U.S. DEPARTMENT OF COMMERCE

U.S. CENSUS BUREAU

FORM

QSS-4fA 

QUARTERLY SERVICES SURVEY

(08-23-2022)

CONTINUE ON PAGE 2

21965017

Due Date

Need help or have questions?

Call 1-800-772-7851

(8:30 a.m. - 5:00 p.m. ET, M-F)

or Visit

https://www.census.gov/services/qss/

respondent-information.html

Title 13 United States Code (U.S.C.),

Sections 131 and 182, authorizes the

Census Bureau to conduct this collection.

The U.S. Census Bureau is required by

Section 9 of the same law to keep your

information confidential and can use

your responses only to produce statistics.

The Census Bureau is not permitted

to publicly release your responses in a

way that could identify your business,

organization, or institution. Per the

Federal Cybersecurity Enhancement Act

of 2015, your data are protected from

cybersecurity risks through screening of

the systems that transmit your data.

This collection has been approved by

the Office of Management and Budget

(OMB). The eight-digit OMB approval

number is 0607-0907 and appears at

the upper right of this page. Without

this approval, we could not conduct this

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

INTERNET REPORTING OPTION AVAILABLE - We encourage you to

complete this survey online at: https://portal.census.gov

Authentication Code:

To view Survey Results:

https://www.census.gov/services

GENERAL INSTRUCTIONS

 

• Any significant change in this firm's operations should be noted in 8

• For establishments sold or acquired during the quarter(s), report data only for the period the establishments

were operated by this firm

 

• Estimates are acceptable if book figures are not available

 

• Enter "0" where applicable

•

 

•

•

Report data on an accrual basis

Dollars should be rounded to the nearest dollar

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

Bil. Mil. Thou. Dol.

Include:

• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and

Construction operations) as defined by the survey coverage in 1

• Data for auxiliary facilities primarily engaged in supporting services to this firm's establishment(s) such as

warehouses, garages, central administrative offices, and repair services

We estimate this survey will take an average of 10 minutes to complete. More information about this estimate and an address where you may

write with comments is on the back of this form.

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT

OMB No. 0607-0907: Approval Expires: 05/31/2027 
-

-

Form QSS-4fA (08-23-2022) Page 2

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21965025

1 SURVEY COVERAGE

Did this firm provide the business activities described below?

Yes

No - Specify this firm's business activity

2

 

Not Applicable.

3 ORGANIZATIONAL CHANGE

A.

 

Did this firm experience any acquisitions, sales, mergers, divestitures, and/or cease operations in the

Yes

No - Go to 4

B.

 

Which of the following organizational changes occurred in the

Check all that apply. If more than one organizational change occurred during the reporting period, explain in 8 .

Acquisition

Sale

Merger

Divestiture

Date of organizational change

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

AND

Enter detailed information below

Ceased Operation - Date of ceased operation/closure

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

 

Month

 

Day

 Year

 

Month

 

Day

 Year

Name of company EIN (9 digits)

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

City, town, village, etc. State ZIP Code

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT
Form QSS-4fA (08-23-2022) Page 3

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21965033

4 REPORTING PERIOD

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

Calendar quarter Beginning Date

 

Month

 

Day

 Year

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

 End Date

 

Month

 

Day

 Year

5 SALES, RECEIPTS, OR REVENUE

Firms operating on a commission basis should report commissions, fees, and other operating revenue income,

not gross billings or sales.

INCLUDE

 

• Net realized gains as well as losses within

specified area(s) of activity

 

• Earned interest

 

• Commissions and fees received from all sources,

including fees earned for exchanging currencies,

selling money orders, and cashing checks

 

• Net gains (losses) from the sale of real property

owned by this establishment for investment, rent, or

lease (NOT gross sales)

 

• Gross sales (NOT net gains (losses)) of real property

developed or buildings built by this establishment

for sale

 

• Gross rents from real property leased by this

establishment to others

 

• Total value of service contracts

EXCLUDE

 

• Taxes (sales, amusement, occupancy, use, or other)

collected directly from customers or clients and paid

directly to a local, state, or Federal tax agency

 

• Revenue from a domestic parent organization, or

from franchise locations owned by others

 

• Revenue of departments or concessions operated

by other companies at this establishment

 

• Revenue of foreign subsidiaries (those located

outside the U.S. , i.e., outside the 50 states, District

of Columbia, U.S. Commonwealth Territories, or

U.S. Possessions)

 

• Intracompany transfers

 

• Commissions from vending machine operators

 

• Revenue from the sale of used equipment

 

• Amounts received for work subcontracted to others

 

• Revenue from services performed by domestic

locations for foreign parent firms, subsidiaries,

branches, etc.

 

• Rents from departments or concessions operated by

other companies at this establishment

 

• Franchise sales, fees, and royalties

 

•

 

•

Sale or licensing of rights to intellectual property

protected by copyright or as industrial property

(e.g., patents, trademarks)

Dues and assessments from members and affiliates

 

$ Bil.

 Mil. Thou. Dol.

A.

 

What was this firm's revenue in the

 .......

B.

 

Does the revenue reported in 5 A represent book figure(s) or estimate(s)?

Book figures

Estimates

6

 

 and 

 

7

 

Not Applicable.

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT
Form QSS-4fA (08-23-2022) Page 4

21965041

8 REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate

where data were estimated.

9 CONTACT INFORMATION

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

Telephone 

Area code

 Number Extension E-mail address

Website

 THANK YOU

for completing your QUARTERLY SERVICES SURVEY.

 We suggest you keep a copy for your records.

We estimate this survey will take an average of 10 minutes to complete, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect

of this voluntary collection of information, including suggestions for reducing this burden, to: sssd.qss@census.gov. Be sure to use "EID Survey Comments 0607-

0907" as the subject.

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT