Form IA-98183 2012 Economic Census -- Guam

2012 ECONOMIC CENSUS

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Guam

FORM

IA-98163

OMB No. 0607-0937: Approval Expires

(DRAFT)

(Please correct any errors in this mailing address.)

DUE DATE
FEBRUARY 12, 2013
Need help or have questions?
• Read the accompanying information sheet(s) before
answering the questions.

IA-98163

• Visit econhelp.census.gov
• Call 1-671-475-7057, between 8:00 a.m. and 5:00 p.m.,
Eastern time, Monday through Friday.

Report Online - It's fast and secure!
Go to:
econhelp.census.gov

U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47134-0001

Mail your
completed
form to:

- OR -

YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, requires businesses and other organizations
that receive this questionnaire to answer the questions and return the report to the U.S. Census Bureau. By the same
law, YOUR CENSUS REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality
of Census Bureau information and may be used only for statistical purposes. Further, copies retained in respondents'
files are immune from legal process.
• Use blue or black ballpoint pen.
• Do not use pencil or felt-tip pen.
• Do not put slashes through 0 or 7.

• Please center numbers in
their respective boxes.
• Place an "X" inside the box.

Examples:

The reporting unit for this form is an establishment. An establishment is generally a single physical location where business is
conducted or where services or industrial operations are performed or a permanent office, payroll office, or other place where
business activities related to construction are conducted. For further clarification, see information sheet(s).

1

EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) shown in the mailing address the same as the one used for this
establishment on its latest 2012 Internal Revenue Service Form 941-SS, Employer's Quarterly Federal Tax Return, or
Form 944-SS, Employer's Annual Federal Tax Return?

98163017

0021

2

Yes - Go to

2

0022

No - Enter current EIN (9 digits)

-

0025

PHYSICAL LOCATION
A. Is this establishment's physical location the same as shown in the mailing address?
(P.O. box and rural route addresses are not physical locations.)
0031

0032

Yes

0035

Number and street or location description

No - Enter
physical
location

0036

City, town, etc.

0037

State, other

0038

ZIP Code

CONTINUE WITH
PENALTY FOR FAILURE TO REPORT

2

ON PAGE 2
CONTINUE ON PAGE 2

Form IA-98163
2

Page 2

(DRAFT)

PHYSICAL LOCATION - Continued
B. District/village where this establishment is physically located

0049

3

OPERATIONAL STATUS
Which ONE of the following best describes this establishment's operational status at the end of 2012?
(Mark "X" only ONE box.)
0011

In operation

0013

Temporarily or seasonally inactive

0014

Ceased operation - Give date at right

0015

Month

Sold or leased to another operator - Give date at right AND
enter name and address of new owner or operator and
Employer Identification Number (EIN) below
0060

Day

Year

0018

Name of new owner or operator

0061

0062

Mailing address (Number and street, P.O. Box, etc.)

0063

City, town, village, etc.

0064

State, other

0065

ZIP Code

0016

4

Other status Specify

0815

Mark "X"
if None

MONTHS IN OPERATION

Number of months in operation during 2012 (If none, mark "X" and go to

HOW TO
REPORT
DOLLAR
FIGURES

98163025

5

30 .)

. . . . . . . . . .
Mark "X"
if None

Dollar figures should be rounded to
thousands of dollars.
If a figure is $2,035,628.79:

Report

If a value is "0" (or less than $500.00):

Report

0002

2012
Thou.

$ Mil.

2

Dol.

0 3 6

EXAMPLE

SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Mark "X"
if None

Sales of merchandise, shipments, operating receipts, and/or revenue
(Exclude grants or any taxes collected.) . . . . . . . . . . . . . . . . .

2012
Number

$ Mil.

2012
Thou.

Dol.

