5

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Physician services (Include physicians with the degree of M.D., D.O., O.D., D.C., D.P.M., D.M.D., D.D.S., or D.D.Sc.)
Office of physicians, excluding specialists in mental health or medical marijuana treatments
(Include practitioner(s) engaged in the practice of general or specialized medicine and/or surgery.)

621111 106

Office of physicians specializing in medical marijuana treatments (except mental health specialists)

621111 201

Pediatrician(s), obstetrics and gynecology physician(s) or other family health physician(s), excluding mental health specialists

621111 108

Psychiatrist(s) or other mental health physician(s)

621112 001

Ophthalmologist(s)

621111 102

Doctor(s) of Optometry

621320 001

Podiatrist(s)

621391 001

Dentist(s) or other specialty dental practitioner(s) having D.M.D., D.D.S., or D.D.Sc. degree, including orthodontists, endodontists, oral and
maxillofacial surgeons, etc.

621210 001

Dermatologist(s)

621111 109

Other health practitioners
Physical therapist(s)

621340 201

Mental health practitioner(s), except physicians and social service agencies
(Include psychologists, psychiatric social workers, clinical psychologists, neuropsychologists, and psychotherapists)

621330 002

Speech-language pathologist(s)

621340 103

Audiologist(s)

621340 102

Occupational therapist(s)

621340 203

Chiropractor(s)

621310 001

Massage therapist(s)

621399 006

Advanced practicing registered nurse(s) (APRN)

621399 005

Licensed practical and licensed vocational nurse(s)

621399 007

Certified registered nurse anesthetist(s)

621399 003

Dietician(s)

621399 004

Orthotist(s) and/or prosthetist(s)

621399 001

Outpatient care facilities
Multi-service clinic - services provided by physicians (with a degree of M.D. or D.O.) and at least one additional category of health
practitioners such as dentists, therapists, optometrists, chiropractors, podiatrists or other health practitioners

621498 007

Mental health clinic

621420 003

Ambulatory surgical center

621493 001

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

6

Urgent care center or stand-alone emergency room

621493 002

Community health center or clinic

621498 001

Alcohol and/or substance abuse treatment clinic

621420 001

Sleep disorder center or clinic

621498 002

Provider of medical services at correctional facilities

621498 003

Health Maintenance Organization (HMO) medical clinic - operated by the provider of a prepaid medical plan

621491 001

Family planning center, including abortion and birth control clinics, fertility clinics, and pregnancy counseling centers

621410 001

Kidney dialysis center

621492 001

Medical and diagnostic laboratories
Medical laboratory - providing professional analytic or diagnostic services to the medical profession, or to the patient on prescription of a
physician

621511 001

Diagnostic imaging center - providing a variety of imaging services such as CT-scan (computer tomography), X-ray, ultrasound, and MRI
(magnetic resonance imaging)

621512 001

Mobile X-ray, mammography, MRI (magnetic resonance imaging), CT-scan (computer tomography), and/or ultrasound services

621512 002

Home health and hospice services
Home health care provider - providing physical, speech, and/or occupational therapy services

621610 004

Home health care provider with medical care, including visiting nurse associations, nursing agencies providing nursing and nursing assistant
services to patients in their home, or management of home health care services

621610 001

Nursing agency primarily providing nursing and nursing assistant services to patients in their homes

621610 003

Non-medical home care provider, including homemaker services such as cooking and cleaning or companion services with no medical
services provided

624120 004

Home hospice care

621610 002

Inpatient hospice facility

623110 001

Home infusion therapy

621610 005

Other activities and facilities associated with health care
Medical case management - assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's
health care needs to provide quality and cost-effective outcomes

621999 101

Health screening services, including drug testing

621999 906

Hearing testing services (except by offices of audiologists)

621999 902

Dental laboratory

339116 002

Mobile physical examination services, including exams for the purpose of obtaining insurance and/or employment

621999 901

Medical utilization review - advises health care providers how to provide cost-effective treatment that meets third-party reimbursement
requirements
(Exclude companies formulating specific treatment plans for individual patients.)

524298 003

Ambulance or emergency rescue services, air or ground

621910 003

Blood or blood product bank or donor station

621991 005

Eye, organ, tissue, or sperm bank, including cryobanks

621991 001

Other primary business or activity

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

7

Nursing agency primarily providing nurses and other employees on a temporary basis to hospitals, doctors' offices, and other health care
providers

561320 001

Other primary business or activity

779000 001

Select Sector

Describe

2022_HC-6210C_su.pdf Generated 2022-02-23 17:04:01

8

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

9

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

2

Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

3

Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

4

Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

5

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Nursing, assisted living, and residential care facilities and health services
Licensed nursing care facility providing inpatient nursing and rehabilitation services, including skilled nursing facilities

623110 003

Home for the elderly, including independent living or assisted living facilities WITHOUT on-site nursing care facility

623312 002

Continuing care retirement community - home for the elderly, including independent living or assisted living facilities WITH on-site nursing
care facility

623311 001

Intellectual and developmental disability facility, including group homes and intermediate care facilities for individuals with intellectual
disabilities (ICF/IID)

623210 002

Adult foster care for the intellectually or developmentally disabled

623210 001

Residential mental health facility, including psychiatric convalescent homes

623220 005

Residential alcohol or substance abuse rehabilitation facility, excluding nursing care facilities

623220 001

Inpatient hospice facility

623110 001

Home hospice care

621610 002

Home health care provider with medical care, including visiting nurse associations, nursing agencies providing nursing and nursing assistant
services to patients in their home, or management of home health care services

621610 001

Non-medical home care provider, including homemaker services such as cooking and cleaning or companion services with no medical
services provided

624120 004

Adult activity or day care center

624120 001

Children's home, group foster home, or orphanage

623990 001

Halfway homes and housing for reintegration of persons recently experiencing incarceration or treatment of substance abuse

623990 004

Group homes without nursing or medical care for persons with a disability

623990 003

Bootcamps or disciplinary camps (except correctional facilities) for delinquent youth

623990 005

Temporary or emergency shelter for the homeless, victims of abuse, families in medical crisis, and runaway youth

624221 001

Other community housing services to low-income individuals and families, including volunteer or non-profit housing construction or repair,
rent or utility assistance, and housing counseling

624229 007

Other health facilities and services
Physical therapist(s)

621340 201

Occupational therapist(s)

621340 203

Speech therapist(s) and/or audiologist(s)

621340 101

Multi-service organization providing a range of social assistance services to the elderly, disabled, intellectually and developmentally disabled,
or mentally ill

624120 003

General medical and surgical hospital, including osteopathic hospitals and combination hospital/nursing care facilities

622110 201

Other primary business or activity

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

6

779000 001

Other primary business or activity
Select Sector

Describe

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

7

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_HC-6230C_su.pdf Generated 2022-02-23 17:04:11

1000

characters remaining

8

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Services for the elderly, disabled, and intellectually and developmentally disabled
Agency for the aging, including adult day care and activity centers

624120 00A

Multi-service organization providing a range of social assistance services to the elderly, disabled, intellectually and developmentally disabled,
or mentally ill

624120 003

Non-medical home care provider, including homemaker services such as cooking and cleaning or companion services with no medical
services provided

624120 004

Non-profit meal delivery services and/or congregate meals

624210 002

Independent living skills training

624120 005

Social work case management services

624120 007

Job placement, training, or counseling program, including sheltered workshops

624310 002

Child early intervention center or services - providing services to children with disabilities, special needs, or delays

624120 00B

Support group for the disabled

624120 006

Childcare or preschool for the developmentally or physically disabled

624410 006

Counseling or therapy services provided by mental health practitioners, excluding services provided by physicians
(Include counseling by psychologists, psychiatric social workers, clinical psychologists, psychotherapists, etc.)

621330 003

Other non-medical counseling services to the elderly or disabled

624120 008

Home health care provider with medical care, including visiting nurse associations, nursing agencies providing nursing and nursing assistant
services to patients in their home, or management of home health care services

621610 001

Medical case management - assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's
health care needs to provide quality and cost-effective outcomes

621999 101

Residential care for the elderly, disabled, and intellectually and developmentally disabled
Intellectual and developmental disability facility, including group homes and intermediate care facilities for individuals with intellectual
disabilities (ICF/IID)

623210 002

Adult foster care for the intellectually or developmentally disabled

623210 001

Home for the elderly, including independent living or assisted living facilities WITHOUT on-site nursing care facility

623312 002

Residential facility for the mentally ill, excluding intellectual and developmental disability facilities

623220 002

Services for children and youth, excluding counseling and health services
Child care services, including those with preschool and/or Head Start programs
(Include services for children with or without disabilities.)

624410 001

Multi-service organization providing a range of social assistance services to children and youth

624110 006

Services for individuals and families, excluding counseling and health services
Community action agency

624190 001

Family services agency

624190 002

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

15

Multi-service organization, primarily providing a range of social assistance services to families and/or individuals, regardless of age

624190 00A

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

19

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

2022
$

,000.00

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

2022
$

,000.00

$

,000.00

21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

2022
$

,000.00

$

,000.00

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Social assistance services for elderly and disabled adults

Product Code

7005014000

7005014003

a. Prepared on-site meals (i.e., at senior centers)

7005014006

b. Vocational rehabilitation services

7005014009

c. Adult day care services
d. Social interaction services, on-site
(Include senior centers.)

7005014012

7005014015

e. Counseling and information services More
f. Other social assistance services
(Include social assistance case management services.) More
2. Non-medical home aide services
(Include prepared meals and delivered meals.)

7005014018

7004575000

a. Home aide services for elderly and disabled adults - Homemaker services More

b. Home aide services for elderly and disabled adults - Personal care services More

c. Home aide services, excluding elderly and disabled adults More

7004575003

7004575006

7004575009

7005002000

3. Adoption services

7005004000

4. Foster care and guardianship arrangement services

5. Counseling and information services for children, youth, and families More

7005006000

7005006003

a. Self-help group services More

7005006006

b. Information and referral services More

7005006009

c. Hotline/Crisis intervention services More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

23

d. Other counseling and information services
(Include mentoring services.)

7005006012

6. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

7005012000

7. Vocational rehabilitation services for the general population, including the homeless, abused, and victims of domestic violence
(Include revenue from providing job training, sheltered workshops, and work experience.)

7005017000

8. Counseling and information services for the general population, including the homeless, abused, and victims of domestic
violence More

7005018000

9. Food, clothing, and related assistance services for the general population, including the homeless, abused, and victims of domestic
violence
(Include social assistance related to donated household goods and food such as soup kitchens, food pantries, and food banks.)

7005019000

10. Shelter and related assistance services for the general population, including the homeless, abused, and victims of domestic
violence

7005020000

11. Other social assistance services for the general population, including the homeless, abused, and victims of domestic violence
(Include social assistance case management and private probation services.)

7005022000

7005010000

12. Children and youth recreational programs More
13. Child care services
(Include disabled children.) More

7005008000

14. Basic education and skills programs
(Include pre-primary grade instructional programs.) More

7003925000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

7003925003

b. Basic education and personal improvement programs and courses, excluding pre-primary instructional programs

7003925006

7005023000

15. Civic and social organization membership services
16. Trade, career, technical and professional development training programs
(Include training services, such as seminars and workshops, to promote social assistance.)

17. Local passenger transportation by road (except fixed-route)

7003950000

7002825000

Add product/service not listed

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

24

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Social assistance services for elderly and disabled adults

a. Prepared on-site meals (i.e., at senior centers)

$

,000.00

7005014003

b. Vocational rehabilitation services

$

,000.00

7005014006

c. Adult day care services

$

,000.00

7005014009

d. Social interaction services, on-site
(Include senior centers.)

$

,000.00

7005014012

e. Counseling and information services More

$

,000.00

7005014015

f. Other social assistance services
(Include social assistance case management services.) More

$

,000.00

7005014018

Subtotal

$

,000.00

7005014000

$

,000.00

7004575003

b. Home aide services for elderly and disabled adults - Personal care services More

$

,000.00

7004575006

c. Home aide services, excluding elderly and disabled adults More

$

,000.00

7004575009

Subtotal

$

,000.00

7004575000

3. Adoption services

$

,000.00

7005002000

4. Foster care and guardianship arrangement services

$

,000.00

7005004000

a. Self-help group services More

$

,000.00

7005006003

b. Information and referral services More

$

,000.00

7005006006

2. Non-medical home aide services
(Include prepared meals and delivered meals.)

a. Home aide services for elderly and disabled adults - Homemaker services More

5. Counseling and information services for children, youth, and families More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

25

c. Hotline/Crisis intervention services More

$

,000.00

7005006009

d. Other counseling and information services
(Include mentoring services.)

$

,000.00

7005006012

Subtotal

$

,000.00

7005006000

6. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

$

,000.00

7005012000

7. Vocational rehabilitation services for the general population, including the homeless, abused, and victims of domestic
violence
(Include revenue from providing job training, sheltered workshops, and work experience.)

$

,000.00

7005017000

8. Counseling and information services for the general population, including the homeless, abused, and victims of
domestic violence More

$

,000.00

7005018000

9. Food, clothing, and related assistance services for the general population, including the homeless, abused, and
victims of domestic violence
(Include social assistance related to donated household goods and food such as soup kitchens, food pantries, and
food banks.)

$

,000.00

7005019000

10. Shelter and related assistance services for the general population, including the homeless, abused, and victims of
domestic violence

$

,000.00

7005020000

11. Other social assistance services for the general population, including the homeless, abused, and victims of domestic
violence
(Include social assistance case management and private probation services.)

$

,000.00

7005022000

12. Children and youth recreational programs More

$

,000.00

7005010000

13. Child care services
(Include disabled children.) More

$

,000.00

7005008000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

$

,000.00

7003925003

b. Basic education and personal improvement programs and courses, excluding pre-primary instructional programs

$

,000.00

7003925006

Subtotal

$

,000.00

7003925000

15. Civic and social organization membership services

$

,000.00

7005023000

16. Trade, career, technical and professional development training programs
(Include training services, such as seminars and workshops, to promote social assistance.)

$

,000.00

7003950000

17. Local passenger transportation by road (except fixed-route)

$

,000.00

7002825000

14. Basic education and skills programs
(Include pre-primary grade instructional programs.) More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

26

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

27

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Social assistance services for elderly and disabled adults

Product Code

7005014000

7005014003

a. Prepared on-site meals (i.e., at senior centers)

7005014006

b. Vocational rehabilitation services

7005014009

c. Adult day care services
d. Social interaction services, on-site
(Include senior centers.)

7005014012

7005014015

e. Counseling and information services More
f. Other social assistance services
(Include social assistance case management services.) More
2. Non-medical home aide services
(Include prepared meals and delivered meals.)

7005014018

7004575000

a. Home aide services for elderly and disabled adults - Homemaker services More

b. Home aide services for elderly and disabled adults - Personal care services More

c. Home aide services, excluding elderly and disabled adults More

7004575003

7004575006

7004575009

7005002000

3. Adoption services

7005004000

4. Foster care and guardianship arrangement services

5. Counseling and information services for children, youth, and families More

7005006000

7005006003

a. Self-help group services More

7005006006

b. Information and referral services More

7005006009

c. Hotline/Crisis intervention services More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

28

d. Other counseling and information services
(Include mentoring services.)

7005006012

6. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

7005012000

7. Vocational rehabilitation services for the general population, including the homeless, abused, and victims of domestic violence
(Include revenue from providing job training, sheltered workshops, and work experience.)

7005017000

8. Counseling and information services for the general population, including the homeless, abused, and victims of domestic
violence More

7005018000

9. Food, clothing, and related assistance services for the general population, including the homeless, abused, and victims of domestic
violence
(Include social assistance related to donated household goods and food such as soup kitchens, food pantries, and food banks.)

7005019000

10. Shelter and related assistance services for the general population, including the homeless, abused, and victims of domestic
violence

7005020000

11. Other social assistance services for the general population, including the homeless, abused, and victims of domestic violence
(Include social assistance case management and private probation services.)

7005022000

7005010000

12. Children and youth recreational programs More
13. Child care services
(Include disabled children.) More

7005008000

14. Basic education and skills programs
(Include pre-primary grade instructional programs.) More

7003925000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

7003925003

b. Basic education and personal improvement programs and courses, excluding pre-primary instructional programs

7003925006

7005023000

15. Civic and social organization membership services
16. Trade, career, technical and professional development training programs
(Include training services, such as seminars and workshops, to promote social assistance.)

17. Local passenger transportation by road (except fixed-route)

7003950000

7002825000

8000025000

18. Government contributions, gifts, and grants
19. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include
commissioned fundraising.)

8000050000

20. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

8000150000

21. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

29

Add product/service not listed

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

30

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Social assistance services for elderly and disabled adults

a. Prepared on-site meals (i.e., at senior centers)

$

,000.00

7005014003

b. Vocational rehabilitation services

$

,000.00

7005014006

c. Adult day care services

$

,000.00

7005014009

d. Social interaction services, on-site
(Include senior centers.)

$

,000.00

7005014012

e. Counseling and information services More

$

,000.00

7005014015

f. Other social assistance services
(Include social assistance case management services.) More

$

,000.00

7005014018

Subtotal

$

,000.00

7005014000

$

,000.00

7004575003

$

,000.00

7004575006

c. Home aide services, excluding elderly and disabled adults More

$

,000.00

7004575009

Subtotal

$

,000.00

7004575000

3. Adoption services

$

,000.00

7005002000

4. Foster care and guardianship arrangement services

$

,000.00

7005004000

a. Self-help group services More

$

,000.00

7005006003

b. Information and referral services More

$

,000.00

7005006006

2. Non-medical home aide services
(Include prepared meals and delivered meals.)

a. Home aide services for elderly and disabled adults - Homemaker services More

b. Home aide services for elderly and disabled adults - Personal care services More

5. Counseling and information services for children, youth, and families More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

31

c. Hotline/Crisis intervention services More

$

,000.00

7005006009

d. Other counseling and information services
(Include mentoring services.)

$

,000.00

7005006012

Subtotal

$

,000.00

7005006000

$

,000.00

7005012000

7. Vocational rehabilitation services for the general population, including the homeless, abused, and victims of domestic
violence
(Include revenue from providing job training, sheltered workshops, and work experience.)

$

,000.00

7005017000

8. Counseling and information services for the general population, including the homeless, abused, and victims of
domestic violence More

$

,000.00

7005018000

9. Food, clothing, and related assistance services for the general population, including the homeless, abused, and
victims of domestic violence
(Include social assistance related to donated household goods and food such as soup kitchens, food pantries, and
food banks.)

$

,000.00

7005019000

10. Shelter and related assistance services for the general population, including the homeless, abused, and victims of
domestic violence

$

,000.00

7005020000

11. Other social assistance services for the general population, including the homeless, abused, and victims of domestic
violence
(Include social assistance case management and private probation services.)

$

,000.00

7005022000

$

,000.00

7005010000

$

,000.00

7005008000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

$

,000.00

7003925003

b. Basic education and personal improvement programs and courses, excluding pre-primary instructional programs

$

,000.00

7003925006

Subtotal

$

,000.00

7003925000

15. Civic and social organization membership services

$

,000.00

7005023000

16. Trade, career, technical and professional development training programs
(Include training services, such as seminars and workshops, to promote social assistance.)

$

,000.00

7003950000

17. Local passenger transportation by road (except fixed-route)

$

,000.00

7002825000

6. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

12. Children and youth recreational programs More
13. Child care services
(Include disabled children.) More
14. Basic education and skills programs
(Include pre-primary grade instructional programs.) More

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

32

18. Government contributions, gifts, and grants

$

,000.00

8000025000

19. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc.
Include commissioned fundraising.)

$

,000.00

8000050000

20. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

$

,000.00

8000150000

21. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

$

,000.00

8000175000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

22. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

33

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

34

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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35

Item 28: Special Items - Grants and Contributions

ITEM 28: SPECIAL ITEMS - GRANTS AND CONTRIBUTIONS
During 2022, did this establishment do any of the following?
Award grants
Make gifts or contributions
Make payments to, or on behalf of, specific individuals
Pay assessments (dues) to the parent or other chapters of the same organization
Transfer funds raised by this establishment to charities or other organizations for charitable purposes
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

36

Item 28: Special Items - Grants and Contributions - Continued

ITEM 28: SPECIAL ITEMS - GRANTS AND CONTRIBUTIONS

2022
What were the amount of grants, transferred contributions, and similar payments?

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

$

,000.00

37

Item 28: Special Items - Social Assistance

ITEM 28: SPECIAL ITEMS - SOCIAL ASSISTANCE
What was the percentage of receipts for social assistance services reported in Item 22, lines 1 through 14b, from the following payers?
2022
%

1. Government payers

2. Private payers

%

3. TOTAL (Sum of lines 1 and 2 should equal 100%.)

%

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

38

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

39

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

40

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

41

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

42

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

43

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

44

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

45

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

46

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

47

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

48

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

1000

characters remaining

49

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_HC-62412_su.pdf Generated 2022-02-17 07:54:40

,000.00

50

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Childcare and selected educational services
Child care services, including those with preschool and/or Head Start programs
(Include services for children with or without disabilities.)

624410 001

Head Start centers and programs
(Include services for children with or without disabilities.)

624410 002

Preschool
(Include services for children with or without disabilities.)

624410 003

Before and/or after school care program, excluding tutoring services and sports and recreational clubs

624410 004

Elementary or secondary school

611110 001

Tutoring and exam preparation services, including college board preparation

611691 003

Babysitting services

624410 005

Case management and other social assistance services for children and youth
Child early intervention center or services for youth with developmental disabilities or delays
(Exclude child care.)

624120 00E

Child care food program

624210 001

Multi-service organization providing a range of social assistance services to children and youth

624110 006

Multi-service organization providing a range of social assistance services to families and individuals, excluding services primarily to children,
the elderly, the disabled, the intellectually and developmentally disabled, or the mentally ill

624190 003

Community action agency

624190 001

Family services agency

624190 002

Adult activity or day care center

624120 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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18

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

2022
$

,000.00

19

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

2022
$

,000.00

$

,000.00

20

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

2022
$

,000.00

$

,000.00

21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Child care services
(Include application, registration, and late fees.)

Product Code

7005008000

7005008003

a. In-home child care services More

7005008006

b. Child care center services More

7003925000

2. Basic education and skills programs More
a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

7003925003

b. Basic education and personal improvement instructional programs
(Exclude pre-primary and sports or recreational instructional programs.)

7003925006

3. Children and youth recreational programs
(Exclude instructional programs.) More

7005010000

4. Counseling and information services for children, youth, and families
(Include mentoring services.)

7005006000

5. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

7005012000

6. Leisure, recreational, and athletic instructional programs
(Include day and/or overnight instructional camps. Exclude overnight recreational camps.)

7002500000

7004025000

7. Academic tutoring and customized learning programs

Add product/service not listed

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Child care services
(Include application, registration, and late fees.)

a. In-home child care services More

$

,000.00

7005008003

b. Child care center services More

$

,000.00

7005008006

Subtotal

$

,000.00

7005008000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

$

,000.00

7003925003

b. Basic education and personal improvement instructional programs
(Exclude pre-primary and sports or recreational instructional programs.)

$

,000.00

7003925006

$

,000.00

7003925000

3. Children and youth recreational programs
(Exclude instructional programs.) More

$

,000.00

7005010000

4. Counseling and information services for children, youth, and families
(Include mentoring services.)

$

,000.00

7005006000

5. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

$

,000.00

7005012000

6. Leisure, recreational, and athletic instructional programs
(Include day and/or overnight instructional camps. Exclude overnight recreational camps.)

$

,000.00

7002500000

7. Academic tutoring and customized learning programs

$

,000.00

7004025000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

2. Basic education and skills programs More

Subtotal

Add product/service not listed

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23

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Child care services
(Include application, registration, and late fees.)

Product Code

7005008000

7005008003

a. In-home child care services More

7005008006

b. Child care center services More

7003925000

2. Basic education and skills programs More
a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

7003925003

b. Basic education and personal improvement instructional programs
(Exclude pre-primary and sports or recreational instructional programs.)

7003925006

3. Children and youth recreational programs
(Exclude instructional programs.) More

7005010000

4. Counseling and information services for children, youth, and families
(Include mentoring services.)

7005006000

5. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

7005012000

6. Leisure, recreational, and athletic instructional programs
(Include day and/or overnight instructional camps. Exclude overnight recreational camps.)

7002500000

7004025000

7. Academic tutoring and customized learning programs

8000025000

8. Government contributions, gifts, and grants
9. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include commissioned
fundraising.)

8000050000

10. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

8000150000

11. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

Add product/service not listed

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24

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Child care services
(Include application, registration, and late fees.)

a. In-home child care services More

$

,000.00

7005008003

b. Child care center services More

$

,000.00

7005008006

Subtotal

$

,000.00

7005008000

a. Pre-primary grade instructional programs
(Include preschool programs combined with child care.)

$

,000.00

7003925003

b. Basic education and personal improvement instructional programs
(Exclude pre-primary and sports or recreational instructional programs.)

$

,000.00

7003925006

Subtotal

$

,000.00

7003925000

3. Children and youth recreational programs
(Exclude instructional programs.) More

$

,000.00

7005010000

4. Counseling and information services for children, youth, and families
(Include mentoring services.)

$

,000.00

7005006000

5. Other social assistance services for children, youth, and families
(Include social assistance case management and vocational rehabilitation services.)

$

,000.00

7005012000

6. Leisure, recreational, and athletic instructional programs
(Include day and/or overnight instructional camps. Exclude overnight recreational camps.)

$

,000.00

7002500000

7. Academic tutoring and customized learning programs

$

,000.00

7004025000

8. Government contributions, gifts, and grants

$

,000.00

8000025000

9. Private contributions, gifts, and grants
(Include contributions, gifts, and grants from individuals, foundations, business and industry, labor unions, etc. Include
commissioned fundraising.)

$

,000.00

8000050000

10. Trading securities and commodity contracts on own account
(Include investment income, interest, and dividends.) More

$

,000.00

8000150000

2. Basic education and skills programs More

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25

11. Gains (losses) from non-financial assets sold
(Report losses by including a minus sign prior to the dollar amount.) More

8000175000

$

,000.00

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

12. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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26

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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27

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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28

Item 28: Special Items - Grants and Contributions

ITEM 28: SPECIAL ITEMS - GRANTS AND CONTRIBUTIONS
During 2022, did this establishment do any of the following?
Award grants
Make gifts or contributions
Make payments to, or on behalf of, specific individuals
Pay assessments (dues) to the parent or other chapters of the same organization
Transfer funds raised by this establishment to charities or other organizations for charitable purposes
Yes
No

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Item 28: Special Items - Grants and Contributions - Continued

ITEM 28: SPECIAL ITEMS - GRANTS AND CONTRIBUTIONS

2022
What were the amount of grants, transferred contributions, and similar payments?

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

$

,000.00

30

Item 28: Special Items - Social Assistance

ITEM 28: SPECIAL ITEMS - SOCIAL ASSISTANCE
What was the percentage of receipts for social assistance services reported in Item 22, lines 1 through 5, from the following payers?
2022
%

1. Government payers

%

2. Private payers

%

3. TOTAL (Sum of lines 1 and 2 should equal 100%.)

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31

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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32

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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33

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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34

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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35

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

42

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_HC-62441_su.pdf Generated 2022-02-17 07:58:02

,000.00

43

Attachment D-17
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 71

Attachment Sector

D-17

71

Instrument
Path
Instrument Path Title

71120
71130
71140
71210

Spectator Sports
Promoters of Performing Arts, Sports, and Similar Events
Agents and Managers for Artists, Athletes, Entertainers, and Other
Public Figures
Museums, Historical Sites, and Similar Institutions

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Professional or semiprofessional sports club
Baseball clubs, professional

711211 321

Baseball clubs, minor-league, semi-professional, and collegiate

711211 421

Football clubs, professional

711211 311

Football clubs, semi-professional and collegiate

711211 411

Basketball clubs, professional

711211 331

Basketball clubs, semi-professional and collegiate

711211 431

Hockey clubs, professional

711211 341

Hockey clubs, semi-professional and collegiate

711211 441

Other sports clubs, professional (e.g., soccer, boxing, etc.)

711211 391

Other sports clubs, semi-professional and collegiate (e.g., soccer, boxing, etc.)

711211 491

Recreational sports team, club, or league with indoor or outdoor facilities

713990 807

Promoters with facilities, live sporting events

711310 301

Promoters without facilities, live sporting events

711320 301

Individual sports professional, including surfers, tennis players, wrestlers, snowboarders, and golfers (Exclude jockeys or race car drivers.)

711219 102

Professional athletes and sports trainers, except jockeys or race car drivers

711219 101

Golf or tennis professional providing instruction only (not participating)

611620 002

Agents or managers for artists, performers, individual sports professionals, authors, speakers, and other public figures

711410 002

Racetrack operation and other racing activities
Auto racetrack

711212 201

Racetrack casino (offering table wagering games), except casino hotels

713210 201

Racetrack casino hotel (offering table wagering games)

721120 201

Horse racetrack operation with other gambling (except table game wagering)

711212 311

Horse racetrack without other gambling activities onsite

711212 321

Dog racetrack operation with other gambling (except table game wagering)

711212 111

Dog racetrack without other gambling activities onsite

711212 121

Race car owner, driver, or team

711219 211

Racing stable, dog or horse - entered in racing events

711219 222

Jockey or harness driver or owner

711219 221

Trainer - animals for racing

711219 223

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15

711219 224

Horse, dog, and other animal racing
Other primary business or activity

779000 001

Other primary business or activity
Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AE-71120_su.pdf Generated 2022-02-18 07:44:06

2022
$

,000.00

$

,000.00

20

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001775000

1. Admissions to live sports events More

2. Live performing arts performances produced under contract More

7010075000

7010275000

3. Live sporting events produced under contract More

7013050000

4. Public relations event management services More
5. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings More

6. Licensing of rights to others to distribute audiovisual works protected by copyright

7. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright

8. Licensing of other rights to use audiovisual works protected by copyright, not elsewhere classified

9. Licensing of rights to use intellectual property protected by trademark More

7009581000

7009575000

7009576000

7009577000

7009625000

7010225000

10. Sporting event broadcast and other media rights More

7010225003

a. Sporting event broadcast rights

7010225006

b. Other sporting event media rights

7002310000

11. Sports coaching services More

7012275000

12. Advertising space in printed publications More

7012300000

13. Television air time for advertising

7012325000

14. Radio air time for advertising

7012350000

15. Internet advertising

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21

7012375000

16. Leased display advertising media space More

7012410000

17. Other advertising space, time, and similar services

7012410006

a. Venue naming rights More

7012410009

b. Sponsorship rights More

7012410012

c. Endorsement services More

7012410015

d. Exclusivity rights More

e. Advertising space, time, and similar services, not elsewhere classified

7012410018

7017200000

18. Race animal training services

7002400000

19. Pari-mutuel sports gambling More

a. Pari-mutuel sports gambling, on the event premises More

b. Pari-mutuel sports gambling, away from the event premises

7002400003

7002400006

7002375000

20. Gambling machine products More

7002350000

21. Table wagering games

7002750000

22. Parking services

23. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

24. Alcoholic beverages, prepared and served or dispensed for immediate consumption

25. Hosting of coin-operated self-service gambling machines More

26. Rental of space for sporting, entertainment, and other events

7000025000

7000050000

7006550000

7006500000

5000350000

27. Retail sales of men's clothing

5000375000

28. Retail sales of women's clothing

29. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including school uniforms

2022_AE-71120_su.pdf Generated 2022-02-18 07:44:06

5000400000

22

30. Retail sales of household goods, not elsewhere classified

5000860000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to live sports events More

$

,000.00

7001775000

2. Live performing arts performances produced under contract More

$

,000.00

7010075000

3. Live sporting events produced under contract More

$

,000.00

7010275000

4. Public relations event management services More

$

,000.00

7013050000

5. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings More

$

,000.00

7009581000

6. Licensing of rights to others to distribute audiovisual works protected by copyright

$

,000.00

7009575000

7. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright

$

,000.00

7009576000

8. Licensing of other rights to use audiovisual works protected by copyright, not elsewhere classified

$

,000.00

7009577000

9. Licensing of rights to use intellectual property protected by trademark More

$

,000.00

7009625000

a. Sporting event broadcast rights

$

,000.00

7010225003

b. Other sporting event media rights

$

,000.00

7010225006

$

,000.00

7010225000

11. Sports coaching services More

$

,000.00

7002310000

12. Advertising space in printed publications More

$

,000.00

7012275000

13. Television air time for advertising

$

,000.00

7012300000

14. Radio air time for advertising

$

,000.00

7012325000

15. Internet advertising

$

,000.00

7012350000

10. Sporting event broadcast and other media rights More

Subtotal

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24

$

,000.00

7012375000

a. Venue naming rights More

$

,000.00

7012410006

b. Sponsorship rights More

$

,000.00

7012410009

$

,000.00

7012410012

d. Exclusivity rights More

$

,000.00

7012410015

e. Advertising space, time, and similar services, not elsewhere classified

$

,000.00

7012410018

Subtotal

$

,000.00

7012410000

$

,000.00

7017200000

a. Pari-mutuel sports gambling, on the event premises More

$

,000.00

7002400003

b. Pari-mutuel sports gambling, away from the event premises

$

,000.00

7002400006

Subtotal

$

,000.00

7002400000

20. Gambling machine products More

$

,000.00

7002375000

21. Table wagering games

$

,000.00

7002350000

22. Parking services

$

,000.00

7002750000

23. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

24. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

25. Hosting of coin-operated self-service gambling machines More

$

,000.00

7006550000

26. Rental of space for sporting, entertainment, and other events

$

,000.00

7006500000

27. Retail sales of men's clothing

$

,000.00

5000350000

16. Leased display advertising media space More
17. Other advertising space, time, and similar services

c. Endorsement services More

18. Race animal training services
19. Pari-mutuel sports gambling More

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25

28. Retail sales of women's clothing

$

,000.00

5000375000

29. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including
school uniforms

$

,000.00

5000400000

30. Retail sales of household goods, not elsewhere classified

$

,000.00

5000860000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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30

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

38

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

39

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Facility operators, including operators promoting arts, sports, and similar events
Promoters with facilities, live performing arts productions (except popular music)

711310 101

Promoters with facilities, live popular music productions

711310 201

Promoters with facilities, live sporting events

711310 301

Promoters with facilities, other live events (i.e. - agricultural fair, beauty pageant)

711310 401

Owner of theater, arena, stadium, or similar facility but not promoting or presenting shows or events - only renting facility to others

531120 905

Promoters of arts, sports, and similar events, without facilities
Promoters without facilities, live popular music productions

711320 201

Promoters without facilities, live sporting events

711320 301

Promoters without facilities, live performing arts productions (except popular music)

711320 101

Promoters without facilities, other live events (i.e. - agricultural fair, beauty pageant)

711320 401

Agents and managers for artists, athletes, entertainers, and other public figures
Agents or managers for artists, performers, individual sports professionals, authors, speakers, and other public figures

711410 002

Talent agency

711410 004

Authors, speakers, and other non-performing artists' agent

711410 001

Modeling agency

711410 005

Literary agency

711410 006

Speakers bureau

711410 003

Independent artists, writers, and performers
Actor, actress, comedian, or other independent entertainer

711510 001

Author, writer, or composer

711510 004

Independent film director or other motion picture artist or technician

711510 002

Other music groups and artists (e.g., bands, musicians, choirs, independent musicians), except symphony orchestras and chamber music
organizations

711130 901

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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18

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

2022
$

,000.00

19

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

2022
$

,000.00

$

,000.00

20

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

2022
$

,000.00

$

,000.00

21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001600000

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

b. Admissions to live musical theater and opera performances

c. Admissions to live symphony and classical music performances

7001600003

7001600006

7001600009

7001600012

d. Admissions to live popular music performances

e. Admissions to live dance performances, musical and non-musical

7001600015

7001600018

f. Admissions to live public appearances and speeches

g. Admissions to live performing arts performances, not elsewhere classified

7001600021

7001775000

2. Admissions to live sports events More

3. Live performing arts performances produced under contract More

7010075000

7010275000

4. Live sporting events produced under contract More

7013050000

5. Public relations event management services

7010100000

6. Audiovisual performances produced under contract

7010225000

7. Sporting event broadcast and other media rights More

7010225003

a. Sporting event broadcast rights

7010225006

b. Other sporting event media rights

7012275000

8. Advertising space in printed publications

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

22

7012300000

9. Television air time for advertising

7012325000

10. Radio air time for advertising

7012350000

11. Internet advertising

7012375000

12. Leased display advertising media space

13. Advertising space in publications on electronic and other media, except online

7012400000

7012410000

14. Other advertising space, time, and similar services

7012410006

a. Venue naming rights More

7012410009

b. Sponsorship rights More

7012410012

c. Endorsement services More

7012410015

d. Exclusivity rights More

e. Advertising space, time, and similar services, not elsewhere classified More

15. Membership services of performing arts societies and cultural institutions More

16. Other membership (including religious congregation) services

17. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption

19. Rental of space for sporting, entertainment, and other events

7012410018

7001650000

7005024000

7000025000

7000050000

7006500000

7006375000

20. Rental and leasing of commercial space More

Add product/service not listed

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

23

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

$

,000.00

7001600003

b. Admissions to live musical theater and opera performances

$

,000.00

7001600006

c. Admissions to live symphony and classical music performances

$

,000.00

7001600009

d. Admissions to live popular music performances

$

,000.00

7001600012

e. Admissions to live dance performances, musical and non-musical

$

,000.00

7001600015

f. Admissions to live public appearances and speeches

$

,000.00

7001600018

g. Admissions to live performing arts performances, not elsewhere classified

$

,000.00

7001600021

$

,000.00

7001600000

2. Admissions to live sports events More

$

,000.00

7001775000

3. Live performing arts performances produced under contract More

$

,000.00

7010075000

4. Live sporting events produced under contract More

$

,000.00

7010275000

5. Public relations event management services

$

,000.00

7013050000

6. Audiovisual performances produced under contract

$

,000.00

7010100000

a. Sporting event broadcast rights

$

,000.00

7010225003

b. Other sporting event media rights

$

,000.00

7010225006

Subtotal

$

,000.00

7010225000

Subtotal

7. Sporting event broadcast and other media rights More

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

24

8. Advertising space in printed publications

$

,000.00

7012275000

9. Television air time for advertising

$

,000.00

7012300000

$

,000.00

7012325000

11. Internet advertising

$

,000.00

7012350000

12. Leased display advertising media space

$

,000.00

7012375000

13. Advertising space in publications on electronic and other media, except online

$

,000.00

7012400000

a. Venue naming rights More

$

,000.00

7012410006

b. Sponsorship rights More

$

,000.00

7012410009

c. Endorsement services More

$

,000.00

7012410012

d. Exclusivity rights More

$

,000.00

7012410015

e. Advertising space, time, and similar services, not elsewhere classified More

$

,000.00

7012410018

Subtotal

$

,000.00

7012410000

15. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

16. Other membership (including religious congregation) services

$

,000.00

7005024000

17. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

19. Rental of space for sporting, entertainment, and other events

$

,000.00

7006500000

20. Rental and leasing of commercial space More

$

,000.00

7006375000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

10. Radio air time for advertising

14. Other advertising space, time, and similar services

Add product/service not listed

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

25

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001600000

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

b. Admissions to live musical theater and opera performances

c. Admissions to live symphony and classical music performances

7001600003

7001600006

7001600009

7001600012

d. Admissions to live popular music performances

e. Admissions to live dance performances, musical and non-musical

7001600015

7001600018

f. Admissions to live public appearances and speeches

g. Admissions to live performing arts performances, not elsewhere classified

7001600021

7001775000

2. Admissions to live sports events More

3. Live performing arts performances produced under contract More

7010075000

7010275000

4. Live sporting events produced under contract More

7013050000

5. Public relations event management services

7010100000

6. Audiovisual performances produced under contract

7010225000

7. Sporting event broadcast and other media rights More

7010225003

a. Sporting event broadcast rights

7010225006

b. Other sporting event media rights

7012275000

8. Advertising space in printed publications

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

26

7012300000

9. Television air time for advertising

7012325000

10. Radio air time for advertising

7012350000

11. Internet advertising

7012375000

12. Leased display advertising media space

13. Advertising space in publications on electronic and other media, except online

7012400000

7012410000

14. Other advertising space, time, and similar services
a. Venue naming rights
Report receipts from granting the right to name a performing arts or spectator sports venue. This right is typically sold to companies
and serves to increase exposure of a company's brand name.

7012410006

b. Sponsorship rights
Report receipts from granting the right to associate specific goods or services, or a corporation or other entity, with an activity,
product, or project that is carried out by another entity. Sponsorships usually include the provision of advertising display space and
may include exclusivity rights.

7012410009

c. Endorsement services
Report receipts from providing product endorsements by individual professional athletes, performing artists, sports teams, or
performing arts groups or companies.

7012410012

d. Exclusivity rights
Report receipts from granting the right to require that all sellers of a specified good or service sell only specific brands of that good or
service (i.e., pouring rights).

7012410015

e. Advertising space, time, and similar services, not elsewhere classified
Report receipts from providing services that attract attention to a product, business, cause, etc., not elsewhere specified. Include the
creation of advertising messages.

7012410018

15. Membership services of performing arts societies and cultural institutions More

16. Other membership (including religious congregation) services

17. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption

19. Rental of space for sporting, entertainment, and other events

7001650000

7005024000

7000025000

7000050000

7006500000

7006375000

20. Rental and leasing of commercial space More

8000025000

21. Government contributions, gifts, and grants

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

27

a. Contributions, gifts, and grants from the National Endowment for the Arts

b. All other federal, state, county, and municipal contributions, gifts, and grants

8000025003

8000025006

8000050000

22. Private contributions, gifts, and grants

8000050003

a. Private contributions, gifts, and grants from individuals

b. Private contributions, gifts, and grants from foundations

c. Private contributions, gifts, and grants from business and industry

d. Other contributions, gifts, and grants, including from labor unions, etc.

23. Program service revenue including government fees and contracts

8000050006

8000050009

8000050012

8000200000

8000175000

24. Gains (losses) from non-financial assets sold More

25. Trading securities and commodity contracts on own account

8000150000

Add product/service not listed

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

28

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

$

,000.00

7001600003

b. Admissions to live musical theater and opera performances

$

,000.00

7001600006

c. Admissions to live symphony and classical music performances

$

,000.00

7001600009

d. Admissions to live popular music performances

$

,000.00

7001600012

e. Admissions to live dance performances, musical and non-musical

$

,000.00

7001600015

f. Admissions to live public appearances and speeches

$

,000.00

7001600018

g. Admissions to live performing arts performances, not elsewhere classified

$

,000.00

7001600021

$

,000.00

7001600000

2. Admissions to live sports events More

$

,000.00

7001775000

3. Live performing arts performances produced under contract More

$

,000.00

7010075000

4. Live sporting events produced under contract More

$

,000.00

7010275000

5. Public relations event management services

$

,000.00

7013050000

$

,000.00

7010100000

a. Sporting event broadcast rights

$

,000.00

7010225003

b. Other sporting event media rights

$

,000.00

7010225006

Subtotal

$

,000.00

7010225000

Subtotal

6. Audiovisual performances produced under contract
7. Sporting event broadcast and other media rights More

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

29

8. Advertising space in printed publications

$

,000.00

7012275000

9. Television air time for advertising

$

,000.00

7012300000

$

,000.00

7012325000

11. Internet advertising

$

,000.00

7012350000

12. Leased display advertising media space

$

,000.00

7012375000

13. Advertising space in publications on electronic and other media, except online

$

,000.00

7012400000

a. Venue naming rights
Report receipts from granting the right to name a performing arts or spectator sports venue. This right is typically sold
to companies and serves to increase exposure of a company's brand name.

$

,000.00

7012410006

b. Sponsorship rights
Report receipts from granting the right to associate specific goods or services, or a corporation or other entity, with an
activity, product, or project that is carried out by another entity. Sponsorships usually include the provision of
advertising display space and may include exclusivity rights.

$

,000.00

7012410009

c. Endorsement services
Report receipts from providing product endorsements by individual professional athletes, performing artists, sports
teams, or performing arts groups or companies.

$

,000.00

7012410012

d. Exclusivity rights
Report receipts from granting the right to require that all sellers of a specified good or service sell only specific brands
of that good or service (i.e., pouring rights).

$

,000.00

7012410015

$

,000.00

7012410018

$

,000.00

7012410000

15. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

16. Other membership (including religious congregation) services

$

,000.00

7005024000

17. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

19. Rental of space for sporting, entertainment, and other events

$

,000.00

7006500000

20. Rental and leasing of commercial space More

$

,000.00

7006375000

10. Radio air time for advertising

14. Other advertising space, time, and similar services

e. Advertising space, time, and similar services, not elsewhere classified
Report receipts from providing services that attract attention to a product, business, cause, etc., not elsewhere
specified. Include the creation of advertising messages.

Subtotal

2022_AE-71130_su.pdf Generated 2022-02-18 07:42:59

30

21. Government contributions, gifts, and grants
a. Contributions, gifts, and grants from the National Endowment for the Arts

$

,000.00

8000025003

b. All other federal, state, county, and municipal contributions, gifts, and grants

$

,000.00

8000025006

Subtotal

$

,000.00

8000025000

a. Private contributions, gifts, and grants from individuals

$

,000.00

8000050003

b. Private contributions, gifts, and grants from foundations

$

,000.00

8000050006

c. Private contributions, gifts, and grants from business and industry

$

,000.00

8000050009

d. Other contributions, gifts, and grants, including from labor unions, etc.

