U.S. DEPARTMENT OF COMMERCE

U.S. CENSUS BUREAU

FORM

QSS-5A 

QUARTERLY SERVICES SURVEY

(08-23-2022)

CONTINUE ON PAGE 2

21969019

Due Date

Need help or have questions?

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(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 15 minutes to complete. More information about this estimate and an address where you may

write with comments is on the back of this form.

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT

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

-

Form QSS-5A (08-23-2022) Page 2

CONTINUE ON PAGE 3

21969027

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-5A (08-23-2022) Page 3

CONTINUE ON PAGE 4

21969035

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.

Taxable Firms

Include:

 

• Total value of service contracts

 

• Amounts received for work subcontracted to others

 

• Revenue from services performed by domestic

locations for foreign parent firms, subsidiaries,

branches, etc.

 

• Market value of compensation in lieu of cash

 

• Franchise sales, fees, and royalties

 

• Sale or licensing of rights to intellectual property

protected by copyright or as industrial property

(e.g., patents, trademarks)

 

• Gross billing, with the exception of racetracks

Exclude:

 

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

collected directly from customers or clients and paid

directly to a local, state, or Federal tax agency

 

• Revenue from a domestic parent organization, or

from franchise locations owned by others

 

• Rents from and revenue of separately operated

departments, concessions, etc., which are leased to

others

 

• Revenue from customers for carrying or other credit

charges

 

• Commissions from vending machine operators

 

• Revenue of foreign subsidiaries (those located

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

of Columbia, U.S. Commonwealth Territories, or

U.S. Possessions)

 

• Nonoperating revenue such as income from

investments, sales of company-owned real estate

(land and building), or other assets (except

inventory held for resale), securities, gifts, loans,

contributions, or grants

 

• Revenue from the sale of used equipment

 

• Installment payments from leasing under capital,

finance, or full-payout leases

 

• Intracompany transfers

 

• Interest income

 

• Gross contributions, gifts, and grants (whether or

not restricted for use in operations)

Tax-exempt Firms

Include:

 

• Program service revenue

 

• Gross sales of merchandise, minus returns and

allowances

 

• Income from interest, dividends, gross rents

(including display space rentals and share of

receipts from departments operated by other

companies), royalties, and other investments

 

• Net gains (losses) from the sale of real estate (land

and buildings), investments, or other assets (except

inventory held for resale)

 

• Gross contributions, gifts, and grants (whether or

not restricted for use in operations)

 

• Dues and assessments from members and affiliates

 

• Commissions earned from the sale of merchandise

owned by others (including commissions from

vending machine operators)

 

• Gross receipts from fundraising activities

Exclude:

 

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

collected directly from customers or clients and paid

directly to a local, State, or Federal tax agency

 

• Gross receipts of departments or concessions

operated by other companies

 

• Amounts transferred to operating funds from capital

or reserve funds

 

$ Bil.

 Mil. Thou. Dol.

What was this firm's revenue in the

 ........

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT
1 0 0

Form QSS-5A (08-23-2022) Page 4

21969043

6 SOURCE OF REVENUE

Admissions - Gross receipts from the sale of general or specific event admissions tickets exclusive of any state

or local admissions taxes (include theater or facilities owners' share, if any). Include receipts from all home, hall or

tour subscriptions, and other minimum guarantee and percentage arrangements. Dinner theatres should include

all combined admission/dinner receipts. Professional athletic clubs should report total receipts form admissions to

their home games, including visiting teams' share (both league and nonleague). Exclude admissions taxes.

How much of the revenue reported in 5 was received from the following sources of revenue in

the Percent

A.

 

Admissions revenue ....................................... 

%

B.

 

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

%

 

%

7

 

Not Applicable.

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 15 minutes to complete, including the time for reviewing instructions, searching existing data sources, gathering

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

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

0907" as the subject.

INFORMATIONAL COPY ONLY 

DO NOT USE TO REPORT