0100

CONTINUE ON PAGE 3

Form IA-98163

Page 3

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
6

E-COMMERCE SALES, SHIPMENTS, RECEIPTS, OR REVENUE
A. Were any of the sales, shipments, receipts, and/or revenue reported in 5 a result of e-commerce transactions?
(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. Please see the information sheet(s)
for further clarification.)
E-commerce transactions include:
• Internet
• E-mail
• Extranet
0181

Yes - Go to line B

0182

No - Go to

• Electronic Data Interchange (EDI)
• Other online systems

2012
7

B. Percent of sales, shipments, receipts, and/or revenue reported in 5 that are a result of ecommerce transactions. (Exclude grants or any taxes collected. Report whole percents.
Estimates are acceptable.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7

Whole percent of
sales and receipts

%

0109

EMPLOYMENT AND PAYROLL
Include:
• Full- and part-time employees working at this establishment whose payroll was reported on Internal Revenue
Service 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) shown in the mailing address or corrected in 1 .
• Non-residential employees working at this establishment, whether or not FICA taxes were withheld.
For further clarification, see information sheet(s).
Mark "X"
if None

A. Number of paid employees for pay period including March 12, 2012
1. For whom FICA taxes were withheld

2012
Number

. . . . . . . . . . . . . . . . . . . 0254

2. For whom FICA taxes were NOT withheld . . . . . . . . . . . . . . . . . 0274
3. TOTAL (Add lines A1 and A2) . . . . . . . . . . . . . . . . . . . . . . 0320
Mark "X"
if None

B. Payroll before deductions (Exclude employer's cost for payroll taxes
and benefits.)
1. Annual payroll for 2012 . . . . . . . . . . . . . . . . . . . . . .

0300

2. First quarter payroll (January-March, 2012) . . . . . . . . . . . . .

0310

$ Mil.

2012
Thou.

Dol.

98163033

C. Employer's cost for fringe benefits

8

1. Payroll taxes and any other legally required employee benefits. . . .

0221

2. Voluntarily provided fringe benefits (Include such items as payments
for life insurance, medical insurance, pensions, etc.) . . . . . . . .

0222

3. TOTAL (Add lines C1 and C2) . . . . . . . . . . . . . . . . . . .

0220

Not Applicable.

CONTINUE ON PAGE 4

Form IA-98163
9

Page 4

(DRAFT)

INVENTORIES
Report inventories using current cost (if using LIFO method of valuation, adjust to obtain FIFO or current cost).
A. Did this establishment own inventory, regardless of where held, at the end of 2012 and/or 2011?
0486

Yes - Go to line B

0487

No - Go to

12

Mark "X"

if None
B. Total Inventories
(Report the total value of
inventories the establishment
owned.) . . . . . . . . . . . . 0460

$ Mil.

End of 2012
Thou.

Dol.

Mark "X"
if None

$ Mil.

End of 2011
Thou.

Dol.

0470

C. Did this establishment engage in either construction or manufacturing activities?
0368

Yes - Go to line D

0369

No - Go to

12

D. Did this establishment have inventories by stage of fabrication (finished goods; work-in-process; and/or materials,
supplies, fuels, etc.) at the end of 2012 and/or 2011? (Total should equal the amounts reported in line B.)
0388

Yes - Complete lines 1 through 3. Total should equal the amounts reported in line B.

0389

No - Go to

12

Mark "X"
if None

$ Mil.

End of 2012
Thou.

Dol.

Mark "X"
if None

1. Finished goods . . . . . . .

0461

0471

2. Work-in-process . . . . . . .

0463

0473

3. Materials, supplies, fuels, etc.

0462

0472

$ Mil.

End of 2011
Thou.

Dol.

10 and 11 Not Applicable.
12 LEGAL FORM OF ORGANIZATION

98163041

Legal form of organization that best describes this establishment at the end of 2012 (Mark "X" only ONE box.)
0691

Individual (sole) proprietorship

0692

Partnership

0693

Corporation

0694

Local government

0695

Federal government

0696

Other - Specify

0806

CONTINUE ON PAGE 5

Form IA-98163

Page 5

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
13 CAPITAL EXPENDITURES AND DEPRECIATION CHARGES
Report the dollar value of capital expenditures including purchases under
capital leases. (Exclude the value of buildings and equipment which you
rent. Do not report payments under operating leases.)
A. Capital expenditures in 2012 for buildings and machinery

Mark "X"
if None

$ Mil.