$

,000.00

8000050012

$

,000.00

8000050000

23. Program service revenue including government fees and contracts

$

,000.00

8000200000

24. Gains (losses) from non-financial assets sold More

$

,000.00

8000175000

25. Trading securities and commodity contracts on own account

$

,000.00

8000150000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

22. Private contributions, gifts, and grants

Subtotal

26. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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31

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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32

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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33

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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34

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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35

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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36

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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41

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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42

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

43

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

44

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Facility operators, including operators promoting arts, sports, and similar events
Promoters with facilities, live performing arts productions (except popular music)

711310 101

Promoters with facilities, live sporting events

711310 301

Promoters with facilities, other live events (i.e. - agricultural fair, beauty pageant)

711310 401

Owner of theater, arena, stadium, or similar facility but not promoting or presenting shows or events - only renting facility to others

531120 905

Promoters of arts, sports, and similar events, without facilities
Promoters without facilities, live popular music productions

711320 201

Promoters without facilities, live performing arts productions (except popular music)

711320 101

Promoters without facilities, live sporting events

711320 301

Promoters without facilities, other live events (i.e. - agricultural fair, beauty pageant)

711320 401

Film festival exhibitor

512131 002

Agents and managers for artists, athletes, entertainers, and other public figures
Agents or managers for artists, performers, individual sports professionals, authors, speakers, and other public figures

711410 002

Talent agency

711410 004

Authors, speakers, and other non-performing artists' agent

711410 001

Modeling agency

711410 005

Literary agency

711410 006

Speakers bureau

711410 003

Independent artists, writers, and performers
Actor, actress, comedian, or other independent entertainer

711510 001

Author, writer, or composer

711510 004

Independent film director or other motion picture artist or technician

711510 002

Other music groups and artists (e.g., bands, musicians, choirs, independent musicians), except symphony orchestras and chamber music
organizations

711130 901

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AE-71140_su.pdf Generated 2022-02-18 07:45:09

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001600000

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

b. Admissions to live musical theater and opera performances

c. Admissions to live symphony and classical music performances

7001600003

7001600006

7001600009

7001600012

d. Admissions to live popular music performances

e. Admissions to live dance performances, musical and non-musical

7001600015

7001600018

f. Admissions to live public appearances and speeches

g. Admissions to live performing arts performances, not elsewhere classified

2. Live performing arts performances produced under contract More
3. Public relations event management services, including sports and performing arts event organization and management
services More

7001600021

7010075000

7013050000

7014950000

4. Career management services More

7014975000

5. Representation services More

7014975003

a. Performance contract representation services

b. Sponsorship and endorsement contract representation services

7014975006

7014975009

c. Other contract representation services

6. Outright sale of rights to intellectual property works protected by copyright More

7009550000

7010100000

7. Audiovisual performances produced under contract

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20

8. Other artistic and literary intellectual property protected by copyright produced under contract, except live performances and
audiovisual works More

7010125000

9. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical compositions and
recordings More

7009581000

10. Licensing of rights to use musical compositions protected by copyright

11. Licensing of rights to others to distribute audiovisual works protected by copyright

12. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright

13. Licensing of other rights to use audiovisual works protected by copyright, not elsewhere classified

14. Licensing of rights to use intellectual property protected by trademark More

7009578000

7009575000

7009576000

7009577000

7009625000

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to live performing arts performances More

a. Admissions to live theatrical performances, non-musical

$

,000.00

7001600003

b. Admissions to live musical theater and opera performances

$

,000.00

7001600006

c. Admissions to live symphony and classical music performances

$

,000.00

7001600009

d. Admissions to live popular music performances

$

,000.00

7001600012

e. Admissions to live dance performances, musical and non-musical

$

,000.00

7001600015

$

,000.00

7001600018

g. Admissions to live performing arts performances, not elsewhere classified

$

,000.00

7001600021

Subtotal

$

,000.00

7001600000

2. Live performing arts performances produced under contract More

$

,000.00

7010075000

3. Public relations event management services, including sports and performing arts event organization and
management services More

$

,000.00

7013050000

4. Career management services More

$

,000.00

7014950000

a. Performance contract representation services

$

,000.00

7014975003

b. Sponsorship and endorsement contract representation services

$

,000.00

7014975006

c. Other contract representation services

$

,000.00

7014975009

Subtotal

$

,000.00

7014975000

$

,000.00

7009550000

f. Admissions to live public appearances and speeches

5. Representation services More

6. Outright sale of rights to intellectual property works protected by copyright More

2022_AE-71140_su.pdf Generated 2022-02-18 07:45:09

22

$

,000.00

7010100000

8. Other artistic and literary intellectual property protected by copyright produced under contract, except live
performances and audiovisual works More

$

,000.00

7010125000

9. Licensing of rights to use intellectual property protected by copyright, excluding audiovisual works and musical
compositions and recordings More

$

,000.00

7009581000

10. Licensing of rights to use musical compositions protected by copyright

$

,000.00

7009578000

11. Licensing of rights to others to distribute audiovisual works protected by copyright

$

,000.00

7009575000

12. Licensing of rights to exhibit, broadcast, or rent audiovisual works protected by copyright

$

,000.00

7009576000

13. Licensing of other rights to use audiovisual works protected by copyright, not elsewhere classified

$

,000.00

7009577000

14. Licensing of rights to use intellectual property protected by trademark More

$

,000.00

7009625000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

7. Audiovisual performances produced under contract

Add product/service not listed

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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27

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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29

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

35

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

36

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Museums and art galleries
Museums

712110 003

Historic or heritage site

712120 001

Art gallery or exhibitor with receipts primarily from admissions, contributions, and/or grants

712110 001

Art gallery with receipts primarily from sales or commissions on sales of artwork

453920 002

Art council

813410 402

Botanical or zoological garden
Botanical gardens and other live plant exhibits (e.g., arboretum, botanical conservatories, plant exhibition, etc.)

712130 201

Zoos, aquariums, and other live animal exhibits (e.g., wild animal or safari parks, petting zoos, etc.)

712130 101

Tree, plant, and flower exhibitions

712130 203

Other attractions or exhibits
Planetarium, observatory, or science center

712110 002

Nature parks and other similar institutions, including wildlife sanctuaries, and conservation areas

712190 001

Conservation area, nature park, or preserve

712190 002

Caverns, natural wonders, nature trails, and similar tourist attractions

712190 003

Foundation - not operating museums, zoos, etc.

813211 003

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

19

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_AE-71210_su.pdf Generated 2022-02-18 07:53:15

2022
$

,000.00

$

,000.00

20

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AE-71210_su.pdf Generated 2022-02-18 07:53:15

2022
$

,000.00

$

,000.00

21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001625000

1. Admissions to cultural institutions More
a. Admissions to museums

7001625003

Include receipts from access or attendance to science centers.

7001625006

b. Admissions to historic sites

7001625009

c. Admissions to botanical gardens

7001625012

d. Admissions to zoological and similar institutions

7001625015

e. Admissions to nature parks and other natural areas

2. Membership services of performing arts societies and cultural institutions More

7001650000

7001675000

3. Traveling exhibits More
4. Leisure, recreational, and athletic instructional programs (Include day and/or overnight camp. Include dance, music, and arts
instruction. Exclude overnight recreational camps.) More

7002500000

7003225000

5. Tour guide services

6. School visits, children's parties and similar children's programs of cultural institutions

7001725000

7001575000

7. Admissions to film exhibitions

7001600000

8. Admissions to live performing arts performances

9. Conservation services for artistic, historical, and cultural works More

7017100000

7002325000

10. Amusement park and arcade services

7002750000

11. Parking services

7003850000

12. Recreational vehicle and tent sites for travelers

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22

13. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

14. Alcoholic beverages, prepared and served or dispensed for immediate consumption

7000025000

7000050000

7006375000

15. Rental and leasing of commercial space More

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to cultural institutions More
a. Admissions to museums

$

,000.00

7001625003

b. Admissions to historic sites

$

,000.00

7001625006

c. Admissions to botanical gardens

$

,000.00

7001625009

d. Admissions to zoological and similar institutions

$

,000.00

7001625012

e. Admissions to nature parks and other natural areas

$

,000.00

7001625015

Subtotal

$

,000.00

7001625000

2. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

3. Traveling exhibits More

$

,000.00

7001675000

4. Leisure, recreational, and athletic instructional programs (Include day and/or overnight camp. Include dance, music,
and arts instruction. Exclude overnight recreational camps.) More

$

,000.00

7002500000

5. Tour guide services

$

,000.00

7003225000

6. School visits, children's parties and similar children's programs of cultural institutions

$

,000.00

7001725000

7. Admissions to film exhibitions

$

,000.00

7001575000

8. Admissions to live performing arts performances

$

,000.00

7001600000

9. Conservation services for artistic, historical, and cultural works More

$

,000.00

7017100000

10. Amusement park and arcade services

$

,000.00

7002325000

11. Parking services

$

,000.00

7002750000

Include receipts from access or attendance to science centers.

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24

12. Recreational vehicle and tent sites for travelers

$

,000.00

7003850000

13. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

14. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

15. Rental and leasing of commercial space More

$

,000.00

7006375000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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25

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7001625000

1. Admissions to cultural institutions More
a. Admissions to museums

7001625003

Include receipts from access or attendance to science centers.

7001625006

b. Admissions to historic sites

7001625009

c. Admissions to botanical gardens

7001625012

d. Admissions to zoological and similar institutions

7001625015

e. Admissions to nature parks and other natural areas

2. Membership services of performing arts societies and cultural institutions More

7001650000

7001675000

3. Traveling exhibits More

4. Leisure, recreational, and athletic instructional programs More

7002500000

7003225000

5. Tour guide services

6. School visits, children's parties and similar children's programs of cultural institutions

7001725000

7001575000

7. Admissions to film exhibitions

7001600000

8. Admissions to live performing arts performances

9. Conservation services for artistic, historical, and cultural works More

7017100000

7002325000

10. Amusement park and arcade services

7002750000

11. Parking services

7003850000

12. Recreational vehicle and tent sites for travelers

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26

13. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

14. Alcoholic beverages, prepared and served or dispensed for immediate consumption

7000025000

7000050000

7006375000

15. Rental and leasing of commercial space More

8000025000

16. Government contributions, gifts, and grants

a. Contributions, gifts, and grants from the National Endowment for the Arts

b. All other federal, state, county, and municipal contributions, gifts, and grants

8000025003

8000025006

8000050000

17. Private contributions, gifts, and grants

8000050003

a. Private contributions, gifts, and grants from individuals

b. Private contributions, gifts, and grants from foundations

c. Private contributions, gifts, and grants from business and industry

d. Other contributions, gifts, and grants, including from labor unions, etc.

18. Program service revenue including government fees and contracts

8000050006

8000050009

8000050012

8000200000

8000175000

19. Gains (losses) from non-financial assets sold

20. Trading securities and commodity contracts on own account

8000150000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Admissions to cultural institutions More
a. Admissions to museums

$

,000.00

7001625003

b. Admissions to historic sites

$

,000.00

7001625006

c. Admissions to botanical gardens

$

,000.00

7001625009

d. Admissions to zoological and similar institutions

$

,000.00

7001625012

e. Admissions to nature parks and other natural areas

$

,000.00

7001625015

Subtotal

$

,000.00

7001625000

2. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

3. Traveling exhibits More

$

,000.00

7001675000

4. Leisure, recreational, and athletic instructional programs More

$

,000.00

7002500000

5. Tour guide services

$

,000.00

7003225000

6. School visits, children's parties and similar children's programs of cultural institutions

$

,000.00

7001725000

7. Admissions to film exhibitions

$

,000.00

7001575000

8. Admissions to live performing arts performances

$

,000.00

7001600000

9. Conservation services for artistic, historical, and cultural works More

$

,000.00

7017100000

10. Amusement park and arcade services

$

,000.00

7002325000

11. Parking services

$

,000.00

7002750000

Include receipts from access or attendance to science centers.

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28

12. Recreational vehicle and tent sites for travelers

$

,000.00

7003850000

13. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

14. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

15. Rental and leasing of commercial space More

$

,000.00

7006375000

a. Contributions, gifts, and grants from the National Endowment for the Arts

$

,000.00

8000025003

b. All other federal, state, county, and municipal contributions, gifts, and grants

$

,000.00

8000025006

$

,000.00

8000025000

a. Private contributions, gifts, and grants from individuals

$

,000.00

8000050003

b. Private contributions, gifts, and grants from foundations

$

,000.00

8000050006

c. Private contributions, gifts, and grants from business and industry

$

,000.00

8000050009

d. Other contributions, gifts, and grants, including from labor unions, etc.

$

,000.00

8000050012

$

,000.00

8000050000

18. Program service revenue including government fees and contracts

$

,000.00

8000200000

19. Gains (losses) from non-financial assets sold

$

,000.00

8000175000

$

,000.00

8000150000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

16. Government contributions, gifts, and grants

Subtotal

17. Private contributions, gifts, and grants

Subtotal

20. Trading securities and commodity contracts on own account

21. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

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9900000002

29

Add product/service not listed

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30

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

42

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

43

Attachment D-18
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 72

Attachment Sector

D-18

72

Instrument
Path
Instrument Path Title

7200C
72110
72130
72230

Accommodation, Food Services, and Drinking Places (Classification)
Traveler Accommodation
Rooming and Boarding Houses
Special Food Services

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 3: Operational Status

ITEM 3: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3: Operational Status - Ceased Operation Date

ITEM 3: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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4

Item 3: Operational Status - New Owner or Operator Information

ITEM 3 - OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

State

ZIP Code
99999-9999

EIN
99-9999999

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Limited-service restaurant (patrons pay before eating), including delivery-only and take-out-only locations

722513 005

Fast food restaurant

722513 002

Bar, tavern, pub, or other drinking place, selling alcoholic beverages for consumption on premises

722410 001

Coffee shop

722515 501

Ice cream/soft serve shop

722515 101

Frozen yogurt shop

722515 201

Doughnut shop, selling for carry-out or eat-in customers

722515 301

Cookie shop

722515 601

Bagel shop, selling for carry-out or eat-in customers

722515 401

Bakery cafe, primarily selling baked goods for eat-in customers

722515 701

Bakery, primarily selling goods baked on premises for carry-out customers (no customer seating)

311811 002

Bakery, primarily selling goods not baked on premises for carry-out customers

445291 001

Pizza take-and-bake store

445299 007

Meal assembly kitchen or store

445299 006

Delicatessen, primarily preparing sandwiches and meals for immediate consumption

722513 004

Delicatessen, primarily selling fresh and prepared meats

445210 001

Supermarket or grocery store, including delicatessen primarily selling meats and a range of grocery items

445110 006

Specialty snack or nonalcoholic beverage shop/stand not listed above (such as pretzel, cupcake, soda, smoothie, or juice shop/stand) selling
from a permanent location for immediate consumption on or near the premises

722515 702

Cafeteria, buffet, or grill buffet, not operating on a contract basis

722514 001

School, university, corporate, government, or other facility cafeteria/dining, operating on a contract basis

722310 001

Contract feeding/food service contractor, including school, university, corporate, government, or other facility cafeteria/dining

722310 007

Caterer for banquets, weddings, etc.

722320 001

Mobile food service, including ice cream, snacks, sandwiches, and meals distributed from trucks, carts, or other vehicles

722330 001

Convenience food store

445120 001

Liquor store

445310 001

Bar or restaurant operated by social or fraternal organization for members

813410 403

Dinner theater, operating food service but not producing shows

722511 002

Trailer park, recreational vehicle (RV) park, or campground, except residential

721211 001

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Sporting or recreation camp, including fishing camp, dude ranch, etc.

721214 001

Bed-and-breakfast inn

721191 001

Hotel (except with casino), motel, or motor hotel

721110 002

Rooming and boarding house including lodging house operated by membership organization

721310 001

Other primary business or activity

779000 001

Select Sector

Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

8

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Hotel (except with casino), motel, or motor hotel

721110 002

Hotel resort with golf course, spa, and/or conference center

721110 003

Bed-and-breakfast inn

721191 001

Casino hotel (gambling) with guestrooms for lodging

721120 101

Casino without guestrooms for lodging (operating table-wagering games such as blackjack, roulette, keno, and craps along with other
gambling activities such as slot machines and sports betting)

713210 101

Ski area or resort with guestrooms for lodging

721110 001

Ski facility, area, or resort without guestrooms for lodging (including operating equipment such as ski lifts and tows)

713920 001

Room and boarding houses, dormitories and workers' camps, including dormitories (off campus), and fraternity and sorority houses

721310 002

All other traveler accommodation, including cabins, guest houses, villas, cottage resorts, and hostels

721199 001

Home for the elderly, including independent living or assisted living facilities WITHOUT on-site nursing care facility

623312 002

Property owners' association, including home owners', condominium owners', and cooperative owners' associations (Not strictly providing
property management.)

813990 401

Sporting or recreation camp, including fishing camp, dude ranch, etc.

721214 001

Trailer park, recreational vehicle (RV) park, or campground, except residential

721211 001

Bar or restaurant operated by social or fraternal organization for members

813410 403

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AF-72110_su.pdf Generated 2022-02-18 07:55:31

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

What were the operating receipts and sales of other merchandise in 2022? (Exclude sales taxes or other taxes
collected.)
For further clarification, click the "Additional Information" link above.

2022_AF-72110_su.pdf Generated 2022-02-18 07:55:31

Check
if
None

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
Estimate the percentage of this establishment's total sales (reported in Item 5) by class of customer.
2022
%

1. Household consumers and individuals
2. Businesses
(billed to expense accounts)

%

3. Governmental bodies
(Federal, state, and local)

%

TOTAL (Sum of lines 1 through 3 should equal 100%.)

%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7003825000

1. Room or unit accommodation for travelers

a. Room or unit accommodation for travelers, with maid service

b. Room or unit accommodation for travelers, without maid service

c. Shared-room accommodation for travelers, including hostel rooms for short-term accommodation

7003825003

7003825006

7003825009

7003850000

2. Recreational vehicle and tent sites for travelers More

3. Home, apartment, rooming house, and other residential space rental and leasing

7000275000

7002350000

4. Table wagering games

5. Gambling machine products, including slot machines and video lottery terminals

7002375000

7002400000

6. Pari-mutuel sports gambling

7. Sale of tickets of/for lotteries and other games of chance to gamblers, for a fee or commission

7002475000

7002425000

8. Sports and other bookmaking
9. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and salad bars, and
prepared sandwiches, dishes, and entrees.)

10. Retail sales of candy, prepackaged cookies, and snack foods

5000150000

5000200000

5000250000

11. Retail sales of soft drinks and nonalcoholic beverages

5000300000

12. Retail sales of alcoholic beverages
13. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

14. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

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5000325000

5000860000

21

15. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

16. Alcoholic beverages, prepared and served or dispensed for immediate consumption

17. Meals, snacks, other food items, and beverages prepared for catered events

18. Short-term access to communications services, including telephone and internet services

19. Short-term entertainment access services including pay-per-view services

7000025000

7000050000

7000060000

7014175000

7003875000

7017275000

20. Laundry and dry-cleaning agency services

21. Laundry machines operated by coin, card, or by an attendant

7000100000

7002750000

22. Parking services
23. Rental of home audiovisual equipment (including cable program distribution equipment), components, and accessories, except
computers and peripherals

7000925000

24. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles, and musical
instruments)

7001800000

7006375000

25. Rental and leasing of commercial space More
26. Rental and leasing of nonresidential space in buildings or other facilities for business or social use, exclude hosting of coinoperated self-service gambling machines and vending machine hosting More

7006575000

7001600000

27. Admissions to live performing arts performances

28. Admissions to dance halls and clubs (including cover charges)

7002000000

7001850000

29. Golf course and country club services

7001875000

30. Skiing facility services

Add product/service not listed

2022_AF-72110_su.pdf Generated 2022-02-18 07:55:31

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Room or unit accommodation for travelers

a. Room or unit accommodation for travelers, with maid service

$

,000.00

7003825003

b. Room or unit accommodation for travelers, without maid service

$

,000.00

7003825006

c. Shared-room accommodation for travelers, including hostel rooms for short-term accommodation

$

,000.00

7003825009

Subtotal

$

,000.00

7003825000

2. Recreational vehicle and tent sites for travelers More

$

,000.00

7003850000

3. Home, apartment, rooming house, and other residential space rental and leasing

$

,000.00

7000275000

$

,000.00

7002350000

5. Gambling machine products, including slot machines and video lottery terminals

$

,000.00

7002375000

6. Pari-mutuel sports gambling

$

,000.00

7002400000

7. Sale of tickets of/for lotteries and other games of chance to gamblers, for a fee or commission

$

,000.00

7002475000

8. Sports and other bookmaking

$

,000.00

7002425000

9. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and
salad bars, and prepared sandwiches, dishes, and entrees.)

$

,000.00

5000150000

10. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

11. Retail sales of soft drinks and nonalcoholic beverages

$

,000.00

5000250000

12. Retail sales of alcoholic beverages

$

,000.00

5000300000

13. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

$

,000.00

5000325000

14. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

$

,000.00

5000860000

4. Table wagering games

2022_AF-72110_su.pdf Generated 2022-02-18 07:55:31

23

15. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

16. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

17. Meals, snacks, other food items, and beverages prepared for catered events

$

,000.00

7000060000

18. Short-term access to communications services, including telephone and internet services

$

,000.00

7014175000

19. Short-term entertainment access services including pay-per-view services

$

,000.00

7003875000

$

,000.00

7017275000

21. Laundry machines operated by coin, card, or by an attendant

$

,000.00

7000100000

22. Parking services

$

,000.00

7002750000

23. Rental of home audiovisual equipment (including cable program distribution equipment), components, and
accessories, except computers and peripherals

$

,000.00

7000925000

24. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles,
and musical instruments)

$

,000.00

7001800000

25. Rental and leasing of commercial space More

$

,000.00

7006375000

26. Rental and leasing of nonresidential space in buildings or other facilities for business or social use, exclude hosting
of coin-operated self-service gambling machines and vending machine hosting More

$

,000.00

7006575000

27. Admissions to live performing arts performances

$

,000.00

7001600000

28. Admissions to dance halls and clubs (including cover charges)

$

,000.00

7002000000

29. Golf course and country club services

$

,000.00

7001850000

30. Skiing facility services

$

,000.00

7001875000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

20. Laundry and dry-cleaning agency services

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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25

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Property Type

ITEM 28: SPECIAL ITEMS - PROPERTY TYPE
Which of the following best describes this establishment?

Limited-service facility - hotels and motels that provide lodging but very few additional services or amenities. These hotels and motels do not earn revenues from food and beverage
services (such as operating a restaurant on-site or providing catering services). A hotel/motel which earns no food and beverage revenues but offers a free continental breakfast should
still be considered a limited-service hotel.
Full-service facility - hotels and motels that offer food and beverage services, lounge facilities, and meeting spaces. These hotels and motels typically also offer bell service and room
service.
Luxury facility - hotels that offer all the services of a full-service hotel as well as additional services, which may include 24-hour room service, upscale restaurants managed in-house,
and concierge services.
Not a hotel/motel - a lodging facility that is not known as a hotel/motel, such as a bed-and-breakfast inn, guest house, hostel, or tourist home.

Limited-service facility
Full-service facility
Luxury facility
Not a Hotel/Motel

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27

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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30

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

38

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

Describe kind of business at this location

2022
What is the number of rooms in this hotel, motel, or other lodging facility?

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

39

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Room and boarding houses, dormitories and workers' camps, including dormitories (off campus), and fraternity and sorority houses

721310 002

Dormitories (off campus)

721310 003

Workers camp

721310 004

All other traveler accommodation, including cabins, guest houses, villas, cottage resorts, and hostels

721199 001

Hotel (except with casino), motel, or motor hotel

721110 002

Bed-and-breakfast inn

721191 001

Sporting or recreation camp, including fishing camp, dude ranch, etc.

721214 001

Trailer park, recreational vehicle (RV) park, or campground, except residential

721211 001

Other primary business or activity

779000 001

Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AF-72130_su.pdf Generated 2022-02-18 07:56:34

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

What were the operating receipts and sales of other merchandise in 2022? (Exclude sales taxes or other taxes
collected.)
For further clarification, click the "Additional Information" link above.

2022_AF-72130_su.pdf Generated 2022-02-18 07:56:34

Check
if
None

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AF-72130_su.pdf Generated 2022-02-18 07:56:34

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
Estimate the percentage of this establishment's total sales (reported in Item 5) by class of customer.
2022
%

1. Household consumers and individuals
2. Businesses
(billed to expense accounts)

%

3. Governmental bodies
(Federal, state, and local)

%

TOTAL (Sum of lines 1 through 3 should equal 100%.)

%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Home, apartment, rooming house, and other residential space rental and leasing

Product Code

7000275000

7003825000

2. Room or unit accommodation for travelers

a. Room or unit accommodation for travelers, with maid service

b. Room or unit accommodation for travelers, without maid service

c. Shared-room accommodation for travelers, including hostel rooms for short-term accommodation More

3. Civic and social organization membership services More

4. Retail sales of perishable prepared foods packaged for future consumption

5. Retail sales of candy, prepackaged cookies, and snack foods

6. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

7003825003

7003825006

7003825009

7005023000

5000150000

5000200000

5000250000

5000300000

7. Retail sales of packaged alcoholic beverages
8. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

9. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

10. Retail sales of household fuels, including oil, LP gas, wood, coal

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

12. Alcoholic beverages, prepared and served or dispensed for immediate consumption

13. Meals, snacks, other food items, and beverages prepared for catered events

14. Short-term access to communications services, including telephone and internet services

2022_AF-72130_su.pdf Generated 2022-02-18 07:56:34

5000325000

5000860000

5001750000

7000025000

7000050000

7000060000

7014175000

21

15. Rental of home audiovisual equipment (including cable program distribution equipment), components, and accessories, except
computers and peripherals

7000925000

16. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles, and musical
instruments)

7001800000

7000100000

17. Access to laundry machines

7002750000

18. Parking services

Add product/service not listed

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

$

,000.00

7000275000

a. Room or unit accommodation for travelers, with maid service

$

,000.00

7003825003

b. Room or unit accommodation for travelers, without maid service

$

,000.00

7003825006

c. Shared-room accommodation for travelers, including hostel rooms for short-term accommodation More

$

,000.00

7003825009

Subtotal

$

,000.00

7003825000

$

,000.00

7005023000

$

,000.00

5000150000

5. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

6. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

$

,000.00

5000250000

7. Retail sales of packaged alcoholic beverages

$

,000.00

5000300000

8. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

$

,000.00

5000325000

9. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

$

,000.00

5000860000

10. Retail sales of household fuels, including oil, LP gas, wood, coal

$

,000.00

5001750000

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

$

,000.00

7000050000

13. Meals, snacks, other food items, and beverages prepared for catered events

$

,000.00

7000060000

14. Short-term access to communications services, including telephone and internet services

$

,000.00

7014175000

1. Home, apartment, rooming house, and other residential space rental and leasing
2. Room or unit accommodation for travelers

3. Civic and social organization membership services More

4. Retail sales of perishable prepared foods packaged for future consumption

12. Alcoholic beverages, prepared and served or dispensed for immediate consumption

2022_AF-72130_su.pdf Generated 2022-02-18 07:56:34

23

15. Rental of home audiovisual equipment (including cable program distribution equipment), components, and
accessories, except computers and peripherals

$

,000.00

7000925000

16. Rental services for recreational, sports, and fitness equipment (including boats, motorcycles, other sports vehicles,
and musical instruments)

$

,000.00

7001800000

17. Access to laundry machines

$

,000.00

7000100000

18. Parking services

$

,000.00

7002750000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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24

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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25

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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26

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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29

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

37

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

Describe kind of business at this location

2022
What is the number of rooms in this hotel, motel, or other lodging facility?

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

38

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Contract feeding/food service contractor, including school, university, corporate, government, or other facility cafeteria/dining

722310 007

School, university, corporate, government, or other facility cafeteria/dining, operating on a contract basis

722310 001

Industrial/institutional/in-plant feeding

722310 002

Caterers, including banquet halls with catering staff

722320 003

Banquet facility (hall) with catering staff

722320 004

Mobile food service, including ice cream, snacks, sandwiches, and meals distributed from trucks, carts, or other vehicles

722330 001

Food and beverage concession service, operating on a contract basis

722310 004

Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Limited-service restaurant (patrons pay before eating), including delivery-only and take-out-only locations

722513 005

Cafeteria, buffet, or grill buffet, not operating on a contract basis

722514 001

Specialty snack or nonalcoholic beverage shop/stand not listed above (such as pretzel, cupcake, soda, smoothie, or juice shop/stand) selling
from a permanent location for immediate consumption on or near the premises

722515 702

Airline (in-flight) catering

722310 003

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_AF-72230_su.pdf Generated 2022-02-18 07:40:45

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

What were the operating receipts and sales of other merchandise in 2022? (Exclude sales taxes or other taxes
collected.)
For further clarification, click the "Additional Information" link above.

2022_AF-72230_su.pdf Generated 2022-02-18 07:40:45

Check
if
None

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_AF-72230_su.pdf Generated 2022-02-18 07:40:45

2022
$

,000.00

$

,000.00

19

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
Estimate the percentage of this establishment's total sales (reported in Item 5) by class of customer.
2022
%

1. Household consumers and individuals
2. Businesses
(billed to expense accounts)

%

3. Governmental bodies
(Federal, state, and local)

%

TOTAL (Sum of lines 1 through 3 should equal 100%.)

%

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Meals, snacks, other food items, and beverages for immediate consumption, prepared under long-term contract

Product Code

7000055000

a. Meals, snacks, other food items, and nonalcoholic beverages prepared for immediate consumption under long-term contract for
transportation businesses

7000055003

b. Meals, snacks, other food items, and nonalcoholic beverages prepared for immediate consumption under long-term contract for
other than transportation businesses More

7000055006

c. Alcoholic beverages prepared for immediate consumption under long-term contract

2. Meals, snacks, other food items, and beverages prepared for catered events More

a. Meals, snacks, other food items, and nonalcoholic beverages prepared for catered events held on the caterer's premises
b. Meals, snacks, other food items, and nonalcoholic beverages prepared and served at catered events held on the customer's
premises

c. Meals, snacks, other food items, and nonalcoholic beverages dropped off at the customer's event More

d. Meals, snacks, other food items, and nonalcoholic beverages prepared for customer pick-up, including party platters

7000055009

7000060000

7000060003

7000060006

7000060009

7000060012

7000060015

e. Alcoholic beverages prepared for catered events

3. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

a. Meals, snacks, and other food items, prepared and served More

7000025000

7000025003

7000025006

b. Nonalcoholic beverages, prepared and served

c. Meals, snacks, and other food items, prepared and dispensed without table service for consumption on the premises More

d. Nonalcoholic beverages, prepared and dispensed without table service for consumption on the premises

e. Meals, snacks, and other food items, prepared and dispensed via drive-through service

f. Nonalcoholic beverages, prepared and dispensed via drive-through service

2022_AF-72230_su.pdf Generated 2022-02-18 07:40:45

7000025009

7000025012

7000025015

7000025018

21

g. Meals, snacks, and other food items, prepared and dispensed for immediate consumption off the premises, except via drivethrough service, including take-out, curbside pick-up, and delivery

7000025021

h. Nonalcoholic beverages, prepared and dispensed for immediate consumption off the premises, except via drive-through service,
including take-out, curbside pick-up, and delivery

7000025024

i. Meals, snacks, and other food items dispensed via mobile vending service

j. Nonalcoholic beverages dispensed via mobile vending service More

4. Alcoholic beverages, prepared and served or dispensed for immediate consumption

a. Wine and wine drinks, prepared and served or dispensed for immediate consumption

b. Beer, ale, and malt beverages, prepared and served or dispensed for immediate consumption (excluding brewed on site)

c. Beer, ale, and malt beverages, brewed on site, prepared and served or dispensed for immediate consumption

d. Drinks with distilled spirits, prepared and served or dispensed for immediate consumption

7000025027

7000025033

7000050000

7000050003

7000050005

7000050007

7000050009

5. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and salad bars, and
prepared sandwiches, dishes, and entrees.) More

5000150000

6. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy milk, and egg
and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and crackers.) More

5000225000

7. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

8. Retail sales of bottled, canned, or packaged alcoholic beverages

9. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

10. Rental of space for weddings, banquets, parties, and similar short-term social uses

11. Rental of space for meetings, conventions, and similar short-term business uses

12. Rental of nonresidential space for hosting rides, games, or vending machines More

13. Rental and leasing of social events equipment, including tents, tables, and chairs

5000250000

5000300000

5000860000

7006475000

7006425000

7006575000

7000760000

7010350000

14. Temporary staffing services More

15. Local transportation and delivery of purchased or serviced items, including food and beverages

7011125000

Add product/service not listed

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22

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Meals, snacks, other food items, and beverages for immediate consumption, prepared under long-term contract
a. Meals, snacks, other food items, and nonalcoholic beverages prepared for immediate consumption under longterm contract for transportation businesses

$

,000.00

7000055003

b. Meals, snacks, other food items, and nonalcoholic beverages prepared for immediate consumption under longterm contract for other than transportation businesses More

$

,000.00

7000055006

c. Alcoholic beverages prepared for immediate consumption under long-term contract

$

,000.00

7000055009

$

,000.00

7000055000

a. Meals, snacks, other food items, and nonalcoholic beverages prepared for catered events held on the caterer's
premises

$

,000.00

7000060003

b. Meals, snacks, other food items, and nonalcoholic beverages prepared and served at catered events held on the
customer's premises

$

,000.00

7000060006

c. Meals, snacks, other food items, and nonalcoholic beverages dropped off at the customer's event More

$

,000.00

7000060009

d. Meals, snacks, other food items, and nonalcoholic beverages prepared for customer pick-up, including party
platters

$

,000.00

7000060012

e. Alcoholic beverages prepared for catered events

$

,000.00

7000060015

Subtotal

$

,000.00

7000060000

a. Meals, snacks, and other food items, prepared and served More

$

,000.00

7000025003

b. Nonalcoholic beverages, prepared and served

$

,000.00

7000025006

c. Meals, snacks, and other food items, prepared and dispensed without table service for consumption on the
premises More

$

,000.00

7000025009

d. Nonalcoholic beverages, prepared and dispensed without table service for consumption on the premises

$

,000.00

7000025012

Subtotal
2. Meals, snacks, other food items, and beverages prepared for catered events More

3. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

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24

e. Meals, snacks, and other food items, prepared and dispensed via drive-through service

$

,000.00

7000025015

f. Nonalcoholic beverages, prepared and dispensed via drive-through service

$

,000.00

7000025018

g. Meals, snacks, and other food items, prepared and dispensed for immediate consumption off the premises, except
via drive-through service, including take-out, curbside pick-up, and delivery

$

,000.00

7000025021

h. Nonalcoholic beverages, prepared and dispensed for immediate consumption off the premises, except via drivethrough service, including take-out, curbside pick-up, and delivery

$

,000.00

7000025024

i. Meals, snacks, and other food items dispensed via mobile vending service

$

,000.00

7000025027

j. Nonalcoholic beverages dispensed via mobile vending service More

$

,000.00

7000025033

Subtotal

$

,000.00

7000025000

a. Wine and wine drinks, prepared and served or dispensed for immediate consumption

$

,000.00

7000050003

b. Beer, ale, and malt beverages, prepared and served or dispensed for immediate consumption (excluding brewed
on site)

$

,000.00

7000050005

c. Beer, ale, and malt beverages, brewed on site, prepared and served or dispensed for immediate consumption

$

,000.00

7000050007

d. Drinks with distilled spirits, prepared and served or dispensed for immediate consumption

$

,000.00

7000050009

Subtotal

$

,000.00

7000050000

5. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and
salad bars, and prepared sandwiches, dishes, and entrees.) More

$

,000.00

5000150000

6. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy
milk, and egg and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and
crackers.) More

$

,000.00

5000225000

7. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

$

,000.00

5000250000

8. Retail sales of bottled, canned, or packaged alcoholic beverages

$

,000.00

5000300000

9. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

$

,000.00

5000860000

10. Rental of space for weddings, banquets, parties, and similar short-term social uses

$

,000.00

7006475000

$

,000.00

7006425000

4. Alcoholic beverages, prepared and served or dispensed for immediate consumption

11. Rental of space for meetings, conventions, and similar short-term business uses

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25

12. Rental of nonresidential space for hosting rides, games, or vending machines More

$

,000.00

7006575000

13. Rental and leasing of social events equipment, including tents, tables, and chairs

$

,000.00

7000760000

14. Temporary staffing services More

$

,000.00

7010350000

$

,000.00

7011125000

$

,000.00

9900000000

15. Local transportation and delivery of purchased or serviced items, including food and beverages

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

39

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

40

Attachment D-19
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Sector 81

Attachment Sector

D-19

81

Instrument
Path
Instrument Path Title

81210
81230
8127X
81349

Personal Care Services
Drycleaning and Laundry Services
Parking Lots and Garages (Enterprise Support)
Civic, Social, and Other Membership Organizations

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Barber, beautician, and nail care services
Beauty shop, spa, or hair salon

812112 005

Nail salon

812113 001

Unisex hair shop, including combined beauty/barber shop

812112 001

Day spa, including hair services

812112 003

Barber shop

812111 001

Day spa, excluding hair services

812199 007

Skin care (i.e., esthetician) services

812112 004

Facial salon

812112 002

Cosmetology or beauty school and barber college or school

611511 003

Other personal care and appearance services
Tanning salon

812199 002

Massage therapist(s) - NCTMB (Nationally Certified in Therapeutic Massage and Bodywork)

621399 00G

Massage salon

812199 001

Hair replacement services, excluding services performed by a physician

812199 006

Tattoo parlor

812199 005

Hair removal services, including electrolysis, laser removal, and waxing

812199 004

Sauna, steam bath, or Turkish bath

812199 003

Diet or weight reducing center, excluding physical fitness facilities

812191 001

Physical fitness, strength development, or weight training center

713940 902

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Check
if
None
What were the total operating receipts?
(Beauty shops and barber shops should include rents from leased stations/booths.)

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2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_OS-81210_su.pdf Generated 2022-02-18 08:04:46

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7005025000

1. Hair care services More

7005025003

a. Permanent hair texture modification

7005025006

b. Hair coloring and tinting

7005025009

c. Hair cut and styling services

7005025012

d. Other hair care services

7005050000

2. Nail care services

7005050003

a. Manicure services

7005050006

b. Pedicure services

7005050009

c. Other nail care services

7005075000

3. Skin care services

7005075009

a. Facial services

7005075012

b. Masks and body wrap services

7005075003

c. Temporary makeup services

7005075006

d. Permanent makeup services

7005075015

e. Other skin care services

7005100000

4. Hair removal services

7005100003

a. Permanent hair removal services

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20

7005100006

b. Temporary hair removal services

7005125000

5. Non-therapeutic massage services
6. Therapeutic massage services

7004925000

Include sports massage therapy.

7. Tattoo, tanning and other body modification services More

7005150000

7005150003

a. Tanning services

7005150006

b. Tattoo services

7005150009

c. Tattoo removal services

7005150012

d. Piercing services

7005150015

e. Other body modification services

7006375000

8. Rental and leasing of commercial space

7006375003

a. Rental and leasing of retail space in shopping malls

b. Rental and leasing of food service space in shopping malls

c. Rental and leasing of retail space in free-standing locations

d. Rental and leasing of food service space in free-standing locations

e. Rental and leasing of booths and chairs in beauty and personal care establishments

7006375006

7006375009

7006375012

7006375015

7006375018

f. Rental and leasing of other commercial space

7005175000

9. Weight loss services More

7005175003

a. Non-medical weight loss programs

7005175006

b. Non-medical diet management services

10. Fitness evaluation and personal fitness training services

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7002100000

21

11. Trade, career, technical and professional development training programs
12. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements, including medicines used for
infusion services

7003950000

5001350000

5001450000

13. Retail sales of cosmetics and fragrances

5001425000

14. Retail sales of personal hygiene supplies
15. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers; frypans; personal
care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

16. Other personal services, including access to public saunas and Turkish baths

5000725000

7002560000

Add product/service not listed

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22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Hair care services More

a. Permanent hair texture modification

$

,000.00

7005025003

b. Hair coloring and tinting

$

,000.00

7005025006

c. Hair cut and styling services

$

,000.00

7005025009

d. Other hair care services

$

,000.00

7005025012

Subtotal

$

,000.00

7005025000

a. Manicure services

$

,000.00

7005050003

b. Pedicure services

$

,000.00

7005050006

$

,000.00

7005050009

$

,000.00

7005050000

a. Facial services

$

,000.00

7005075009

b. Masks and body wrap services

$

,000.00

7005075012

c. Temporary makeup services

$

,000.00

7005075003

d. Permanent makeup services

$

,000.00

7005075006

e. Other skin care services

$

,000.00

7005075015

Subtotal

$

,000.00

7005075000

2. Nail care services

c. Other nail care services

Subtotal
3. Skin care services

4. Hair removal services

2022_OS-81210_su.pdf Generated 2022-02-18 08:04:46

23

$

,000.00

7005100003

$

,000.00

7005100006

$

,000.00

7005100000

5. Non-therapeutic massage services

$

,000.00

7005125000

6. Therapeutic massage services

$

,000.00

7004925000

a. Tanning services

$

,000.00

7005150003

b. Tattoo services

$

,000.00

7005150006

c. Tattoo removal services

$

,000.00

7005150009

$

,000.00

7005150012

e. Other body modification services

$

,000.00

7005150015

Subtotal

$

,000.00

7005150000

a. Rental and leasing of retail space in shopping malls

$

,000.00

7006375003

b. Rental and leasing of food service space in shopping malls

$

,000.00

7006375006

c. Rental and leasing of retail space in free-standing locations

$

,000.00

7006375009

d. Rental and leasing of food service space in free-standing locations

$

,000.00

7006375012

e. Rental and leasing of booths and chairs in beauty and personal care establishments

$

,000.00

7006375015

f. Rental and leasing of other commercial space

$

,000.00

7006375018

Subtotal

$

,000.00

7006375000

a. Permanent hair removal services

b. Temporary hair removal services

Subtotal

Include sports massage therapy.
7. Tattoo, tanning and other body modification services More

d. Piercing services

8. Rental and leasing of commercial space

9. Weight loss services More

2022_OS-81210_su.pdf Generated 2022-02-18 08:04:46

24

a. Non-medical weight loss programs

$

,000.00

7005175003

b. Non-medical diet management services

$

,000.00

7005175006

$

,000.00

7005175000

10. Fitness evaluation and personal fitness training services

$

,000.00

7002100000

11. Trade, career, technical and professional development training programs

$

,000.00

7003950000

12. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements, including
medicines used for infusion services

$

,000.00

5001350000

$

,000.00

5001450000

14. Retail sales of personal hygiene supplies

$

,000.00

5001425000

15. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers;
frypans; personal care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

$

,000.00

5000725000

16. Other personal services, including access to public saunas and Turkish baths

$

,000.00

7002560000

$

,000.00

9900000000

Subtotal

13. Retail sales of cosmetics and fragrances

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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25

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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26

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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28

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_OS-81210_su.pdf Generated 2022-02-18 08:04:46

30

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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36

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

38

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_OS-81210_su.pdf Generated 2022-02-18 08:04:46

,000.00

39

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

If more than one establishment:
Do not consider branch locations of laundries and drycleaners (including industrial, linen, and diaper supply) that are only providing pick-up and distribution of finished work as
separate establishments. Data for these locations should be included with the plant in which the work is actually done.

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Laundry and drycleaning services
Self-service laundry and/or drycleaning store

812310 201

Coin-operated laundry washing machine route, including service provided in apartments, dormitories, etc.

812310 101

Drycleaning services, excluding rug cleaning

812320 201

Carpet, rug, and upholstery cleaning services

561740 001

Commercial or family laundry services

812320 101

Linen supply services on a rental or contract basis

812331 001

Industrial laundry services on a rental or contract basis

812332 001

Drop off/pick up site or garment pressing, including laundry or cleaning done by others

812320 301

Retail agent for laundries and drycleaners (work done by others)

812320 302

Wash and fold services

812320 303

Leather and/or fur cleaning services

812320 401

Other clothing and fabric services
Garment alteration or repair service

811490 401

Footwear, luggage, handbag, briefcase and leather goods repair

811430 001

Other primary business or activity
Car washes and automotive detailing services

811192 001

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

%

16

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts?
For further clarification, click the "Additional Information" link above.

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

2022
$

,000.00

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

2022
$

,000.00

$

,000.00

19

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7000100000

1. Access to laundry machines More

7000100003

a. Access to washing machines

7000100006

b. Access to drying machines

7000100009

c. Access to dry-cleaning machines

7000150000

2. Dry-cleaning services More

7000150003

a. General dry-cleaning services

7000150006

b. Specialty dry-cleaning services

7017250000

3. Commercial laundry services More

7000125000

4. Non-commercial laundry services

7017275000

5. Laundry and dry-cleaning agency services More

7017275003

a. Laundry agency services

7017275006

b. Dry-cleaning agency services

7017300000

6. Uniform rental and linen supply services

7017300003

a. Garments supply, including gowns, coats, aprons, etc.

7017300006

b. Flatwork and full dry linens supply

c. Industrial garments supply, excluding 'clean room' garments

7017300009

7017300012

d. Industrial 'clean room' garments supply

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20

7017300015

e. Industrial wiping cloths supply

f. Industrial mats supply, including launderable and unlaunderable

g. Industrial mops, cloths, and miscellaneous dust control items supply

7017300018

7017300021

7000175000

7. Steam pressing and ironing services

7000225000

8. Seasonal apparel and textile storage services
9. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

10. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry More

a. Restoration and repair services for garments and textiles

7006575000

7000200000

7000200003

7000200006

b. Garment alteration services

7000200009

c. Footwear maintenance and repair services

7000200012

d. Watch and jewelry maintenance and repair services

Add product/service not listed

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21

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Access to laundry machines More

a. Access to washing machines

$

,000.00

7000100003

b. Access to drying machines

$

,000.00

7000100006

c. Access to dry-cleaning machines

$

,000.00

7000100009

Subtotal

$

,000.00

7000100000

a. General dry-cleaning services

$

,000.00

7000150003

b. Specialty dry-cleaning services

$

,000.00

7000150006

$

,000.00

7000150000

3. Commercial laundry services More

$

,000.00

7017250000

4. Non-commercial laundry services

$

,000.00

7000125000

a. Laundry agency services

$

,000.00

7017275003

b. Dry-cleaning agency services

$

,000.00

7017275006

Subtotal

$

,000.00

7017275000

a. Garments supply, including gowns, coats, aprons, etc.

$

,000.00

7017300003

b. Flatwork and full dry linens supply

$

,000.00

7017300006

c. Industrial garments supply, excluding 'clean room' garments

$

,000.00

7017300009

2. Dry-cleaning services More

Subtotal

5. Laundry and dry-cleaning agency services More

6. Uniform rental and linen supply services

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

22

$

,000.00

7017300012

e. Industrial wiping cloths supply

$

,000.00

7017300015

f. Industrial mats supply, including launderable and unlaunderable

$

,000.00

7017300018

g. Industrial mops, cloths, and miscellaneous dust control items supply

$

,000.00

7017300021

Subtotal

$

,000.00

7017300000

$

,000.00

7000175000

8. Seasonal apparel and textile storage services

$

,000.00

7000225000

9. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service
gambling machines

$

,000.00

7006575000

a. Restoration and repair services for garments and textiles

$

,000.00

7000200003

b. Garment alteration services

$

,000.00

7000200006

$

,000.00

7000200009

d. Watch and jewelry maintenance and repair services

$

,000.00

7000200012

Subtotal

$

,000.00

7000200000

$

,000.00

9900000000

d. Industrial 'clean room' garments supply

7. Steam pressing and ironing services

10. Maintenance, repair, and alteration services for apparel, footwear, watches, and jewelry More

c. Footwear maintenance and repair services

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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23

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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24

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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25

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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26

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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27

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

28

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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29

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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30

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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31

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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32

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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33

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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34

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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35

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

1000

characters remaining

36

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_OS-81230_su.pdf Generated 2022-02-18 08:05:50

,000.00

37

Location Information

DEFINITION OF ESTABLISHMENT
An establishment is generally a single physical location where business is conducted or where services or industrial operations are performed. This includes all locations of a company or
organization, including administrative offices, warehouses, etc., that were in operation at any time during 2022. Report activity for each establishment on a separate form.
DEFINITION OF AN ENTERPRISE
An enterprise or company is a business, service, or membership organization consisting of one or more establishments within the United States under common ownership or control. It
includes all establishments of subsidiary companies, where there is more than 50 percent ownership, as well as establishments of firms which the enterprise has the power to direct or
cause the direction of management and policies.
DEFINITION OF AN ENTERPRISE SUPPORT ESTABLISHMENT
An enterprise support establishment is an establishment that is primarily engaged in performing management, supervision, general administrative functions, and supporting services for
other establishments of the same enterprise, rather than for the general public or other business firms.

PHYSICAL ADDRESS
Please update the location's physical address if needed.

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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1

Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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4

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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5

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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6

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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7

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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8

Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Automobile parking
Parking lots and garages providing parking space for motor vehicles (usually on an hourly, daily or monthly basis) including valet parking
services

812930 001

Parking garage, underground

812930 002

Metered parking

812930 006

Valet parking services

812930 003

Other parking services - Describe

812930 005

Describe
Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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9

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

%

10

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Sales, Receipts, or Revenue
Include:
Sales, receipts, or revenue from customers outside your enterprise originating from this location.
Exclude:
Sales, receipts, or revenue from other establishments within your own enterprise.
For further clarification, click "Additional Information" link above.
Check
if
None
What were the sales, receipts, or revenue (exclude billings) from customers outside your enterprise originating from
this location?