2012
Thou.

Dol.

Mark "X"
if None

$ Mil.

2012
Thou.

Dol.

1. Building improvements and repairs (Exclude land.) . . . . . . . . . 0528
2. Machinery and equipment (Include vehicles.) . . . . . . . . . . . . 0534
3. Total capital expenditures (Exclude land.) . . . . . . . . . . . . . . 0521
B. Depreciation charges (Include depreciation charges taken against
tangible assets owned and used by your firm, tangible assets and
improvements owned by your firm under leaseholds, tangible assets
obtained, as the lessee, through capital lease agreements in 2012.) . . . 0540
14 and 15 Not Applicable.
16 SELECTED EXPENSES
A. Operating expenses (Include payroll, fringe benefits, utilities,
depreciation, etc. Exclude cost of goods sold, interest, capital
expenditures, and bad debt.) . . . . . . . . . . . . . . . . . . . . .

0136

B. Net purchases of merchandise for resale. (Include amounts allowed
for trade-ins. Exclude returns, allowances, trade/cash discounts, and
merchandise for further processing.) . . . . . . . . . . . . . . . . .

0137

C. Interest paid (Include both short-term and long-term interest paid in
2012.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5050

17 and 18 Not Applicable.
19 PRINCIPAL KIND OF BUSINESS
Which ONE of the following best describes this establishment's PRINCIPAL kind of business in 2012?
(Mark "X" only ONE box. Continue with 19 on the following pages.)
Health care and social assistance

98163058

0700

621 110 00 1

Office of physician (M.D. or D.O.)

621 210 00 2

Office of dentist

621 310 00 2

Office of chiropractor

621 320 00 3

Office of optometrist

621 390 00 1

Office of other health practitioners

621 410 00 6

Family planning center

621 420 00 6

Outpatient mental health and substance abuse center

621 610 00 6

Home health care services

623 310 00 1

Residential care facilities for the elderly
CONTINUE WITH

19

ON PAGE 6
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Form IA-98163

Page 6

(DRAFT)

19 PRINCIPAL KIND OF BUSINESS - Continued
Health care and social assistance - Continued
0700

624 110 00 C

Social assistance service for children and youth

624 120 00 C

Social assistance service for the elderly and disabled

624 410 00 7

Child day care services

772 000 00 B

Other health care and social assistance - Specify

0701

Repair and maintenance services
811 110 00 1

General automotive repair shop

811 120 00 1

Automotive body, paint, interior, glass repair, and maintenance

811 190 00 1

Carwash, oil change, lubrication, or other automotive services and maintenance

811 210 00 1

Electronic repair and maintenance

811 310 00 1

Commercial or industrial equipment repair and maintenance

772 000 00 8

Other maintenance and repair services - Specify

0701

Accommodations
721 110 00 6

Hotel or motel

772 000 00 4

Other traveler accommodation - Specify

0701

98163066

Food services
722 511 00 1

Full-service restaurants

722 515 00 1

Refreshment places selling snacks and nonalcoholic beverages

722 320 00 3

Caterer for banquets, weddings, conferences, seminars, etc.

722 410 00 9

Bar, tavern, pub, or other drinking place (alcoholic beverages)

772 000 00 2

Other food services - Specify

0701

Information, professional, business, educational and personal services
511 110 00 1

Newspaper publisher except Internet publisher

511 120 00 2

Periodical publisher and shopping news publisher except Internet publisher

519 130 00 1

Internet publishing and broadcasting

CONTINUE WITH

19

ON PAGE 7

CONTINUE ON PAGE 7

Form IA-98163

Page 7

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 PRINCIPAL KIND OF BUSINESS - Continued
Information, professional, business, educational and personal services - Continued
0700