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

2022
$

,000.00

11

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

2022
$

,000.00

$

,000.00

12

Item 8: Support Services

ITEM 8: SUPPORT SERVICES
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of your enterprise (rather than for the general public or
other business firms) in 2022?
Yes
No

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13

Item 8: Support Services - Continued

ITEM 8: SUPPORT SERVICES - PRIMARY BUSINESS OR ACTIVITY OF THE OPERATING ESTABLISHMENTS SERVICED
What primary kind of business or activity is performed by the establishments of your enterprise that are managed or serviced by this establishment?
Example: If this establishment is a corporate, subsidiary, or regional managing office, data processing service center, or administrative/support office to a chain of clothing stores, please
describe "clothing stores" below.
Describe

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14

Item 16: Selected Expenses

ITEM 16: SELECTED EXPENSES
Report the payment of selected expenses allocated by category
Report payments for expenses directly incurred by this establishment in column 1.
Report payments made by this establishment for expenses incurred by other establishments of your enterprise in column 2 (where applicable).
Exclude:
Transfers made within the company
Capitalized expenses
Impairment
Interest
Bad debt
Income tax
Taxes collected from customers (e.g., sales and excise)
Cost of merchandise for resale
Personnel costs, except payroll

1. Employer's cost for employer paid insurance premiums,
pension plans, payroll taxes, and other employee
benefits More

Check
if
None

2022 Expenses of this
establishment ONLY
$

,000.00

$

,000.00

3. Expensed computer hardware and other equipment More

$

,000.00

4. Expensed purchases of other materials, parts, and
supplies More

$

,000.00

5. Expensed purchases of software More

$

,000.00

6. Purchased electricity More

$

,000.00

7. Purchased fuels (Exclude motor fuels.) More

$

,000.00

2. Temporary staff and leased employee expense More
Expensed equipment and materials

Expensed purchased services

2022 Payments made by
this establishment on
behalf of other
establishments of your
enterprise

Check
if
None
8. Data processing and other purchased computer
services More

$

,000.00

$

,000.00

9. Purchased communication services More

$

,000.00

$

,000.00

10. Purchased repairs and maintenance to machinery,
vehicles, and equipment More

$

,000.00

$

,000.00

11. Purchased repairs and maintenance to buildings,
structures, and offices More

$

,000.00

$

,000.00

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

15

12. Water, sewer, refuse removal, and other utility
payments More

$

,000.00

$

,000.00

13. Purchased advertising and promotional services More

$

,000.00

$

,000.00

$

,000.00

$

,000.00

15. Lease and rental payments for machinery, equipment,
and other tangible items More

$

,000.00

$

,000.00

16. Lease and rental payments for land, buildings,
structures, store spaces, and offices More

$

,000.00

$

,000.00

17. Governmental taxes and license fees (Exclude sales,
excise, and income taxes.) More

$

,000.00

$

,000.00

18. Depreciation and amortization charges More

$

,000.00

19. All other selected expenses
(Describe - If more than 50% of TOTAL reported on line
20.) More

$

,000.00

$

,000.00

14. Purchased professional and technical services More
Other selected expenses

Describe

20. TOTAL SELECTED EXPENSES of this establishment
ONLY, excluding payroll (Add lines 1 through 19.)

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16

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
Estimate the percentage of receipts (reported in Item 5) from services provided to clients outside your enterprise by class of customer.
2022
%

1. Business firms and farms

2. Not-for-profit organizations (Include religious organizations.)

%

3. Federal government

%

4. State and local governments

%

5. Household consumers and individuals

%

%

6. TOTAL (Sum of lines 1 through 5 should equal 100%.)

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17

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7002750000

1. Parking services

7002750003

a. Off-street parking services, hourly or daily

b. Off-street parking services, weekly or monthly, in buildings

7002750006

7002750009

c. Off-street parking services, weekly or monthly, on lots

7002750012

d. On-street parking services

7002750015

e. Valet parking services
2. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

7006575000

Add product/service not listed

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18

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Parking services

a. Off-street parking services, hourly or daily

$

,000.00

7002750003

b. Off-street parking services, weekly or monthly, in buildings

$

,000.00

7002750006

c. Off-street parking services, weekly or monthly, on lots

$

,000.00

7002750009

d. On-street parking services

$

,000.00

7002750012

$

,000.00

7002750015

$

,000.00

7002750000

2. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service
gambling machines

$

,000.00

7006575000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

e. Valet parking services

Subtotal

Add product/service not listed

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19

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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20

Item 28: Special Items - Exported Services Revenue

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES REVENUE
What were the receipts or revenue for exported services in 2022?
(This is a breakout of receipts or revenue reported in Item 5 - $,000.00.)
Include:
Services provided to unaffiliated and affiliated foreign businesses (i.e., foreign parent firms, subsidiaries, branches, etc.) located
outside the U.S.
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

2022
$

,000.00

21

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_OS-8127X_mu.pdf Generated 2022-02-18 07:58:55

22

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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23

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

30

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

City, town, village, etc.

ZIP Code

State

99999-9999

Select State or Territory

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY

Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Civic, social, and recreational associations
Property owners' association, including home owners', condominium owners', and cooperative owners' associations (Not strictly providing
property management.)

813990 401

Civic, social, or fraternal association (Include alumni associations, community membership clubs, etc., exclude scouting and related youth
development organizations.)

813410 405

Veterans membership organization

813410 404

Scouting and related youth development membership organization developing life, leadership, or business skills

813410 301

Youth development membership organization developing life, leadership, or business skills. (Exclude scouting membership organizations.)

813410 302

Day camp, excluding overnight and instructional camps

713990 80A

Youth or adult sports instructional day camp

611620 003

Adult or family sporting or recreation overnight camp, including fishing and hunting camps and camps operated by membership
organizations

721214 005

Adult activity or day care center

624120 001

Recreational sports club, program, or team for youth and adults

713990 806

Fitness or recreational sports center, membership or non-membership

713940 903

Bar or restaurant operated by social or fraternal organization for members

813410 403

Bar, tavern, pub, or other drinking place, selling alcoholic beverages for consumption on premises

722410 001

Child care services, including those with preschool and/or Head Start programs

624410 001

Business and professional membership associations
Business association - organized to promote the business interests of its members (Include trade associations, farm bureaus, chambers of
commerce, boards of realtors, etc.)

813910 001

Professional membership organization - organized to advance the professional interests of their members and the profession as a whole
(Include bar associations, accountants' associations, physicians' associations, sports players' associations, etc.)

813920 001

Labor, political, and religious organizations
Labor unions or similar labor organizations

813930 001

Political organization

813940 001

Religious organization for worship, religious training or study, or administration of an organized religion

813110 001

Other membership organizations
Sports governing body (Include professional leagues, collegiate sports conferences, athletic regulatory associations, etc.)

813990 901

Automobile enthusiast club

813410 401

Automobile club, road and travel services

561599 201

Art council

813410 402

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Economic or industrial planning or development organization (non-government)

561990 301

Grantmaking, giving, and advocacy
Philanthropic trust or foundation - making grants but not directly providing services

813211 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

How to Report Percents:
Percents should be rounded to whole percents.

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS
Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Item 28: Special Items - questions vary by survey (if applicable)
Note:
All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Was all or part of the income of this establishment or organization exempt from Federal income taxes under section 501, 521, 527, or 528 of the Internal Revenue Code?
For further clarification, click the "Additional Information" link above.
Yes
No

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Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total operating receipts of this taxable establishment?
For further clarification, click the "Additional Information" link above.

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2022
$

,000.00

20

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Revenue and expenses of this tax-exempt establishment
For further clarification, click the "Additional Information" link above.
Check
if
None
1. What was the total revenue?
2. What were the total expenses?
(Include payroll, exclude bad debt.)

2022_OS-81349_su.pdf Generated 2022-02-18 08:11:47

2022
$

,000.00

$

,000.00

21

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue Service Form 941, Employer's Quarterly Federal Tax Return, and filed
under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

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

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

2022_OS-81349_su.pdf Generated 2022-02-18 08:11:47

2022
$

,000.00

$

,000.00

22

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Membership services of performing arts societies and cultural institutions More

2. Civic and social organization membership services More

3. Business and professional association membership services More

Product Code

7001650000

7005023000

7017150000

7005024000

4. Other membership services More

a. Condominium and homeowners' association membership services More
b. Other membership services, except condominium and homeowners' associations, labor unions, civic and social organizations,
performing arts societies and clubs, and business and professional associations

5. Trade, career, technical and professional development training programs More

6. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

7. Alcoholic beverages, prepared and served or dispensed for immediate consumption

8. Meals, snacks, other food items, and beverages prepared for catered events

9. Charitable gaming (Include net charitable gaming income.) More

10. Directories, professional and technical periodicals, and periodicals of general interest More

7005024003

7005024006

7003950000

7000025000

7000050000

7000060000

7002450000

7014505000

7012425000

11. Advertising space, time and similar services More
12. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines More

13. Home, apartment, rooming house, and other residential space rental and leasing

7006575000

7000275000

7003825000

14. Room or unit accommodation for travelers

15. Other social assistance services for the general population

2022_OS-81349_su.pdf Generated 2022-02-18 08:11:47

7005022000

23

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

2. Civic and social organization membership services More

$

,000.00

7005023000

3. Business and professional association membership services More

$

,000.00

7017150000

a. Condominium and homeowners' association membership services More

$

,000.00

7005024003

b. Other membership services, except condominium and homeowners' associations, labor unions, civic and social
organizations, performing arts societies and clubs, and business and professional associations

$

,000.00

7005024006

Subtotal

$

,000.00

7005024000

5. Trade, career, technical and professional development training programs More

$

,000.00

7003950000

6. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

7. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

8. Meals, snacks, other food items, and beverages prepared for catered events

$

,000.00

7000060000

9. Charitable gaming (Include net charitable gaming income.) More

$

,000.00

7002450000

10. Directories, professional and technical periodicals, and periodicals of general interest More

$

,000.00

7014505000

11. Advertising space, time and similar services More

$

,000.00

7012425000

12. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated selfservice gambling machines More

$

,000.00

7006575000

13. Home, apartment, rooming house, and other residential space rental and leasing

$

,000.00

7000275000

14. Room or unit accommodation for travelers

$

,000.00

7003825000

15. Other social assistance services for the general population

$

,000.00

7005022000

4. Other membership services More

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25

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

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26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

1. Membership services of performing arts societies and cultural institutions More

2. Civic and social organization membership services More

3. Business and professional association membership services More

Product Code

7001650000

7005023000

7017150000

7005024000

4. Other membership services

a. Condominium and homeowners' association membership services More
b. Other membership services, except condominium and homeowners' associations, labor unions, civic and social organizations,
performing arts societies and clubs, and business and professional associations

5. Trade, career, technical and professional development training programs More

6. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

7. Alcoholic beverages, prepared and served or dispensed for immediate consumption

8. Meals, snacks, other food items, and beverages prepared for catered events

9. Charitable gaming (Include net charitable gaming income.) More

10. Directories, professional and technical periodicals, and periodicals of general interest More

7005024003

7005024006

7003950000

7000025000

7000050000

7000060000

7002450000

7014505000

7012425000

11. Advertising space, time and similar services More
12. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines More

13. Home, apartment, rooming house, and other residential space rental and leasing

7006575000

7000275000

7003825000

14. Room or unit accommodation for travelers

15. Other social assistance services for the general population

2022_OS-81349_su.pdf Generated 2022-02-18 08:11:47

7005022000

27

8000025000

16. Government contributions, gifts, and grants

a. Contributions, gifts, and grants from the National Endowment for the Arts

b. All other federal, state, county, and municipal contributions, gifts, and grants

8000025003

8000025006

8000050000

17. Private contributions, gifts, and grants

8000050003

a. Private contributions, gifts, and grants from individuals

b. Private contributions, gifts, and grants from foundations

c. Private contributions, gifts, and grants from business and industry

d. Other contributions, gifts, and grants, including from labor unions, etc.

18. Program service revenue including government fees and contracts More

8000050006

8000050009

8000050012

8000200000

8000175000

19. Gains (losses) from non-financial assets sold More

20. Trading securities and commodity contracts on own account More

21. Appropriations from general government revenues and intergovernmental transfers

8000150000

8000225000

Add product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Membership services of performing arts societies and cultural institutions More

$

,000.00

7001650000

2. Civic and social organization membership services More

$

,000.00

7005023000

3. Business and professional association membership services More

$

,000.00

7017150000

a. Condominium and homeowners' association membership services More

$

,000.00

7005024003

b. Other membership services, except condominium and homeowners' associations, labor unions, civic and social
organizations, performing arts societies and clubs, and business and professional associations

$

,000.00

7005024006

Subtotal

$

,000.00

7005024000

5. Trade, career, technical and professional development training programs More

$

,000.00

7003950000

6. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

7. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

8. Meals, snacks, other food items, and beverages prepared for catered events

$

,000.00

7000060000

9. Charitable gaming (Include net charitable gaming income.) More

$

,000.00

7002450000

10. Directories, professional and technical periodicals, and periodicals of general interest More

$

,000.00

7014505000

11. Advertising space, time and similar services More

$

,000.00

7012425000

12. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated selfservice gambling machines More

$

,000.00

7006575000

13. Home, apartment, rooming house, and other residential space rental and leasing

$

,000.00

7000275000

14. Room or unit accommodation for travelers

$

,000.00

7003825000

15. Other social assistance services for the general population

$

,000.00

7005022000

4. Other membership services

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29

16. Government contributions, gifts, and grants
a. Contributions, gifts, and grants from the National Endowment for the Arts

$

,000.00

8000025003

b. All other federal, state, county, and municipal contributions, gifts, and grants

$

,000.00

8000025006

$

,000.00

8000025000

a. Private contributions, gifts, and grants from individuals

$

,000.00

8000050003

b. Private contributions, gifts, and grants from foundations

$

,000.00

8000050006

c. Private contributions, gifts, and grants from business and industry

$

,000.00

8000050009

$

,000.00

8000050012

$

,000.00

8000050000

18. Program service revenue including government fees and contracts More

$

,000.00

8000200000

19. Gains (losses) from non-financial assets sold More

$

,000.00

8000175000

20. Trading securities and commodity contracts on own account More

$

,000.00

8000150000

$

,000.00

8000225000

$

,000.00

8000250003

$

,000.00

8000250006

$

,000.00

Subtotal

17. Private contributions, gifts, and grants

d. Other contributions, gifts, and grants, including from labor unions, etc.

Subtotal

21. Appropriations from general government revenues and intergovernmental transfers

22. All other nonoperating or tax-exempt revenue
a. All other nonoperating or tax-exempt revenue - write-in #1
Describe

b. All other nonoperating or tax-exempt revenue - write-in #2
Describe

TOTAL - Sum of lines should equal total Revenue reported in Item 5

9900000002

Add product/service not listed

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30

Item 26: Business Cooperative

ITEM 26: 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, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

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Item 28: Special Items - Social Assistance

ITEM 28: SPECIAL ITEMS - SOCIAL ASSISTANCE
If applicable, estimate the percent of receipts for social assistance services reported in Item 22, line 15, from the following payers:
2022
%

1. Government payers

2. Private payers

%

3. TOTAL (Sum of lines 1 and 2 should equal 100%.)

%

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32

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services provided to any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

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33

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).
Include:
Services purchased from any foreign businesses, whether affiliated or unaffiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

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34

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. In 2022, did this establishment use touchscreens/kiosks for customer interface in its own operations?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.
Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. In 2022, did this establishment use additive manufacturing (e.g., 3D printing) in its own operations?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. In 2022, did this establishment use radio-frequency identification (RFID) in its own operations?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.
Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. In 2022, did this establishment use industrial robots in its own operations?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.
Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. In 2022, did this establishment use service robots in its own operations?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.
Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

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35

Yes
No
Do not know
6. In 2022, did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).
Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

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Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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37

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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38

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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39

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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40

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

43

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

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,000.00

44

Attachment D-20
Department of Commerce
United States Census Bureau
OMB Information Collection Request
2022 Economic Census
OMB Control Number 0607-XXXX
Draft Previews of Standard, Consolidated, and Classification Questionnaires
Island Areas

Attachment Sector

Instrument
Path
Instrument Path Title

D-20

92104

N/A

92304
93104
94204
94404
95104
95204
97204

American Samoa - Mining, Utilities, Transportation, and
Warehousing
American Samoa - Construction
American Samoa - Manufacturing
American Samoa - Wholesale Trade
American Samoa - Retail Trade
American Samoa - Services
American Samoa - Finance, Insurance, Real Estate, Rental and
Leasing
American Samoa - Accommodation and Food Services

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

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2022_IA-92104_su.pdf Generated 2022-02-23 17:12:30

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Mining
Sand, gravel, clay, and ceramic and refractory minerals mining and quarrying

212320 001

Support activities for mining

213110 001

Utilities
Electric power generation

221110 001

Natural gas distribution

221210 003

Water supply and water treatment, except irrigation

221310 003

Sewerage system, including sewage treatment plant

221320 001

Pipeline transportation
Pipeline transport of refined petroleum including liquefied gas

486910 002

Air transportation
Scheduled air transportation including passenger and freight carrier

481110 001

Sightseeing airplane or helicopter

487990 001

Nonscheduled air transportation including charter passenger and freight services, air taxi, and specialized flying services, such as aerial
advertising and photography, and aerial surveying

481210 001

Airport operation and terminal services including air traffic control, airfreight and baggage handling, hanger operations, runway maintenance,
etc.

488110 001

Other airport and aircraft transportation services including aircraft maintenance and repair (except factory conversion, factory overhaul,
factory rebuilding)

488190 003

Water transportation
Deep sea and coastal transportation of cargo and passengers to and from foreign ports

483110 001

Scenic and sightseeing water transportation including dinner cruises, excursions, and charter fishing

487210 001

Inland waterways including water taxis and towing services for barges

483210 001

Port and harbor operations including operation of a port or waterfront terminal

488310 001

Marine cargo handling including stevedoring

488320 002

Navigational services to shipping including fleeting and harbor service, piloting of vessels, and marine salvaging

488330 001

Other services incidental to water transportation including boat barge cleaning, marine cargo inspector and surveyors, ship dismantling,
floating dry-docks, etc.

488390 005

Truck transportation
General freight trucking

484110 001

Used household and office goods moving

484210 001

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Specialized local freight trucking (except used goods), including hazardous materials, agricultural products, and auto and boat transport

484220 001

Truck or weighing stations operations and other services for road transportation

488490 004

Motor vehicle towing

488410 002

Warehousing and Storage
General warehousing and storage

493110 001

Refrigerated products warehousing

493120 001

Farm products warehousing and storage except cold storage

493130 004

Specialized goods (except refrigerated) including bulk petroleum, chemicals, and other products requiring special storage

493190 001

Courier and Messenger Service
Courier services including intercity and air courier services

492110 001

Local messenger and delivery services including bicycles

492210 003

Transit and ground passenger transportation
Urban transit systems, including bus transportation

485110 001

Interurban and rural bus transportation

485210 002

Taxi or ridesharing service by automobile or van

485310 001

Limousine or luxury sedan with drivers, excluding scheduled airport shuttle services

485320 002

School or employee bus service

485410 001

Charter bus service except scenic and sightseeing

485510 001

Sightseeing bus

487110 001

Other transit and ground passenger transportation

485990 001

Other transportation-related activities
Freight forwarding service such as marine shipping agents or customs brokers

488510 001

Other services incidental to transportation including packing, crating, and preparing goods for shipping

488990 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-92104_su.pdf Generated 2022-02-23 17:12:30

%

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None

2022
$

,000.00

A. What was the operating revenue for this establishment in 2022?

B. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

C. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
D. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

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2022
%

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)

Check
if
None

2022
$

,000.00

2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

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Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

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End of 2021
$

,000.00

21

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

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Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

$

,000.00

C. TOTAL (Add lines A and B)

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Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

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Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

$

,000.00

C. Interest paid

$

,000.00

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

$

,000.00

A. Cost of products bought for resale without further processing

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Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line D, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 28: Special Items

ITEM 28: SPECIAL ITEMS
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of the same company (rather than for the general public or
other business firms) in 2022?
Yes
No

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Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

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Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

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Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

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32

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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33

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

34

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-92104_su.pdf Generated 2022-02-23 17:12:30

,000.00

35

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

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1

2022_IA-92304_su.pdf Generated 2022-02-23 17:19:10

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Construction of buildings
New single-family, multifamily housing construction, or residential remodeling contractors

236110 001

Industrial building construction (e.g., processing and assembly plants, factories, refineries, waste disposal facilities), excluding warehouses
and sewage disposal plants

236210 001

Commercial and institutional building construction (e.g., office and school buildings, hospitals, health and data facilities, stores, and
warehouses)

236220 001

Heavy and civil engineering construction
Water and sewer line and related structures construction (e.g., mains, sewage disposal plants, pumping stations, and water well drilling)

237110 001

Power and communication line and related structures construction (e.g., alternative energy structures, power plants, transformer stations,
high voltage transmission cable connections, and cellular phone towers)

237130 001

Land subdivision and development (installation of utility, infrastructure) into lots for sale to builders

237210 001

Highway, street, and bridge construction, including curbs, airport runway construction, and line painting of streets and parking lots

237310 001

Other heavy and civil engineering construction (e.g., tunnels, railways, outside recreation areas, dams, flood and drainage control projects,
dredging, trenching, and marine facilities)

237990 001

Specialty trade contractors
Poured concrete foundation and structure contractor (e.g., shotcrete, mud-jacking, gunning, gunite, pumping, and placement footing)

238110 001

Structural steel and precast concrete contractor, including structural iron work

238120 001

Framing contractor, including wood and steel (excluding structural steel or precast concrete)

238130 001

Masonry contractor (e.g., brick, stone, slate, glass block, cement, cinder blocking, stucco setting and other stone work)

238140 001

Glass and glazing contractor (e.g., glass coating and tinting (excluding automotive), window pane, glass sheet, glass curtain wall, and mirror
installation)

238150 001

Roofing contractor, including treating roofs (i.e., spraying, painting or coating) and skylight installation

238160 001

Siding contractor (e.g., gutters, downspouts, fascia, soffit, eavestrough, flashing, and ice apron)

238170 001

Other foundation, structure, and building exterior contractor (e.g., awning, metal balcony and stairway, and falsework construction), including
decorative steel and wrought iron work; poured concrete form installation and dismantling; and welding at site

238190 001

Electrical and other wiring installation contractor (e.g., electronic and environmental controls, telecommunications and fiber optic equipment
(excluding transmission line), solar panel installation, traffic signals, and fire and security systems)

238210 001

Plumbing, heating, and air-conditioning (HVAC) contractor, including installation, maintenance, and repair of refrigeration systems, sprinkler
systems, water systems, gas and oil line individual hookups, and steam and pipe fittings

238220 001

Other building equipment contractor (e.g., millwrights, machine rigging), including installation, maintenance, and repair of ATM equipment,
elevators, escalators, service station gasoline pumps, commercial and industrial doors)

238290 001

Drywall and insulation contractor, including acoustical, plastering, and fireproofing contractors

238310 001

Painting and wall covering contractor, including on-site electrostatic painting, whitewashing, and rustproofing of buildings, ships, bridges,
tanks, and towers (excluding automotive)

238320 001

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15

Flooring contractor (e.g., laying carpet, linoleum, hardwood, laminate, and vinyl flooring), excluding fireproof, stone, concrete, and ceramic
tile flooring

238330 001

Tile and terrazzo contractor (e.g., marble, granite, slate, ceramic, stone, and mosaic work for floors, walls, and ceilings), excluding exterior
marble, granite, and slate work

238340 001

Finish carpentry contractor (e.g., door, window, cabinetry, countertop, stairway, deck, molding, trim, and paneling work, residential-type,
installation), excluding framing

238350 001

Other building finishing contractor (e.g., waterproofing, spectator seating, modular furniture system attachments, closet organizer systems,
concrete coating, window shades and blinds, and trade show exhibit installation and dismantling)

238390 001

Site preparation contractor, without land subdivision (e.g., land clearing, drilling, demolition, trenching, and earthmoving), and rental of
construction equipment with operators (excluding cranes))

238910 001

All other specialty trade contractor (e.g., driveway paving; constructions of residential and commercial parking lots, sidewalks, patios, and
outdoor swimming pools; installation of fences (excluding electric) and playground equipment; and crane rental with operator)

238990 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. Receipts, Billings, or Sales for Construction Work
Include:
Receipts (or billings) derived from contract construction work done for others.
Sales of houses and other buildings you built and sold.
Construction management and design-build contracts.
Site preparation, such as land clearing, laying roads, installing utilities, and subdividing land into lots.
New construction and remodeling, as well as maintenance and repair work.
The work of prime and trade contractors.
The work of some trades not traditionally thought of as construction, such as land subdivision, excavation, building demolition, painting, carpet-laying, and water well drilling.
Exclude:
Cost of land other than site preparation.
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building structure).
Check
if
None

2022
$

What were the receipts, billings, or sales for construction work?

,000.00

B. Receipts for Other Business Activities
Include:
Architectural services, except the design portion of integrated design-build contracts.
Engineering services.
Manufacturing.
Mining and quarrying.
Rental or lease of properties.
Real estate commissions and property management fees.
Rental of construction machinery or equipment to others, without an operator.
Retail trade.
Transportation.
Wholesale trade.
Other business activities.
Check
if
None

2022
$

What were the receipts for all other business activities done by this establishment?

Check
if
None

2022
$

C. TOTAL (Add lines A and B)

,000.00

,000.00

D. Were any of the sales, shipments, receipts, or revenue reported in line C a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet

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18

Extranet
Other online systems
Yes
No

Check
if
None

2022

E. What is the percent of total sales, shipments, receipts, or revenue reported in line C that are a result of e-commerce
transactions?

%

Check
if
None
F. What is the percent of total sales, shipments, receipts, or revenue reported in line C that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

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2022
%

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Number of employees at this establishment
Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941-SS,
Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1.
If the legal form of organization for this business is a corporation, the reporting of other employees and other payroll at this domestic reporting unit is required. If payroll and
employment for this EIN are zero, please indicate if the EIN is a joint venture in Item 31.
All persons on paid sick leave, paid holidays, and paid vacation during the year at this domestic reporting unit.
Spread on stock options that are taxable to employees at this domestic reporting unit as wages.

Exclude:
Full- or part-time leased employees whose payroll was filed under a professional employer organization's EIN. (Report values in Item 16, line F.)
Temporary staffing obtained from a staffing service. (Report values in Item 16, line F.)
Contractors, subcontractors, or independent contractors.
Purchased or managed services, such as janitorial, guard, or landscape services. (Report values in Item 16, line F.)
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services. (Report values in Item
16, line F.)
Members of the Armed Forces and pensioners carried on your active rolls.
Proprietors and partners, if an unincorporated concern.
Number of construction workers at this establishment include:
Apprentices
Working foremen
Equipment operators and mechanics
Journeymen
Job-site record keepers
Craftsmen
Laborers
Truck drivers and helpers
Others engaged directly in construction
Number of other employees at this establishment include:
Supervisors above working foremen
Office staff
Executives
Architects
Others engaged in nonconstruction activities
Personnel staff
Engineers
Accounting staff
Purchasing agents
A. Report the number of employees at this establishment for pay periods including the 12th of:
March 2022

June 2022

September 2022

December 2022

1. What was the number of construction workers
(direct labor including first-line supervisors)?

2. What was the number of other employees?

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20

TOTAL (Add lines A1 and A2.)

B. Hours Worked
Check
if
None

2022 Hours

What was the annual number of hours worked by the construction workers at this establishment (direct labor
including first-line supervisors) reported in line A?

,000

C. Payroll
Include:
Payroll for officers at this establishment
Exclude:
Income or costs not recorded as payroll for IRS by establishment.
Employer-paid annual cost for fringe benefits reported in lines 7D1 and 7D2
Check
if
None

2022

1. What was the annual payroll at this establishment before deductions for construction workers (direct labor
including first-line supervisors)?

$

,000.00

2. What was the annual payroll before deductions for other employees?

$

,000.00

TOTAL (Add lines C1 and C2.)

$

,000.00

3. Of the $0,000.00 reported above, what was the first quarter payroll at this establishment before deductions
(January-March 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)
2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

TOTAL (Add lines D1 and D2)

2022_IA-92304_su.pdf Generated 2022-02-23 17:19:10

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

21

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories of materials and supplies, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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22

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories of materials and
supplies owned by this establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-92304_su.pdf Generated 2022-02-23 17:19:10

End of 2021
$

,000.00

23

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

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Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

C. TOTAL (Add lines A and B)

$

,000.00

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Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the rental payments for the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None
A. Construction equipment and tools, machinery, office equipment, furniture, and vehicles

B. Buildings, job-site trailers, and other structures

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2022
$

,000.00

$

,000.00

27

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
A. Materials, parts, containers, and supplies
Include:
All job-site, office, and construction materials and supplies
Cost of materials purchased by this establishment for subcontractors

Check
if
None

2022
$

,000.00

B. Construction work subcontracted out to others

$

,000.00

C. Fuels consumed for heat, power, or the generation of electricity

$

,000.00

D. Electricity

$

,000.00

E. Cost of products bought for resale without further processing

$

,000.00

F. All other operating expenses
(Include payroll, benefits, office supplies, communication services, computer services, and routine maintenance and
repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as reported
in Item 13.)

$

,000.00

G. Interest paid

$

,000.00

Exclude:
Cost of manufacturing and production machinery, furniture, etc. (any item installed that is not part of a building
structure)

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Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line F, what was the estimated percentage of this establishment's total sales (reported in Item 5, line C) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

%

4. Wholesalers/distributors for resale

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 28: Special Items Additional Information

ITEM 28: SPECIAL ITEMS
A. Ownership of Construction Projects
What was the percent of receipts for construction work reported in Item 5, line A, on projects owned by the following?
2022
%

1. Private businesses and individuals

2. Federal, commonwealth, territorial, and municipal governments

%

3. TOTAL (Sum of lines A1 and A2 should equal 100%)

%

B. Construction Work Done as a Subcontractor
What was the percent of receipts for construction work reported in Item 5, line A, which represents work you did for contractors or
builders?
(Enter "0" if you did not subcontract work from contractors or builders.)

2022
%

C. Type of Construction
What was the percent of receipts for construction work reported in Item 5, line A, for the following types of construction?
1. New building construction
(Include the original construction work done, all finishing work, land development work on the site, demolition of existing
structures, etc.)

2022
%

2. Building additions, alterations, or reconstruction
(Include construction work which adds to the value of an existing building or which adapts a building to a new or different use,
including major replacements of building systems such as new roofs, etc.)

%

3. Building maintenance and repair work
(Include incidental construction work which keeps a property in ordinary working conditions. Exclude trash removal, lawn
maintenance, landscaping, cleaning, and janitorial services.)

%

4. Other types of new construction
(Include the original construction work done, all finishing work, land development work on the site, demolition of existing streets,
highways, structures, etc.)

%

5. Other types of additions, alterations, or reconstruction
(Include construction work which adds to the value of existing streets, highways, structures, etc., and major replacements of
nonbuilding systems such as resurfacing of streets and highways, improvements to structures, etc.)

%

6. Other types of maintenance and repair work
(Include incidental construction work which keeps streets, highways, structures, etc., in ordinary working conditions. Exclude
trash removal, lawn maintenance, landscaping, and cleaning services.)

%

7. TOTAL (Sum of lines C1 through C6 should equal 100%)

%

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31

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

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32

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

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33

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

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34

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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35

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

36

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-92304_su.pdf Generated 2022-02-23 17:19:10

,000.00

37

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

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1

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:36

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Food manufacturing
Animal food manufacturing

311110 001

Sugar manufacturing and refining

311310 001

Nonchocolate confectionery manufacturing, including retailing nonchocolate confectioneries made on premises, not for immediate
consumption

311340 001

Chocolate confectionery manufacturing

311350 001

Frozen food manufacturing, including juices, vegetables, and specialty foods (excluding bakery, dairy, meat, and seafood-based products)

311410 001

Fruit and vegetable canning, pickling, and drying

311420 001

Dairy product (except frozen) manufacturing

311510 001

Ice cream and frozen dessert manufacturing (excluding bakery products)

311520 001

Slaughtering and processing animals

311610 001

Seafood product (fresh or frozen) preparation and packaging, including seafood soups

311710 001

Bread and bakery product manufacturing, fresh and frozen

311810 001

Cookie, cracker, and pasta manufacturing

311820 001

Tortilla manufacturing

311830 001

Snack food manufacturing, including potato chips, pretzels (except soft), and other similar snacks

311910 001

Coffee and tea manufacturing, including concentrates (instant and freeze-dried), herbal tea, coffee substitutes, and coffee extracts and
flavorings (excluding bottled beverages)

311920 001

Flavoring syrup and concentrate manufacturing, for soda fountain use or for the manufacture of soft drinks (excluding coffee, tea, chocolate,
or milk-based)

311930 001

Seasoning and dressing manufacturing, including mayonnaise, sauces (except tomato-based sauces), table salt, and spices

311940 001

All other food manufacturing

311990 001

Beverage manufacturing
Soft drink and ice manufacturing, including purified and bottled water

312110 001

Brewery

312120 001

Winery

312130 001

Distillery

312140 001

Fabrics and textile products
Carpet and rug mill, excluding cutting and binding only

314110 001

Curtain and linen mill (made from purchased materials), including sheets, towels, pillows, and shower curtains; and textile products made on
a custom basis for sale to individual retail customers (excluding lace curtains made on lace machines)

314120 001

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15

Textile bag and canvas mill (made from purchased materials), including boat, swimming pool, and truck covers; awnings; sails; tarpaulins;
and tents (excluding blinds and shades, handbags, and luggage)

314910 001

All other textile product mills, including ropes, cordage, twine, tire cord, etc.

314990 001

Apparel manufacturing
Cut and sew apparel contractor (on materials owned by others), including tailors and seamstresses (excluding embroidering apparel)

315210 001

Men's and boys' cut and sew apparel made from purchased fabric, including manufacturers, jobbers, and custom tailors (excluding
contractors and apparel made in knitting mills)

315220 001

Women's, girls', and infants' cut and sew apparel made from purchased fabric, including manufacturers, jobbers, and custom tailors
(excluding contractors and apparel made in knitting mills)

315240 001

Other cut and sew apparel (uniforms, costumers, etc.) made from purchased fabric, including manufacturers, jobbers, and custom tailors
(excluding contractors and apparel made in knitting mills)

315280 001

Apparel accessories and other apparel made from purchased fabrics, including belts, caps, gloves (excluding medical, sporting, and safety),
hats, and neckties (excluding products made in knitting mills)

315990 001

Leather and allied products manufacturing, except apparel
Footwear manufacturing, including athletic and cleated shoes, rubber footwear, and ballet slippers

316210 001

Other leather and allied product manufacturing

316990 001

Wood products manufacturing
Sawmills and wood preservation

321110 001

Veneer, plywood, and engineered wood product manufacturing

321210 001

Millwork, including wood products for construction (e.g., windows, doors, frames, floors, etc.)

321910 002

Wood container and pallet manufacturing

321920 001

All other wood product manufacturing (except burial caskets)

321990 001

Paper manufacturing
Paper mill

322120 001

Paperboard container manufacturing

322210 001

Paper bag and coated and treated paper manufacturing

322220 001

Stationery product manufacturing, including computer paper, die-cut paper products for office use made from purchased paper or
paperboard, envelopes, and tablets

322230 001

Other converted paper product manufacturing, including disposable diapers, egg cartons, paper plates, etc.

322290 001

Printing and related support activities
Printing of newspapers, magazines, continuous forms, rapid printing, and printing on clothing

323110 001

Support activities for printing (prepress, postpress, and binding)

323120 001

Petroleum and coal products manufacturing
Petroleum refinery

324110 001

Asphalt paving, roofing, and saturated materials manufacturing

324120 001

Other petroleum and coal products manufacturing

324190 001

Chemical manufacturing
Petrochemical manufacturing (excluding products made from refining crude petroleum)

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:36

325110 001

16

Pharmaceutical and medicine manufacturing

325410 001

Paint and coating manufacturing

325510 001

Adhesive manufacturing

325520 001

Soap and cleaning compound manufacturing

325610 001

Toilet preparation manufacturing (including perfumes, shaving preparations, hair preparations, face creams, lotions, sunscreens, and other
cosmetic preparations)

325620 001

Plastic and rubber products manufacturing
326160 001

Plastics bottle manufacturing
Nonmetallic mineral products manufacturing
Cement manufacturing

327310 001

Ready-mix concrete manufacturing

327320 001

Concrete pipe, brick, and block manufacturing

327330 001

Other concrete product manufacturing, including precast slabs and tile, wall panels, prefabricated building components, bridge beams, burial
boxes and vaults, etc.

327390 001

Sand, gravel, clay, and ceramic and refractory minerals mining and quarrying

212320 001

Primary metal manufacturing
Iron and steel mills and ferroalloy manufacturing

331110 001

Alumina and aluminum production and processing

331310 001

Fabricated metal products manufacturing
Forging and stamping

332110 001

Cutlery and handtools manufacturing

332210 001

Plate work and fabricated structural product manufacturing

332310 001

Ornamental and architectural metal product manufacturing, including metal windows and doors

332320 001

Power boiler and heat exchanger manufacturing

332410 001

Metal tank (heavy gauge) manufacturing, including cutting, forming, and joining heavy gauge metal

332420 001

Hardware manufacturing, including hinges, handles, keys, doorlocks, etc.

332510 001

Spring and wire product manufacturing

332610 001

Machine shop, machining metal and plastic parts and parts of other composite materials on a job or order basis, using machine tools

332710 001

Turned product and screw, nut, and bolt manufacturing

332720 001

Metal coating, engraving (except jewelry and silverware), electroplating, plating, polishing, anodizing, and coloring

332810 001

All other fabricated metal product manufacturing

332990 001

Machinery manufacturing
Commercial and service industry machinery manufacturing

333310 001

Ventilation, heating, air-conditioning, and commercial refrigeration equipment manufacturing

333410 001

Metalworking machinery manufacturing, including accessories such as special dies, tools, jigs, fixtures, and industrial molds

333510 001

Computer and electronic products manufacturing

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17

Computer and peripheral equipment manufacturing

334110 001

Audio and video equipment manufacturing, including home entertainment, motor vehicle, public address, and musical instrument
applications

334310 001

Semiconductor and other electronic component manufacturing

334410 001

Navigational, measuring, electromedical, and control instruments manufacturing

334510 002

Manufacturing and reproducing magnetic and optical media, including prerecorded CD, tape, and record reproducing

334610 001

Electrical equipment, appliance, and components
335310 001

Electrical equipment manufacturing
Transportation equipment
Motor vehicle body and trailer manufacturing

336210 001

Motor vehicle gasoline engine and engine parts manufacturing, including rebuilding engines and engine parts

336310 001

Other motor vehicle parts manufacturing, including engine filters, air-conditioning systems, air bag assemblies, wheels, frames, bumpers,
radiators, fuel tanks, exhaust system parts, etc.

336390 001

Ship and boat building, and repairing

336610 001

Furniture and related products
Wood kitchen cabinet and countertop manufacturing

337110 001

Household and institutional furniture manufacturing

337120 001

Office furniture (including fixtures) manufacturing

337210 001

Mattress manufacturing

337910 001

Miscellaneous manufacturing
Medical equipment and supplies manufacturing

339110 001

Jewelry and silverware manufacturing, including lapidary work, and manufacturing unassembled jewelry parts and stock shop products
(excluding manufacturing synthetic stones and plating jewelry)

339910 001

Sporting and athletic goods manufacturing, excluding apparel, footwear, and small arms and ammunition

339920 001

Doll, toy, and game manufacturing, including electronic games, and doll parts and clothes (excluding metal bicycles and tricycles, coinoperated game machines, electronic video game cartridges, and reproducing video game software)

339930 001

Office supplies (excluding paper) manufacturing, including crayons, chalk, modeling clay, and stencils (excluding writing, drawing, and india
inks; rubber erasers; loose-leaf binders and devices; and inkjet and toner cartridges)

339940 001

Manufacturer of signs and related displays, excluding printing paper and paperboard signs, notices, and displays

339950 002

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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%

19

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
A. What was the total value of shipments for products manufactured at this establishment?
(Include interplant transfers)

2022
$

,000.00

$

,000.00

$

,000.00

$

,000.00

D. What were the total receipts for resales?
(Sales of products bought and sold without further manufacture, processing, or assembly. Report cost in Item 16, line F.)

$

,000.00

E. TOTAL (Add lines A through D)

$

,000.00

B. What were the total receipts for contract work performed for others on their materials?

C. What were the miscellaneous receipts for the following?

1. Sales of scrap and refuse

2. Other miscellaneous receipts

F. Were any of the sales, shipments, receipts, or revenue reported in line E a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

G. What was the percent of total sales, shipments, receipts, or revenue reported in line E that were a result of e-commerce
transactions?

%

Check
if
None
H. What is the percent of total sales, shipments, receipts, or revenue reported in line E that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

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2022
%

20

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. Exclude
subcontractors and their employees. For further clarification, see Additional Information.

EMPLOYMENT
A. What was the number of paid production workers for pay periods including the following?
(Exclude proprietors and partners)
Check
if
None

2022 Number

Check
if
None

2022 Hours

1. March 12 (Q1)

2. June 12 (Q2)

3. September 12 (Q3)

4. December 12 (Q4)

5. Add lines A1 through A4

6. Average annual production workers (Divide line A5 by 4 - omit fractions)

7. What was the number of all other paid employees for pay period including March 12?

8. TOTAL (Add lines A6 and A7)

Hours Worked

,000

B. What was the annual number of hours worked by the production workers at this establishment?

TOTAL PAYROLL BEFORE DEDUCTIONS
C. What was the annual payroll at this establishment for the following?
(Report payroll only for employees reported in lines A5 and A7. Exclude employer's cost for fringe benefits.)
Check
if
None

2022
$

1. Production workers

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,000.00

21

2. All other employees

$

,000.00

3. TOTAL (Add lines C1 and C2)

$

,000.00

4. What was the first quarter payroll for all employees (January-March, 2022)?

$

,000.00

D. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)

Check
if
None

2022
$

,000.00

2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

$

,000.00

TOTAL (Add lines D1 and D2)

$

,000.00

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Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

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End of 2021
$

,000.00

24

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

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25

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

C. TOTAL (Add lines A and B)

$

,000.00

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Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

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Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. Fuels consumed for heat, power, or the generation of electricity

$

,000.00

C. Electricity

$

,000.00

D. Contract work and nonproduction labor done for you by others

$

,000.00

E. Contract labor for production

$

,000.00

F. Cost of products bought for resale without further processing
(Report sales in Item 5, line D)

$

,000.00

G. All other operating expenses
(Include payroll, benefits, office supplies, communication services, computer services, and routine maintenance and
repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as reported
in Item 13.)

$

,000.00

H. Interest paid

$

,000.00

A. Materials, parts, containers, and supplies

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29

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line H, what was the estimated percentage of this establishment's total sales (reported in Item 5, line E) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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30

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

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Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:36

33

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:36

34

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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35

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:37

1000

characters remaining

36

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-93104_su.pdf Generated 2022-02-23 17:25:37

,000.00

37

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

1

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

14

Item 4A: Primary Business or Activity Additional Information

ITEM 4A: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Motor vehicles and motor vehicle parts and supplies
Wholesaler of automobiles and other motor vehicles, new and used

423110 001

New motor vehicle parts excluding tires and tubes

423120 001

Tires and tubes

423130 001

Used parts dealers

423140 003

New motor vehicle dealer

441110 002

Motor vehicle sales, used only

441120 002

Automotive parts and accessories store, new and/or used

441310 001

Furniture and home furnishings
Household, lawn, office, and business furniture including church pews and school desks

423210 001

Household china, glassware, crockery, linens, domestics, curtains, draperies, floor coverings including carpet pads, and other home
furnishings

423220 001

Lumber and other construction materials
Lumber, plywood, millwork, and wood panels, including wood roofing and siding

423310 001

Brick, block, clay/cement sewer pipe, sand, gravel, stone, asphalt, cement, concrete mixtures, and related products

423320 001

Roofing, siding, and insulation materials

423330 001

Other construction materials including flat glass, ironwork and fencing accessories

423390 001

Professional and commercial equipment and supplies
Photographic equipment and supplies

423410 001

Office equipment, excluding furniture

423420 001

Software publishers, including developing and publishing or publishing only, packaged software, including cloud-based

511210 001

Custom computer programming services

541511 004

Systems integrators engaged in the development or modification of software and the "bundling" of software with computers and peripheral
equipment to create an integrated system designed for a specific application

541512 103

Computer and peripheral equipment and software (packaged)

423430 001

Restaurant and hotel equipment and supplies, store machines and equipment and other commercial equipment, and supplies

423440 001

Medical, surgical, dental, and hospital equipment and supplies

423450 001

Optical and ophthalmic goods, including eyewear, sunglasses, reading glasses, and frames

423460 001

Other professional equipment and supplies, including school supplies and equipment, religious supplies, scientific instruments, and
surveying equipment and supplies

423490 001

Metal and mineral, except petroleum

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

15

Ferrous/nonferrous metal service center or sales office distributing products including pipes, metal bars, plates, sheets, and nails

423510 001

Coal, other minerals, and ores

423520 001

Electrical and electronic goods
Electrical apparatus and equipment, wiring supplies, and construction materials, including industrial controls

423610 001

Electrical household appliances excluding water heaters

423620 003

Communication equipment and supplies including blank audio and video tapes and other electronic parts and equipment

423690 001

Hardware, and plumbing and heating equipment and supplies
Hardware

423710 001

Plumbing and heating equipment and supplies, i.e. hydronics

423720 004

Warm air heating and air-conditioning equipment and supplies

423730 003

Refrigeration equipment and supplies

423740 001

Machinery, equipment, and supplies
Construction and mining machinery and equipment

423810 004

Farm, lawn, and garden machinery and equipment

423820 001

Other industrial machinery and equipment including food processing machinery and equipment, hydraulic and pneumatic (fluid power)
pumps, motors, and parts

423830 001

Industrial supplies including mechanical power transmission supplies, welding supplies, containers, valves and fittings, except fluid power

423840 603

Service establishment equipment and supplies including beauty, barber, custodial (janitorial), laundry, and dry-cleaning equipment and
supplies

423850 001

Transportation equipment and supplies (except motor vehicle and marine pleasure craft) including aircraft, aeronautical, and marine
machinery equipment and supplies

423860 001

Miscellaneous durable goods
Sporting and recreational goods and supplies

423910 001

Toys and hobby goods and supplies

423920 003

Recyclable material including iron and steel scrap, recyclable paper and paperboard, and other recyclable products

423930 001

Jewelry, watches, diamonds, gemstones, silverware, and other precious metals (except ore)

423940 001

Miscellaneous durable goods including forest products (except lumber), extinguishers, fire safety equipment, musical instruments and
supplies, prerecorded compact discs, audio tapes, phonograph records, luggage, and works of art

423990 001

Paper and paper products
Printing and writing paper

424110 001

Stationery, office supplies, and greeting cards

424120 004

Industrial and personal service paper including paper and plastic eating utensils and dishes, paper napkins and bags, and sanitary paper
products

424130 006

Drugs and druggists' sundries
424210 001

Drugs and druggists' sundries
Apparel, piece goods, and notions
Piece goods, notions, and other dry goods

424310 001

Men's and boys' clothing and furnishings

424320 001

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

16

Women's, children's, and infants' clothing and accessories

424330 001

Footwear

424340 001

Grocery and related products
Warehouse club

452311 101

General-line groceries

424410 001

Packaged frozen food

424420 008

Dairy products excluding dried and canned

424430 001

Poultry and poultry products

424440 001

Confectioneries

424450 003

Fish and seafood

424460 001

Meat and meat products, excluding frozen packaged, canned, and boxed beef

424470 004

Fresh fruits and vegetables

424480 001

Other grocery specialties including coffee, tea, spices, bread, baked goods, soft drinks, bottled water, beverage concentrates, canned foods,
food and beverage basic materials

424490 001

Farm product raw materials
Grain and field beans

424510 001

Livestock

424520 001

Other farm product raw materials including hides, skins, leaf tobacco, wool, and cotton

424590 001

Chemical and allied products
Plastics materials and basic shapes and forms

424610 001

Other chemicals and allied products including industrial gases and excluding liquefied petroleum

424690 001

Petroleum and petroleum products
Bulk stations and terminals including liquefied petroleum, sold for resale

424710 001

Petroleum distributor with no storage capacity

424720 005

Fuel dealer including heating oil and liquefied petroleum gas (except gasoline stations)

454310 001

Gasoline station with convenience store

447110 001

Gasoline station with no convenience store

447190 106

Petroleum futures commodity traders

523130 004

Beer, wine, and distilled alcoholic beverage
Beer and ale

424810 001

Wine and/or distilled alcoholic beverages

424820 001

Miscellaneous nondurable goods
Farm supplies

424910 001

Books, periodicals, newspapers, and other printed materials

424920 001

Flowers, plants, trees, nursery stock, soil, landscaping and florists' supplies (excluding plant bulbs and seeds)

424930 002

Tobacco and tobacco products, including electronic cigarettes

424940 001

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17

Retail paint and wallpaper store or dealer

444120 002

Paints, varnishes, wallpaper, and supplies

424950 004

Miscellaneous nondurable goods including art materials and supplies, textile bags and bagging, yarns, leather products, and wigs

424990 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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18

Item 4B: Type of Operation Additional Information

ITEM 4B: TYPE OF OPERATION
Which ONE of the following best describes this establishment's primary type of operation in 2022?
Merchant wholesaler, buying and selling on own account
12

Importer

13

Exporter

11

Merchant wholesale distributor or jobber

14

Own-brand importer and marketer

20

Manufacturers' sales branch or office

Agent, broker, or commission merchant
46

Manufacturers' representative or agent

41

Auction company

42

Broker, representing buyers and sellers

43

Commission merchant

44

Import agent

45

Export agent

49

Electronic market - business-to-business marketplace that facilitates the sale of goods via the Internet or other electronic
means, and operates on a commission or fee basis

Other type of operation
77

Other type of operation - Describe
Describe

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

19

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

%

20

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
A. What were the total sales and operating receipts?
(Include the gross selling value of business conducted for others. Include shipping and handling charges.)