772 200 00 Z

Other publisher except Internet publisher - Specify

512 130 00 1

Motion picture theaters

541 110 00 3

Office of lawyers

541 190 00 1

All other legal services

541 211 00 6

Accounting, tax preparation, bookkeeping, and payroll services

541 310 00 1

Architectural services, excluding landscape

541 330 00 E

Engineering services

541 430 00 1

Graphic design services

541 610 00 1

Management consulting service

541 810 00 3

Advertising agency

541 900 00 3

Other professional, scientific, and technical services including photographic studios, marketing
research, translation services, and veterinary services

551 111 00 2

Management of Companies and Enterprises

561 320 00 6

Temporary help services

561 720 00 B

Janitorial Services

561 730 00 B

Landscaping services

611 620 00 1

Sports and recreation instruction, including swimming, gymnastics, horseback riding, martial
arts, etc.

713 120 00 1

Arcade or video game arcade

812 100 00 1

Personal care services including hair, nail, and skin care services or diet center

812 200 00 1

Death care services including funeral homes and cemeteries

812 300 00 1

Drycleaning and laundry services

772 300 00 3

Other personal services - Specify

98163074

0701

0701

Transportation and warehousing
484 110 00 1

General freight trucking

484 120 00 1

Used household and office goods moving

485 310 00 5

Taxi service

485 990 00 2

Other transit and ground passenger transportation
CONTINUE WITH

19

ON PAGE 8
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Form IA-98163

Page 8

(DRAFT)

19 PRINCIPAL KIND OF BUSINESS - Continued
Transportation and warehousing - Continued
0700

561 510 00 1

Travel agency

561 520 00 2

Tour operator

772 300 00 4

Other travel arrangement and reservation services - Specify

488 110 00 5

Support activities for air transportation

488 410 00 2

Towing services

488 510 00 2

Air, ocean, or other freight forwarder

492 110 00 2

Courier services

492 210 00 4

Local messenger and delivery services

493 110 00 5

Warehousing and storage for general merchandise

562 110 00 3

Waste collection

772 200 00 5

Other transportation and storage services - Specify

0701

0701

98163082

Retail
441 110 00 D

Motor vehicle dealer new and used

441 120 00 6

Motor vehicle dealer, used

441 310 00 1

Automotive parts and accessories store

441 320 00 2

Tire dealer

442 110 00 1

Furniture store

442 210 00 1

Floor coverings store

442 290 00 1

Homefurnishing store

443 140 00 1

Electronics and appliance stores

444 130 00 1

Hardware store

444 220 00 2

Nursery, garden center, or farm supplies store or dealer

445 110 00 6

Supermarket or grocery store

445 120 00 1

Convenience food store

445 200 00 3

Specialty food stores including meat, fish, or fruit and vegetable markets and other specialty
stores

445 210 00 2

Meat market

445 290 00 3

Other specialty food stores
CONTINUE WITH

19

ON PAGE 9
CONTINUE ON PAGE 9

Form IA-98163

Page 9

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 PRINCIPAL KIND OF BUSINESS - Continued
Retail - Continued
0700

445 310 00 1

Liquor store

446 110 00 1

Pharmacy or drug store

446 130 00 7

Optical goods store including sunglasses stores

447 110 00 1

Gasoline station with convenience store

447 190 00 1

Gasoline station with no convenience store

448 110 00 1

Men's clothing store

448 120 00 1

Women's clothing store

448 130 00 1

Children's and infants' clothing store

448 140 00 1

Family clothing store

448 210 00 1

Shoe store

448 310 00 1

Jewelry store

448 320 00 1

Luggage and leather goods store

451 110 00 1

Sporting goods store

451 210 00 1

Book/newsstand/comic book store

452 110 00 1

Department store including discount or mass merchandising

452 990 00 1

General merchandise store, including variety, dollar, and home and auto supply

453 110 00 1

Florist

453 220 00 8

Gift, novelty, craft, and souvenir store

453 210 00 6

Office supply, stationery, and school supplies store

453 310 00 1

Used merchandise store

453 910 00 6

Pet and pet supplies store

772 000 00 9

Other retail business - Specify

98163090

0701

CONTINUE WITH

19

ON PAGE 10

CONTINUE ON PAGE 10

Form IA-98163

Page 10

(DRAFT)