2022
$

,000.00

B. Did this establishment earn commissions for the sale of merchandise?
Yes
No

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

21

Item 5: Sales, Shipments, Receipts, or Revenue - Commissions Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - COMMISSIONS

2022
C. What was the gross selling value of business conducted on a commission basis?
(Include on line A)

$

,000.00

2022
D. What were the total commissions received on transactions reported on line C?

$

,000.00

2022
E. What was this establishment's average commission rate earned for the transactions reported on line C?

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

%

22

Item 5: Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE - CONTINUED
F. What percent of products sold by this establishment was manufactured or mined in the United States, Puerto Rico, or other U.S. territories by your company or its subsidiaries?
0%
1-25%
26-49%
50-75%
76-100%
G. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

H. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
I. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

2022
%

23

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)

Check
if
None

2022
$

,000.00

2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

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24

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

25

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

End of 2021
$

,000.00

26

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

27

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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28

Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

$

,000.00

C. TOTAL (Add lines A and B)

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29

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

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30

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

$

,000.00

C. Interest paid

$

,000.00

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

$

,000.00

A. Cost of products bought for resale without further processing

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

31

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. Excluding the exports reported in Item 5, line I, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

32

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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33

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following categories best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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34

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

35

Item 28: Special Items Additional Information

ITEM 28: SPECIAL ITEMS

Employment by Primary Function
A. What was the number of employees reported in Item 7, line A, by the employee's primary function?
Number
1. Selling

2. Sales support - including office, clerical, warehousing, customer service, maintenance employees, and drivers
3. General support of other establishments in your company - including central administrative, accounting, research, and other
support employees

4. Packaging
5. Production - including employees who manufacture products from raw materials or semi-finished products (Report assembly
employees on line 6 below.)

6. Assembly - assembling prefabricated components designed for a single application or reassembly of completed products

7. Other

Describe

8. TOTAL (Add lines 1 through 7)

Storage Space

B. What was the warehouse, stockroom, or other inventory storage space at the end of 2022?
(Include only usable under-roof storage space. Exclude space occupied by interior walls, permanent aisles, elevator
shafts, stairways, offices, shipping platforms, etc.)

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

Check
if
None

Square feet as of
December 31,
2022

36

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

37

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

38

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

39

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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40

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

1000

characters remaining

41

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-94204_su.pdf Generated 2022-02-25 07:52:24

,000.00

42

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

1

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

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3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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14

Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Motor vehicle and parts dealers
New motor vehicle dealer

441110 002

Motor vehicle dealer, used

441120 001

Recreational vehicle (RV) dealer, including travel trailers, camping trailers, motor homes, truck campers, etc.

441210 002

Motorcycle, boat, and all other motor vehicle dealers including aircraft, all-terrain vehicles (ATV's), utility trailers, etc.

441220 001

Automotive parts and accessories store, new and/or used

441310 001

Tire dealer, new and/or used

441320 003

Furniture and homefurnishings stores
Furniture store, except custom or used

442110 001

Ceramic tile and/or wood flooring store or dealer

444190 001

Other floor coverings store or dealer including rugs, carpets, vinyl floor coverings, floor tiles, except ceramic, or wood only

442210 005

Home furnishings store including china, glassware, lamps, linens, etc.

442299 008

Building material and garden equipment and supplies dealers
Home improvement center

444110 001

Paint and wallpaper store

444120 004

Hardware store

444130 001

Retail lumber yard

444190 002

Electrical supplies store or dealer including ceiling fan/light fixture store

444190 003

Plumbing equipment and supplies store or dealer

444190 004

Door and window store or dealer including rolling doors, hurricane aluminum shutters, iron grilles, garage doors, etc.

444190 005

Outdoor power equipment store or dealer including lawnmowers, chainsaws, trimmers, etc.

444210 003

Nursery, garden center, or farm supplies store or dealer including feed, seed, grain, and fertilizer

444220 001

Food and beverage stores
Food supermarket

445110 003

Convenience food store

445120 001

Liquor store

445310 001

Meat market

445210 002

Fish (seafood) market

445220 001

Fruit stand, vegetable market (permanent location)

445230 001

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

15

Other specialty food stores, including baked goods, confectionery, and nut stores

445290 001

Food services
Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Limited-service restaurant (patrons pay before eating), including delivery-only and take-out-only locations

722513 005

Cafeterias, grill buffets, and buffets

722514 002

Snack and nonalcoholic beverage shops serving specialty snacks such as ice cream, doughnuts, bagels, coffee, popcorn, and cookies for
consumption on or near the premises

722515 001

Food service contractors, including airline food service contractors, food concession contractors, and cafeteria food service contractors

722310 005

Caterer for banquets, weddings, conferences, seminars, etc.

722320 002

Bar, tavern, pub, or other drinking place, selling alcoholic beverages for consumption on premises

722410 001

Health and personal care stores
Pharmacy or drug store (except Internet only or mail-order)

446110 001

Cosmetics, beauty supplies, and perfume store

446120 001

Health food, vitamins, and food supplements store

446191 002

Hearing aids, convalescent aids, and medical equipment store

446199 006

Optical goods store including sunglasses (except offices of optometrists)

446130 005

Other health and personal care store

446190 001

Gasoline stations
Gasoline station with convenience store

447110 001

Gasoline station with no convenience store

447190 001

Clothing and clothing accessories stores
Women's clothing store including maternity shop

448120 002

Men's clothing store

448110 001

Children's and infants' clothing store

448130 001

Family clothing store

448140 001

Accessory store including costume jewelry, ties, wigs, hairpieces, etc.

448150 005

Specialized clothing store including women's lingerie, bridal wear, custom printed T-shirts, uniforms, except athletic, etc.

448190 001

Formal wear and costume rental

532281 001

Shoe store

448210 001

Jewelry store

448310 001

Luggage and leather goods store

448320 001

Sporting goods, hobby, book, and music stores
General (full-line) sporting goods store

451110 102

Hobby, toy, and game store

451120 101

Sewing, fabric, and piece goods store including upholstery fabrics

451130 006

Musical instrument and supply store

451140 001

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16

Book / newsstand / comic book store

451210 001

Electronics stores

443140 001

Department stores, including discount or mass merchandising

452210 001

General merchandise stores, including warehouse clubs and supercenters

452310 001

Miscellaneous store retailers
Florist

453110 001

Office supply, stationery, and school supplies store

453210 005

Gift, novelty, party supply or souvenir store including crafts and greeting cards

453220 005

Used merchandise store including antique, flea market, thrift, etc. (except pawn shop)

453310 001

Pet and pet supplies store

453910 006

Art dealer/gallery

453920 001

Manufactured (mobile) home retailer, new and used

453930 001

Other miscellaneous retailer including tobacco, trophy, religious goods (except books), etc.

453990 001

Nonstore retailers
Electronic shopping, mail-order, and TV shopping

454110 001

Vending machine operator

454210 003

Fuel dealer including heating oil and liquefied petroleum gas (except gasoline stations)

454310 001

Other direct selling establishment including house-to-house, party plan, home delivery newspaper routes, coffee break services, etc.

454390 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

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17

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

%

18

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What were the merchandise sales and operating receipts in 2022?
(Exclude sales and other taxes collected. Include shipping and handling charges.)

Check
if
None

2022
$

,000.00

B. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

C. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
D. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

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2022
%

19

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)
2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

TOTAL (Add lines C1 and C2)

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

20

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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21

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

End of 2021
$

,000.00

22

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

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23

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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24

Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

C. TOTAL (Add lines A and B)

$

,000.00

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25

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

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26

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

$

,000.00

C. Interest paid

$

,000.00

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

$

,000.00

A. Cost of products bought for resale without further processing
B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

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27

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. Excluding the exports reported in Item 5, line D, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

%

9. Construction contractors

%

10. Federal government
11. Commonwealth or territorial government

%

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28

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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29

Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following categories best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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30

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

5000025000

1. Retail sales of fresh meat and poultry

5000050000

2. Retail sales of fresh fish and seafood

5000075000

3. Retail sales of fresh fruit and vegetables

5000175000

4. Retail sales of frozen foods

5000100000

5. Retail sales of eggs and dairy, excluding ice cream

5000125000

6. Retail sales of baked goods
7. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and salad bars, and
prepared sandwiches, dishes, and entrees.)

8. Retail sales of candy, prepackaged cookies, and snack foods

5000150000

5000200000

5000250000

9. Retail sales of soft drinks and nonalcoholic beverages
10. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy milk, and egg
and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and crackers.)

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

12. Alcoholic beverages, prepared and served or dispensed for immediate consumption

13. Retail sales of bottled, canned, or packaged alcoholic beverages

5000225000

7000025000

7000050000

5000300000

14. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

5000325000

15. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements, including medicines used for
infusion services

5001350000

5001350003

a. Retail sales of prescriptions

5001350006

b. Retail sales of nonprescription medicines

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31

c. Retail sales of vitamins, minerals, and other dietary supplements

5001350009

5001450000

16. Retail sales of cosmetics and fragrances
17. Retail sales of home health care equipment and supplies, including first aid products, prescription accessories, wheelchairs,
mobility assistance appliances, durable medical equipment, orthopedic equipment and appliances (excluding shoes), and orthotics

5001375000

5000775000

18. Retail sales of household cleaning supplies

5000350000

19. Retail sales of men's clothing

5000375000

20. Retail sales of women's clothing

21. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)
22. Retail sales of new children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including school
uniforms

5000450000

5000400000

5000475000

23. Retail sales of footwear and footwear accessories

24. Retail sales of fabrics, yarns, and other sewing materials and supplies
25. Retail sales of domestics and other textile home furnishings (except carpet and rugs) (Include furniture coverings, towels, sheets,
blankets, table linens and coverings, etc.)

26. Retail sales of major household appliances and related parts and accessories

5001775000

5000650000

5000700000

5000875000

27. Retail sales of televisions, audio and video equipment

5001875000

28. Retail sales of flooring and floor coverings

29. Retail sales of computers and peripheral equipment, communications equipment, and related products

5001550000

5000680000

30. Retail sales of other home furnishings and accessories

5000500000

31. Retail sales of fine jewelry and watches

5000925000

32. Retail sales of books

33. Retail sales of toys, games, and hobby and craft supplies

5001125000

5001400000

34. Retail sales of glasses and contact lenses

35. Retail sales of other sporting goods and equipment, excluding sport vehicles

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

5001105000

32

5001900000

36. Retail sales of plumbing, electrical, and HVAC supplies
37. Retail sales of hardware, nonpower hand tools, and other building materials and supplies (Include nontreated dimensional lumber,
treated lumber, boards, glue-lam, floor trusses, roof trusses, doors and moulding, windows, skylights, insulation, ladders and
scaffolding, welding supplies, lawn and garden tools, etc.)

5001930000

38. Retail sales of power tools and equipment, including portable electric power tools, power air tools, stationary/bench top power tools,
and accessories (blades, bits, etc.)

5001675000

39. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants (Include powered lawn and garden
tools, outdoor grills, pools, pool chemicals, and pool supplies, and outdoor nursery stock.)

5000805000

5001850000

40. Retail sales of paint and sundries

5001275000

41. Retail sales of automobiles and light-duty trucks

5001725000

42. Retail sales of automotive fuels

5001950000

43. Retail sales of automotive parts and supplies

44. Retail sales of household fuels, including oil, LP gas, wood, coal

5001750000

5001250000

45. Retail sales of pet foods and supplies
46. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry and
miscellaneous materials and supplies

47. Retail sales of luggage and leather goods, including briefcases

48. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

5001935000

5001325000

5000860000

Add product/service not listed

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33

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Retail sales of fresh meat and poultry

$

,000.00

5000025000

2. Retail sales of fresh fish and seafood

$

,000.00

5000050000

3. Retail sales of fresh fruit and vegetables

$

,000.00

5000075000

4. Retail sales of frozen foods

$

,000.00

5000175000

5. Retail sales of eggs and dairy, excluding ice cream

$

,000.00

5000100000

6. Retail sales of baked goods

$

,000.00

5000125000

7. Retail sales of perishable prepared foods purchased for future consumption (Include delicatessen items, soup and
salad bars, and prepared sandwiches, dishes, and entrees.)

$

,000.00

5000150000

8. Retail sales of candy, prepackaged cookies, and snack foods

$

,000.00

5000200000

9. Retail sales of soft drinks and nonalcoholic beverages

$

,000.00

5000250000

10. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt,
nondairy milk, and egg and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies,
pasta, and crackers.)

$

,000.00

5000225000

11. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

12. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

13. Retail sales of bottled, canned, or packaged alcoholic beverages

$

,000.00

5000300000

14. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

$

,000.00

5000325000

a. Retail sales of prescriptions

$

,000.00

5001350003

b. Retail sales of nonprescription medicines

$

,000.00

5001350006

15. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements, including
medicines used for infusion services

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

34

c. Retail sales of vitamins, minerals, and other dietary supplements

$

,000.00

5001350009

Subtotal

$

,000.00

5001350000

16. Retail sales of cosmetics and fragrances

$

,000.00

5001450000

17. Retail sales of home health care equipment and supplies, including first aid products, prescription accessories,
wheelchairs, mobility assistance appliances, durable medical equipment, orthopedic equipment and appliances
(excluding shoes), and orthotics

$

,000.00

5001375000

18. Retail sales of household cleaning supplies

$

,000.00

5000775000

19. Retail sales of men's clothing

$

,000.00

5000350000

20. Retail sales of women's clothing

$

,000.00

5000375000

21. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)

$

,000.00

5000450000

22. Retail sales of new children's wear, including boys', girls', and infants' and toddlers' clothing and accessories,
including school uniforms

$

,000.00

5000400000

23. Retail sales of footwear and footwear accessories

$

,000.00

5000475000

24. Retail sales of fabrics, yarns, and other sewing materials and supplies

$

,000.00

5001775000

25. Retail sales of domestics and other textile home furnishings (except carpet and rugs) (Include furniture coverings,
towels, sheets, blankets, table linens and coverings, etc.)

$

,000.00

5000650000

26. Retail sales of major household appliances and related parts and accessories

$

,000.00

5000700000

27. Retail sales of televisions, audio and video equipment

$

,000.00

5000875000

28. Retail sales of flooring and floor coverings

$

,000.00

5001875000

29. Retail sales of computers and peripheral equipment, communications equipment, and related products

$

,000.00

5001550000

30. Retail sales of other home furnishings and accessories

$

,000.00

5000680000

31. Retail sales of fine jewelry and watches

$

,000.00

5000500000

32. Retail sales of books

$

,000.00

5000925000

33. Retail sales of toys, games, and hobby and craft supplies

$

,000.00

5001125000

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

35

34. Retail sales of glasses and contact lenses

$

,000.00

5001400000

35. Retail sales of other sporting goods and equipment, excluding sport vehicles

$

,000.00

5001105000

36. Retail sales of plumbing, electrical, and HVAC supplies

$

,000.00

5001900000

37. Retail sales of hardware, nonpower hand tools, and other building materials and supplies (Include nontreated
dimensional lumber, treated lumber, boards, glue-lam, floor trusses, roof trusses, doors and moulding, windows,
skylights, insulation, ladders and scaffolding, welding supplies, lawn and garden tools, etc.)

$

,000.00

5001930000

38. Retail sales of power tools and equipment, including portable electric power tools, power air tools, stationary/bench
top power tools, and accessories (blades, bits, etc.)

$

,000.00

5001675000

39. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants (Include powered lawn
and garden tools, outdoor grills, pools, pool chemicals, and pool supplies, and outdoor nursery stock.)

$

,000.00

5000805000

40. Retail sales of paint and sundries

$

,000.00

5001850000

41. Retail sales of automobiles and light-duty trucks

$

,000.00

5001275000

42. Retail sales of automotive fuels

$

,000.00

5001725000

43. Retail sales of automotive parts and supplies

$

,000.00

5001950000

$

,000.00

5001750000

45. Retail sales of pet foods and supplies

$

,000.00

5001250000

46. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry
and miscellaneous materials and supplies

$

,000.00

5001935000

47. Retail sales of luggage and leather goods, including briefcases

$

,000.00

5001325000

$

,000.00

5000860000

$

,000.00

9900000000

44. Retail sales of household fuels, including oil, LP gas, wood, coal

48. Retail sales of household goods, not elsewhere classified (Include souvenirs and novelty items.)

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

Add product/service not listed

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36

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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37

Item 28: Special Items

ITEM 28: SPECIAL ITEMS

Floor Space
Include:
Only the floor space used/controlled by this company.
All space occupied by this establishment on every floor of multi-story buildings.
EXAMPLE: How to compute floor space in square feet
(1) Under-roof selling space is:
200 ft. x 80 ft. = 16,000 sq. ft.
(2) Total under-roof floor space is:
200 ft. x 100 ft. = 20,000 sq. ft.

1. What was the under-roof selling space?
(Enter the square footage of in-store selling space at the end of 2022. Include all store areas open to customers, including aisles,
elevators, etc. Exclude display windows fronting onto streets or walks, outdoor entrance ways, or other outdoor space.)

Square feet as of
December 31,
2022

2. What was the total under-roof floor space?
(Enter the total square footage of all under-roof selling space plus all other space available at the end of 2022. Include dry storage,
refrigerated space, offices, workrooms, display windows, and enclosed entrance ways. Exclude outdoor space, even if covered.)

Shopping Center or Mall
Was this establishment physically located in a shopping center or mall?
Yes
No

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38

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

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39

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

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Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

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41

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

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1000

characters remaining

43

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-94404_su.pdf Generated 2022-02-23 17:34:28

,000.00

44

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

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2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Publishing
Newspaper publisher except Internet-exclusive publisher

511110 001

Periodical publisher and shopping news publisher except Internet-exclusive publisher

511120 001

Book publisher, atlas/map publisher except Internet-exclusive publisher

511130 001

Database and directory publisher except Internet-exclusive publisher

511140 001

Software publisher

511210 005

Other publishers except Internet-exclusive publishers

511190 001

Internet-exclusive publishers including newspapers, books, periodicals, greeting cards, databases, etc.

519130 002

Motion pictures and sound industries
Producer of motion pictures, television programs, or other videos, including commercials, infomercials, and music videos (except
independent production)

512110 008

Motion picture, television film, and video distribution (without production)

512120 006

Motion picture theater and drive-in

512130 001

Postproduction and other services for film and video production and distribution

512190 001

Sound recording studio, including independent establishments recording musical performances, but not engaged in production or distribution

512240 001

Broadcasting
Radio broadcasting

515110 001

Television broadcasting

515120 001

Cable and other subscription programming

515210 001

Internet publishing and broadcasting, web search portals, publishing exclusively on the Internet

519130 001

Telecommunications
Wired and wireless telecommunications carriers, including cable distribution, Internet service providers, and cellular telecommunications.

517310 001

Satellite telecommunications

517410 001

Other telecommunications services

517919 902

Other information services
Data processing, hosting, and related services (except software publishing)

518210 001

News syndicates supplying the news media with information such as news, reports, and pictures

519110 001

Libraries and archives

519120 001

Other information services

519190 002

Professional, scientific, and technical services

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15

Offices of lawyers

541110 001

All other legal services

541190 001

Accounting services including auditing, tax preparation, payroll, etc.

541210 001

Architectural services, excluding landscape

541310 001

Landscape architectural services

541320 001

Engineering services

541330 007

Drafting services

541340 004

Home or building inspection services

541350 001

Geophysical surveying and mapping services

541360 001

Surveying and mapping services excluding geophysical

541370 008

Testing laboratories, excluding medical and veterinary

541380 004

Interior design services and consulting

541410 005

Industrial design services and consulting

541420 003

Graphic design and commercial art services

541430 003

Fashion design and other specialized design services

541490 003

Computer systems design and related services, including custom computer programming services, computer systems integrators, computer
systems consultants, and computer facilities management services

541510 001

Management consulting services

541610 001

Environmental consulting services excluding engineering

541620 003

Other scientific or technical consulting services

541690 001

Research and development in physical, engineering, and life sciences

541710 001

Research and development in the social sciences and humanities

541720 001

Advertising agencies

541810 002

Public relations agency

541820 001

Media buying services - purchasing advertising time or space and reselling

541830 001

Radio, television, or publishers' advertising representatives independent of media owners

541840 001

Display advertising

541850 004

Direct mail advertising

541860 003

Advertising material direct distribution

541870 002

Welcoming services, advertising distribution, sign shops, and other advertising related services

541890 001

Marketing research and public opinion polling

541910 003

Photographic services including portrait and commercial

541920 001

Translation and interpretation services including sign language

541930 003

Veterinary services including veterinary testing laboratories

541940 003

All other professional, scientific, and technical services excluding real estate

541990 001

Management of companies and enterprises
Corporate, subsidiary, and regional managing offices and offices of bank and other holding companies

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

551110 001

16

Administrative and support services
Office administrative services

561110 003

Facilities support services

561210 003

Employment services
Temporary help support services

561320 002

Employment placement office (agency)

561311 001

Professional employer organizations, including employee leasing services

561330 001

Business support services including document preparation services, telephone call centers, telemarketing bureaus, etc.
Document preparation services

561410 002

Telephone answering services

561421 001

Business service centers including copy and private mail centers

561430 001

Collection agencies

561440 001

Credit bureaus

561450 001

Other business support services including court reporting or stenotype

561490 001

Travel arrangement and reservation services
Travel agency

561510 001

Tour operator - assembling tour packages and selling directly to travelers or through other travel agencies

561520 001

Other travel arrangement and reservation services

561590 001

Investigation and security services
Investigation, guard, and armored car services

561610 001

Security system services including locksmiths

561620 001

Cleaning services, excluding carwash
Exterminating and pest control services, except agricultural

561710 001

Janitorial services

561720 001

Landscaping services including lawn, garden, ornamental shrub, and tree services

561730 004

Carpet, rug, and upholstery cleaning services

561740 001

Other specialized cleaning services including ventilation; drain, gutter and duct cleaning; and swimming pool cleaning and maintenance
services

561790 001

Other support services to businesses or organizations
Packaging and labeling services (i.e., apparel folding and packaging, shrink wrapping), excluding aerosol packaging

561910 001

Convention and trade show organizers or management services

561920 001

All other support services to businesses or organizations

561990 001

Waste management and remediation services
Waste collection

562110 001

Waste treatment or disposal

562210 001

Remediation services including remediation or cleaning up of contaminated sites, asbestos abatement, and lead paint removal

562910 001

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17

Materials recovery facilities

562920 002

All other waste management services including cesspool and septic tank cleaning as well as portable toilet rental

562990 001

Educational services
Business and secretarial schools, e.g., clerical, secretarial, or court reporting

611410 001

Computer training services, excluding computer repair training

611420 003

Professional and management development training

611430 001

Technical or vocational schools for learning a trade (plumbing, electrical, barber, etc.)