19 PRINCIPAL KIND OF BUSINESS - Continued
Wholesale
0700

772 200 00 7

Merchant wholesaler, durable goods such as automobiles, furniture, construction materials,
equipment and supplies, computer and computer equipment, hardware, appliances, machinery,
etc. - Specify

772 200 00 8

Merchant wholesaler, nondurable goods such as paper, groceries, plastic materials, petroleum
and petroleum products, alcoholic beverages, etc. - Specify

0701

0701

Manufacturing
311 000 00 4

Food manufacturing including fruit and vegetable canning, pickling, and drying of fruits;
seafood preparation and packaging or canning; bread and bakery products; etc.

323 000 00 1

Printing and related support activities

772 200 00 Y

Other manufacturing - Specify

0701

Construction
236 000 00 1

Building construction - residential and nonresidential construction or remodeling/additions to
buildings by general contractors or operative builders

237 000 00 1

Heavy and civil engineering construction including streets, bridges, sewers, land subdivision,
etc.

238 000 00 1

Specialty trade contractors including painting, electrical work, plumbing, site preparation
activities, etc.

98163108

Finance, insurance, and real estate
522 110 00 3

Commercial bank

522 120 00 3

Savings institution

522 130 00 1

Credit union

522 290 00 8

Consumer finance or small loan company

522 310 00 3

Mortgage and other loan brokers

524 110 00 1

Life, accident, health, and medical insurance carrier

524 210 00 E

Insurance agent

531 110 00 2

Lessor of residential buildings and dwellings

531 120 00 2

Lessor of nonresidential buildings

531 210 00 3

Real estate agent or broker

772 000 00 6

Other finance, insurance and real estate - Specify

0701

CONTINUE WITH

19

ON PAGE 11
CONTINUE ON PAGE 11

Form IA-98163

Page 11

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
19 PRINCIPAL KIND OF BUSINESS - Continued
Rental and leasing services, except real estate
0700

532 100 00 3

Passenger car rental and leasing

532 210 00 1

Consumer electronics and appliances

532 230 00 3

Video tape/DVD rental store

532 290 00 5

Rental of personal items or items for the home including hospital beds, party supplies, etc.

532 310 00 3

General rental center

532 400 00 4

Commercial and Industrial machinery and equipment rental and leasing

772 200 00 F

Other rental and leasing excluding real estate - Specify

0701

Other kinds of business or activity
813 110 00 2

Church or other religious organization

813 410 00 3

Civic, social, or fraternal organizations

772 200 00 G

Utility - Specify

814 110 00 1

Private household, employing domestic help, e.g., cooks, maids, etc.

110 000 00 1

Crop or animal production or agricultural services

772 000 00 C

Other business or activity - Specify

0701

98163116

0701

CONTINUE ON PAGE 12

Form IA-98163

Page 12

(DRAFT)

20 CLASS OF CUSTOMER
2012
Whole percent of
sales and receipts

A.
B.

Estimate the percentage of sales and receipts generated from exports (Include all exports from
Guam to foreign countries, the United States, and U.S. territories.) . . . . . . . . . . . . . . . .

0262

%

Excluding the exports reported in line A, estimate the percentage of this establishment's total sales
and receipts (reported in 5 ) by class of customer:
1.

Household consumers (Exclude visiting tourists.) . . . . . . . . . . . . . . . . . . . . . . .

6251

%

2.

Visiting tourists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6252

%

3.

Retailers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0263

%

4.

Wholesalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0264

%

5.

Construction contractors

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

0269

%

6.

Local government

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

3109

%

7.

Federal government

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

3105

%

8.

Other - Specify
0272

%

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

1 0 0 %

0874

9.