611510 001

Fine art schools including dance, art, drama, and music

611610 001

Sports and recreation instruction

611620 004

Language schools

611630 002

All other schools and instruction including tutoring and automobile driving schools

611690 001

Educational consulting and other educational support services

611710 001

Offices of health practitioners
Office of physician(s) (M.D. or D.O.)

621110 001

Office of dentist(s)

621210 002

Chiropractor(s)

621310 001

Optometrist(s)

621320 003

Mental health practitioner(s) excluding physicians

621330 005

Physical, occupational, or speech therapist or audiologist

621340 001

Other health practitioners

621390 001

Outpatient care facilities and medical and diagnostic laboratories
Family planning centers

621410 003

Outpatient mental health and substance abuse treatment clinics

621420 006

Medical laboratories and diagnostic imaging centers

621510 001

Home and ambulatory health services
Home health care providers

621610 006

Ambulance or emergency rescue services, air or ground

621910 003

All other ambulatory health care services

621990 001

Hospitals
General medical and surgical hospitals

622110 001

Psychiatric and substance abuse hospitals

622210 001

Specialty (except psychiatric and substance abuse) hospitals

622310 001

Nursing and residential care facility
Nursing care facilities (skilled nursing facilities)

623110 005

Residential intellectual and developmental disability facility

623210 005

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18

Residential mental health and substance abuse facility

623220 006

Continuing care retirement communities and assisted living facilities for the elderly without onsite nursing care

623310 001

Other residential care facilities of social or personal assistance including homes for children, orphanages, etc.

623990 006

Social services to individuals and families
Child and youth services (except scouting and related youth development organizations)

624110 00B

Services for the elderly and persons with disabilities

624120 00D

Other individual and family services including alcoholism and drug addiction self-help organizations, hotline centers, community health
education and social work case management services for families or individuals

624190 00O

Social services to the community
Community food services

624210 006

Community housing services including temporary shelters

624220 001

Emergency and other relief services

624230 003

Vocational rehabilitation services

624310 007

Child care services

624410 007

Artistic, sports, and other related services
Theater companies and dinner theaters

711110 001

Dance companies engaged in producing all types of live theatrical dance (e.g., ballet, contemporary dance, folk dance) presentations

711120 001

Musical groups and artists

711130 001

Other performing arts companies

711190 001

Sports teams or clubs, racetracks, trainers, racing stables, and individual sports professionals

711210 001

Promoters with facilities, live performing arts productions (except popular music)

711310 101

Promoters without facilities, live performing arts productions (except popular music)

711320 101

Agents or managers for artists, performers, individual sports professionals, authors, speakers, and other public figures

711410 002

Independent artists, writers, and performers

711510 008

Museums, historical sites, and similar institutions
Museums

712110 003

Zoos, aquariums, and other live animal exhibits (e.g., wild animal or safari parks, petting zoos, etc.)

712130 101

Nature parks and other similar natural wonder tourist attractions

712190 004

Amusement, gambling, and recreation industries
Amusement and theme parks, including water or kiddie parks

713110 001

Arcade and family fun centers

713120 002

Casinos (gambling) without guestrooms for lodging

713210 004

Other gambling services or games, including slot machine operators, lotteries, off-track betting, and other betting operation (excluding
casinos or hotels with casinos)

713290 001

Golf courses and country clubs

713910 002

Marinas, yacht clubs, or boat docks

713930 003

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

19

Fitness center, gymnasium, or athletic club

713940 001

Bowling center

713950 001

Other amusement attractions including billiard parlors, mini golf, etc.

713990 001

Repairs and maintenance of automobiles, machinery, and equipment
General or specialized motor vehicle mechanical and electrical repair and maintenance

811110 001

Motor vehicle body, paint, interior, and glass repair and maintenance

811120 001

Other motor vehicle care and maintenance including oil change and lubrication, air conditioning repair, carwash, rustproofing services, etc.

811190 001

Electronic and precision equipment repair and maintenance

811210 001

Commercial and industrial machinery repair, including construction, farm, and material handling equipment repair

811310 001

Home and garden equipment and appliance repair and maintenance

811410 001

Furniture repair, refinishing, and reupholstery

811420 001

Footwear, luggage, handbag, briefcase and leather goods repair

811430 001

Other personal and household goods repair and maintenance

811490 001

Personal services
Beauty shops, barber shops, unisex hair shops, facial salons, or nail salons

812110 001

Other personal care services including weight loss centers, massage salons, permanent make-up clinics

812190 001

Funeral homes and funeral services

812210 001

Cemeteries or crematories

812220 004

Coin operated laundries and drycleaners

812310 001

Drycleaning and laundry services (except coin-operated)

812320 001

Laundry services in combination with linen or uniform rental services

812331 002

Pet care excluding veterinary services

812910 001

Photofinishing

812920 001

Parking lots or garages

812930 004

Other personal services including bail bonding, dating services, wedding planning, etc.

812990 001

Religious, grantmaking, civic, professional, and similar organizations
Religious organizations

813110 002

Philanthropic trusts, fundraising organizations, or grantmaking foundations

813210 001

Social advocacy organizations promoting a specific social or political cause, including human rights organizations, environment and
conservation advocacy, and peace advocacy organizations

813311 001

Civic, social, or fraternal organizations

813410 002

Business associations

813910 002

Professional organizations

813920 002

Labor unions or similar labor organizations

813930 001

Property owners' associations, including tenants' and condominium associations

813990 001

Other primary business or activity

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

20

Private households employing cooks, maids, housekeepers, nannies, gardeners, etc.

814110 001

Other primary business or activity

779000 001

Select Sector

Describe

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21

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

%

22

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None

2022
$

A. What were the operating receipts of this establishment in 2022?

,000.00

B. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

C. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
D. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

2022
%

23

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)

Check
if
None

2022
$

,000.00

2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

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24

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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25

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

End of 2021
$

,000.00

26

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

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27

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

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28

Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

$

,000.00

C. TOTAL (Add lines A and B)

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29

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

30

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

$

,000.00

C. Interest paid

$

,000.00

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

$

,000.00

A. Cost of products bought for resale without further processing

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31

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line D, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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32

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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33

Item 28: Special Items

ITEM 28: SPECIAL ITEMS
Support Services
Was this establishment primarily engaged in providing management, administrative, or support services to other establishments of the same company (rather than for the general public or
other business firms) in 2022?
Yes
No
Merchandise Sold
Did the sale of merchandise account for more than half of the total receipts of this establishment in 2022?
Yes - Describe merchandise sold
Describe
No
Shopping Center or Mall
Was this establishment physically located in a shopping center or mall?
Yes
No

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34

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

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35

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

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36

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

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37

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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38

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

1000

characters remaining

39

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-95104_su.pdf Generated 2022-02-23 17:39:06

,000.00

40

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

1

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

14

Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Depository credit intermediation
Commercial Banking

522110 001

Saving institution, remedial loan society or mutual benefit association accepting deposits

522120 001

Credit Union

522130 001

Finance companies, consumer credit, and credit card issuance
Bank primarily issuing credit cards, or personal credit card issuance by personal credit institution or nondepository credit institution

522210 001

Sales finance including automotive, commercial and inventory finance (except trade finance), and insurance premium finance

522220 001

Consumer (personal) finance or small loan company, including nondepository industrial bank or Morris Plan, pawn shop, federally-sponsored
credit agency, mortgage banker, mortgage company, or loan correspondent, international trade credit loan, finance company or other
nondepository credit intermediation

522290 002

Loan or mortgage broker or agent

522310 003

Reserve and clearinghouse activities including automated teller machine (ATM) or automated loan machine (ALM) network, electronic funds
transfer network, electronic payment service, and credit card processing service

522320 001

Check cashing agency, money order or traveler's check issuance, loan/mortgage loan servicing, or credit related services

522390 003

Investment banking, dealing, and brokerage
Investment banking and securities dealing

523110 001

Securities brokerage (full service and discount)

523120 003

Commodity brokerage

523140 001

Securities or commodities exchange

523210 003

Trading/dealing (except securities and commodities), oil royalty trader (investing on own account), venture capital company, investment club,
or other investor for own account

523910 001

Asset/portfolio manager

523920 002

Investment advice

523930 004

Other financial investment activities

523990 001

Insurance carriers and related activities
Life, accident, health, and medical insurance carrier

524110 001

Insurance carrier excluding life, accident and health, and medical

524120 001

Reinsurance carrier including life, accident and health, property and casualty, surety, fidelity and liability, title or other reinsurance carrier

524130 005

Insurance agent or broker, not owned or operated by any insurance carrier, including risk finance consulting

524210 007

Insurance claims adjusting, appraiser, third party administrator of workers' compensation or other self insurance, pension, health, or welfare
fund, insurance advisory services, insurance rate making organization, or other insurance services

524290 001

Lessor of real estate (property owned by you)

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

15

Lessor of residential real estate

531110 002

Lessor of nonresidential buildings including office/professional buildings, industrial buildings, shopping centers and retail stores, except
miniwarehouses

531120 001

Lessor of self-service storage or miniwarehouses

531130 001

Lessor of other real estate property including manufactured or mobile home sites and vacant lots

531190 001

Real estate agent or broker including time share sales

531210 001

Property manager including residential and nonresidential, resort/vacation, and time share

531310 001

Real estate appraiser

531320 001

Real estate listing or auction service, escrow or fiduciary agent, real estate consultant, or other real estate related service

531390 007

Consumer goods rental or leasing
Renting or leasing without drivers and on a short term basis: passenger cars, passenger vans, and sport utility vehicles

532110 001

Renting or leasing without drivers and on a short term basis: trucks including nonpassenger vans, truck tractors, truck trailers, semi trailers,
and storage semi trailers

532120 001

Consumer electronics and appliances rental

532210 001

General rental center - wide range of consumer items and equipment

532310 002

Other consumer goods rental, including formal wear and costume rental, video rental store, home health equipment rental, and recreational
goods rental

532280 001

Commercial and industrial machinery and equipment rental and leasing
Construction, transportation, mining, and forestry machinery and equipment rental and leasing

532410 001

Office furniture and machines including computers and computer peripheral equipment rental and leasing

532420 001

Medical machinery and equipment, traffic equipment including barricades, cones and signage, motion picture equipment, theatrical
equipment or other nonconsumer type machinery or equipment rental and leasing

532490 001

Intangible assets (except copyrighted works) leasing or licensing
Franchise, trademarks, and patents leasing/licensing (except copyrighted works)

533110 001

Other primary business or activity
779000 001

Other primary business or activity
Select Sector

Describe

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

16

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

%

17

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None

2022
$

A. What was the revenue for this establishment in 2022?

,000.00

B. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

C. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
D. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

2022
%

18

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)

Check
if
None

2022
$

,000.00

2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

$

,000.00

TOTAL (Add lines C1 and C2)

$

,000.00

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

19

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

20

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

End of 2021
$

,000.00

21

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

22

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

23

Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

$

,000.00

C. TOTAL (Add lines A and B)

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

24

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

25

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

$

,000.00

C. Interest paid

$

,000.00

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

$

,000.00

A. Cost of products bought for resale without further processing

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

26

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line D, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

%

3. Retailers for resale

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

9. Construction contractors

%

10. Federal government

%

11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

27

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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28

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

29

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

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30

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

31

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

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32

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

1000

characters remaining

33

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-95204_su.pdf Generated 2022-02-23 17:43:00

,000.00

34

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

ATTN

Name 1

Store/Plant

Name 2

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

PHYSICAL LOCATION
Please provide information on the establishment’s physical location. The physical location is where business is conducted or where services or industrial operations are performed, as
opposed to the establishment’s mailing address. P.O. Boxes are not physical locations.

In which village is this establishment physically located?
Village
Select Village

Please describe this establishment’s physical location, such as number and name of street (if applicable), nearby landmarks, etc.

For Census Bureau Use Only
CFN

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

1

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

2

Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return or Form 944-SS,
Employer's Annual Federal Tax Return?

Yes
No

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

3

Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941-SS, Employer’s Quarterly Federal Tax Return or
Form 944-SS, Employer's Annual Federal Tax Return?
EIN
99-9999999

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4

Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

5

Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: 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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6

Item 2C: Ownership or Control - Management and Policy

ITEM 2C: 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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7

Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: 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%

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

8

Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

EIN
99-9999999

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

9

Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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10

Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

11

Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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12

Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

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

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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13

Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

14

Item 4: Primary Business or Activity Additional Information

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
If none of the provided options seem appropriate, please select Other primary business or activity and enter a description that most closely matches the establishment's primary
business or activity.
Select only ONE.

Hotel with casino

721120 002

Hotel (except with casino), motel, or motor hotel

721110 002

Other traveler accommodation including tourist villa, or parador

721190 001

Travel trailer park, recreational vehicle park, or campground except residential

721211 003

Recreation or vacation camp (except campground)

721214 004

Rooming and boarding house including lodging house operated by membership organization

721310 001

Apartment building operator

531110 001

Property owners' associations, including tenants' and condominium associations

813990 001

Bar or restaurant operated by social or fraternal organization for members

813410 001

Bar, tavern, pub, or other drinking place, selling alcoholic beverages for consumption on premises

722410 001

Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Fast food restaurant

722513 002

Cafeterias, grill buffets, and buffets

722514 002

Snack and nonalcoholic beverage shops serving specialty snacks such as ice cream, doughnuts, bagels, coffee, popcorn, and cookies for
consumption on or near the premises

722515 001

Food service contractors

722310 006

Caterer for banquets, weddings, conferences, seminars, etc.

722320 002

Mobile food service, including ice cream, snacks, sandwiches, and meals distributed from motorized vehicles or nonmotorized carts

722330 002

Other primary business or activity

779000 001

Select Sector

Describe

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15

General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period
Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941-SS (Employer’s Quarterly Federal Tax Return)
IRS Form 944-SS (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.
Providing Estimates
If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:
Dollar figures should be rounded to thousands of dollars.

EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

How to Report Percents:
Percents should be rounded to whole percents.

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

%

16

Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

A. What were the merchandise sales and operating receipts in 2022?
(Exclude sales and other taxes collected. Include shipping and handling charges.)

Check
if
None

2022
$

,000.00

B. Were any of the sales, shipments, receipts, or revenue reported in line A a result of e-commerce transactions?
(E-commerce includes sales, commissions, rent, or fees collected from any transactions completed online. Transactions are agreements between buyers and sellers to transfer
ownership of, or rights to use, goods or services. Payment for these goods or services may or may not be made online.)
E-commerce transactions include:
Electronic Data Interchange (EDI)
E-mail
Internet
Extranet
Other online systems
Yes
No

Check
if
None

2022

C. What was the percent of total sales, shipments, receipts, or revenue reported in line A that were a result of e-commerce
transactions?

%

Check
if
None
D. What is the percent of total sales, shipments, receipts, or revenue reported in line A that were generated from exports?
(Include all exports to foreign countries, the United States, and other U.S. territories)

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

2022
%

17

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL
Include full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service (IRS) Form 941SS, Employer's Quarterly Federal Tax Return, or Form 944-SS, Employer's Annual Federal Tax Return, and filed under the Employer Identification Number (EIN) in Item 1. For further
clarification, see Additional Information.
A. Number of Paid Employees
Check
if
None

2022 Number

1. What was the number of paid employees for the pay period including March 12, 2022?

B. Payroll Before Deductions
(Exclude employer's cost for fringe benefits)
Check
if
None
1. What was the annual payroll for 2022 before deductions?

2. What was the first quarter payroll (January-March, 2022)?

2022
$

,000.00

$

,000.00

C. Employer's Annual Cost for Fringe Benefits

1. What were the legally required fringe benefits?
(Include employer payments for Social Security, Medicare, unemployment compensation, workmen's
compensation, and State disability programs, if required.)
2. What were the voluntarily provided fringe benefits?
(Include such items as payments for life insurance, medical insurance, pensions, welfare benefits, and unionnegotiated benefits.)

TOTAL (Add lines C1 and C2)

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

Check
if
None

2022
$

,000.00

$

,000.00

$

,000.00

18

Item 9: Value of Inventories Additional Information

ITEM 9: VALUE OF INVENTORIES
A. Did this establishment own inventories, regardless of where held, at the end of 2022 and/or 2021?
Yes
No

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19

Item 9: Value of Inventories - Continued Additional Information

ITEM 9: VALUE OF INVENTORIES

Check
if
None
B. What was the total value of inventories owned by this
establishment?

Check
if
None

End of 2022
$

,000.00

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

End of 2021
$

,000.00

20

Item 12A: Legal Form of Organization

ITEM 12A: LEGAL FORM OF ORGANIZATION
A. What legal form of organization best describes this establishment at the end of 2022?
Individual (sole) proprietorship
Partnership
Cooperative organization
Corporation
Other
Describe

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

21

Item 12B: Legal Form of Organization - Corporation Type

ITEM 12B: LEGAL FORM OF ORGANIZATION - CORPORATION TYPE
B. Which of the following is this type of corporation?
Private (nonprofit)
Private (for-profit)
Public

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

22

Item 13: Capital Expenditures Additional Information

ITEM 13: CAPITAL EXPENDITURES
What were the capital expenditures in 2022 for the following?
(Report the dollar value of capital expenditures including value of acquisitions under capital leases. Include capitalized repairs and improvements that increased the value of the building
or equipment or adapted it for a different use. Do not include costs of routine maintenance and repairs. Do not include rental payments made under operating leases.)
Check
if
None

2022

A. Buildings and structures, including building and leasehold improvements
(Exclude land.)

$

,000.00

B. Machinery and equipment
(Include vehicles.)

$

,000.00

C. TOTAL (Add lines A and B)

$

,000.00

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23

Item 14: Rental Payments Additional Information

ITEM 14: RENTAL PAYMENTS
What were the total costs for rental or lease of the following?
(Exclude capital leases, i.e., leases with a contract to own at the end of the lease)
Check
if
None

2022
$

,000.00

$

,000.00

A. Machinery, equipment, and other items, excluding computer software

B. Land, buildings, structures, store space, and offices

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:57

24

Item 16: Selected Expenses Additional Information

ITEM 16: SELECTED EXPENSES
What were the operating expenses paid by this establishment in 2022 for the following?
Check
if
None

2022
$

,000.00

B. All other operating expenses
(Include payroll, benefits, utilities, office supplies, communication services, computer services, and routine maintenance
and repair. Exclude cost of products bought for resale, interest, depreciation, bad debt, and capital expenditures as
reported in Item 13.)

$

,000.00

C. Interest paid

$

,000.00

$

,000.00

A. Cost of products bought for resale without further processing

D. Depreciation charges
(Include depreciation charges in 2022 for buildings, structures, and leasehold improvements, equipment and machinery
that your company owns or acquired under a capital lease agreement.)

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25

Item 20: Class of Customer Additional Information

ITEM 20: CLASS OF CUSTOMER
A. Excluding the exports reported in Item 5, line D, what was the estimated percentage of this establishment's total sales (reported in Item 5, line A) by class of customer?
2022
1. Household consumers and individuals
(Exclude visiting tourists)

%

2. Visiting tourists
(Include business travelers)

%

3. Retailers for resale

%

4. Wholesalers/distributors for resale

%

5. Manufacturing and mining industrial users for use as input goods in production

%

6. Hotels, restaurants, food services, and drinking places

%

7. Other services not included above
(Include banks, insurance, real estate, travel agencies and other passenger transportation services, and other service
establishments including truck and passenger car rental and leasing)

%

8. Businesses for end use in their own operation, not for resale or production

%

%

9. Construction contractors

%

10. Federal government
11. Commonwealth or territorial government

%

12. Local government
(Include county, town, village, and municipio)

%

13. Other - Describe

%

Describe

%

14. TOTAL (Sum of lines 1 through 13 should equal 100%)

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26

Item 22: Detail of Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
Select ALL that apply.
Description

Select

Product Code

7003825000

1. Room or unit accommodation for travelers

7002375000

2. Gambling machine products

7002450000

3. Lotteries

7002400000

4. Pari-mutuel sports gambling

7002350000

5. Table wagering games

7006550000

6. Hosting of coin-operated self-service gambling machines

7. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

8. Alcoholic beverages, prepared and served or dispensed for immediate consumption

9. Rental of space for meetings, conventions, and similar short-term business uses

10. Rental of space for weddings, banquets, parties, and similar short-term social uses

11. Retail sales of bottled, canned, or packaged alcoholic beverages

7000025000

7000050000

7006425000

7006475000

5000300000

Add product/service not listed

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

27

Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued Additional Information

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Description

Value

Product Code

1. Room or unit accommodation for travelers

$

,000.00

7003825000

2. Gambling machine products

$

,000.00

7002375000

3. Lotteries

$

,000.00

7002450000

4. Pari-mutuel sports gambling

$

,000.00

7002400000

5. Table wagering games

$

,000.00

7002350000

6. Hosting of coin-operated self-service gambling machines

$

,000.00

7006550000

7. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

$

,000.00

7000025000

8. Alcoholic beverages, prepared and served or dispensed for immediate consumption

$

,000.00

7000050000

9. Rental of space for meetings, conventions, and similar short-term business uses

$

,000.00

7006425000

10. Rental of space for weddings, banquets, parties, and similar short-term social uses

$

,000.00

7006475000

11. Retail sales of bottled, canned, or packaged alcoholic beverages

$

,000.00

5000300000

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

$

,000.00

9900000000

Add product/service not listed

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

28

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

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29

Item 28: Special Items

Number and Type of Accommodations

A. What was the number of rooms, units, or quarters primarily rented as transient as of December 31, 2022?
(Consists of the number which can be rented as single units. Suites of rooms which cannot be subdivided should be counted as a
single unit.)

Number as of
December 31,
2022

B. Were more than half of guestroom or unit rental receipts from transient guests?
Yes
No

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

30

Item 30A: Majority Ownership - Ethnicity

ITEM 30A: MAJORITY OWNERSHIP - ETHNICITY
Is the majority ownership of this establishment of Hispanic, Latino, or Spanish origin?
(Select only ONE)
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin - Describe origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc.
Describe
Not known / not determinable, such as publicly traded

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

31

Item 30B: Majority Ownership - Race

ITEM 30B: MAJORITY OWNERSHIP - RACE
B. What is the race of the majority ownership of this establishment?
(Select ALL that apply)
White
Black or African American
American Indian or Alaska Native - Describe name of enrolled or principal tribe
Describe
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian - Describe race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
Describe
Other Pacific Islander - Describe race, for example, Fijian, Tongan, etc.
Describe
Some other race - Describe race
Describe
Not known / not determinable, such as publicly traded

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

32

Item 30C: Majority Ownership - Citizenship

ITEM 30C: MAJORITY OWNERSHIP - CITIZENSHIP
C. What is the citizenship of the majority ownership of this establishment?
(Select only ONE)
Born in this territory
Born in the United States or another U.S. territory or commonwealth
Naturalized citizen
Not known / not determinable, such as publicly traded
Not a U.S. citizen or national

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

33

Item 30D: Majority Ownership - Gender

ITEM 30D: MAJORITY OWNERSHIP - GENDER
D. What is the gender of majority ownership of this establishment?
(Select only ONE)
Male-owned
Female-owned
50/50 Male/Female - Equal percent of ownership
Not known/not determinable (such as publicly traded)

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

34

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

1000

characters remaining

35

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

Village

State

Select Village

Select State or Territory

ZIP Code
99999-9999

Describe kind of business at this location

2022
What is the number of rooms in this hotel, motel, or other lodging facility?

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

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_IA-97204_su.pdf Generated 2022-02-23 17:46:58

,000.00

36


File Typeapplication/pdf
AuthorBlynda K Metcalf (CENSUS/EWD FED)
File Modified2022-03-01
File Created2022-03-01

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