TOTAL (Add lines B1 through B8 - should add to 100%)

98163124

21 Not Applicable.

CONTINUE ON PAGE 13

Form IA-98163

Page 13

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
HOW TO
REPORT
PERCENTS

Percents should be rounded to
whole percents.

2012
Percent

If figure is 38.76% of total sales: Report

3 9 %

22 DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
A. Briefly describe your principal business activities and report as whole percent of total sales, shipments,
revenue, or other operating receipts reported in 5 .
2012
Census
use

Description of principal business activities

0723

0720

1.
2.
3.
Note - Answer only if the principal kind of business activity reported in
or OTHER TRAVELER ACCOMMODATION. Otherwise, go to 27 .

19

Whole percent of
sales and receipts
0722

19811

%

19812

%

19813

%

for this establishment is HOTEL, MOTEL,

B. Report receipts by source, as a whole percent of total receipts (reported in
Do not combine data for two or more receipt lines.

5

).
2012

Description of principal business activities

0723

0720

Whole percent of
sales and receipts
0722

1. Guestroom or unit rentals, including campground and RV rental fees EXCLUDING
OCCUPANCY TAXES (If meals are included as a room package, estimate the
percentage for meals on line 2.) . . . . . . . . . . . . . . . . . . . . . . . . . . .

20010

%

2. Meals, unpackaged snacks, sandwiches, unpacked ice cream and yogurt, bakery items,
and nonalcoholic beverages generally served for immediate consumption . . . . . . .

20120

%

3. Alcoholic drinks served at this establishment

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

20130

%

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

20140

%

5. All other merchandise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29810

%

6. All other nonmerchandise receipts, including receipts from rental of conference/
convention meeting rooms, ballrooms, other public rooms; storage, other services
provided to customers, and receipts OTHER than from customers EXCLUDING SALES
AND OTHER TAXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29980

%

4. Packaged liquor, wine, and beer

98163132

Census
use

7. TOTAL (Add lines B1 through B6 - should add to 100%) . . . . . . . . . . . . . . . . . . .

1 0 0 %

23 – 25 Not Applicable.
CONTINUE ON PAGE 14

Form IA-98163

(DRAFT)

Page 14

26 SPECIAL INQUIRIES
NOTE - Answer only if the principal kind of business reported in 19 for this establishment is HOTEL, MOTEL, OR
OTHER TRAVELER ACCOMMODATION. Otherwise, go to 27 .

NUMBER AND TYPE OF ACCOMMODATIONS
1. Number of rooms, units, or quarters primarily rented as transient as of December 31,
2012 (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.) . . . . . . . . . . 2402

2012
Number as of December 31

2. Were more than half of guestroom or unit rental receipts from transient guests?
2921

Yes

2922

No

27 OWNERSHIP
A. Citizenship of majority ownership of this establishment in 2012 (Mark "X" only ONE box.)
6095

U.S. citizen - Guam born

6096

U.S. citizen - Other

6088

Japanese citizen

6089

Filipino citizen

6090

Korean citizen

6085

Dual citizenship/other citizenship - Specify

0885

0699

Not known/not determinable (Such as publicly traded)

B. Gender of majority ownership of this establishment in 2012 (Mark "X" only ONE box.)
6077

Male-owned

6084

Female-owned

6078

50/50 Male/Female - Equal percent of ownership

6079

Not known/not determinable (Such as publicly traded)

98163140

28 and 29 Not Applicable.

CONTINUE ON PAGE 15

Form IA-98163

Page 15

(DRAFT)

If not shown, please enter your 11-digit Census File
Number (CFN) from the mailing address.
REMARKS (Please use this space for any explanations that may be essential in understanding your reported data.)

$$CENSUS_REMARKS$$

30 CERTIFICATION - This report is substantially accurate and was prepared in accordance with the instructions.
Is the time period covered by this report a
calendar year?

98163157

Yes

Month

No - Enter time period covered

Telephone

-

Year

TO
Title

Number

-

Month

FROM

Name of person to contact regarding this report

Area code

Year

Extension

-

Area code

Fax

E-mail address

Number

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