The American Community Survey 2023

Start Here

You have two ways to respond:
Respond online today at: https://respond.census.gov/acs.
OR
Complete this form and mail it back as soon as possible.

Your response is required by law.
The American Community Survey is conducted by the U.S. Census Bureau. This survey is one of only a few surveys for which all recipients are required by law to respond. The U.S. Census Bureau is required by law to protect your information.

If you need help or have questions about completing this form, please call 1-800-354-7271.

Telephone Device for the Deaf (TDD): Call 1-800-582-8330.

¿NECESITA AYUDA? Llame sin cargo alguno al 1-877-833-5625.

For more information about the American Community Survey, visit our website at: http://www.census.gov/acs

Please print the name and telephone number of the person who is filling out this form. We will only contact you if needed for official Census Bureau business.

Last Name
___________________________________

First Name
___________________________________

MI
____
Area Code + Number [ ][ ][ ] [ ][ ][ ] - [ ][ ][ ][ ]

How many people are living or staying at this address?

INCLUDE everyone who is living or staying here for more than 2 months.
INCLUDE yourself if you are living here for more than 2 months.
INCLUDE anyone else staying here who does not have another place to stay, even if they are here for 2 months or less.
DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

Number of people [ ][ ]

Fill out pages 2-7 for everyone, including yourself, who is living or staying at this address for more than 2 months. Then complete the rest of the form.

Person 1
(Person 1 is the person living or staying here in whose name this house or apartment is owned, being bought, or rented. If there is no such person, start with the name of any adult living or staying here.)

Please print today's date.

Month [ ][ ]
Day [ ][ ]
Year [ ][ ][ ][ ]

1. What is Person 1's name?
Last Name (Please print) ______________________

First Name _____________________

MI ___

2. How is this person related to Person 1?

[X] Person 1

3. What is Person 1's sex? Mark (X) ONE box.

[ ] Male
[ ] Female

4. What is Person 1's age and what is Person 1's date of birth? For babies less than 1 year old, do not write the age in months. Write 0 as the age.

Print numbers in boxes.
Age (in years) [ ][ ][ ]

Month [ ][ ]

Day [ ][ ]

Year of birth [ ][ ][ ][ ]

-- NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.

5. Is Person 1 of Hispanic, Latino, or Spanish origin?

[ ] No, not of Hispanic, Latino, or Spanish origin
[ ] Yes, Mexican, Mexican Am., Chicano
[ ] Yes, Puerto Rican
[ ] Yes, Cuban
[ ] Yes, another Hispanic, Latino, or Spanish origin -- Print, for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. -- ______________________________________

6. What is Person 1's race? Mark (X) one or more boxes AND print origins.

[ ] White -- Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. -- ______________________________________
[ ] Black or African Am.-- Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. --__________________________
[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. -- __________________
[ ] Chinese
[ ] Vietnamese
[ ] Native Hawaiian
[ ] Filipino
[ ] Korean
[ ] Samoan
[ ] Asian Indian
[ ] Japanese
[ ] Chamorro
[ ] Other Asian -- Print,, for example, Pakistani, Cambodian, Hmong, etc. -- ___________________________
[ ] Other Pacific Islander -- Print, for example, Tongan, Fijian, Marshallese, etc.. -- ___________________________
[ ] Some other race -- Print race or origin. -- ___________________________

[Repeat for persons X = 2 - 5.]

1. What is Person X's name?

Last Name (Please print)______________________

First Name _____________________

MI___

2. How is this person related to Person 1? Mark (X) ONE box.

[ ] Opposite-sex husband/wife/spouse
[ ] Opposite-sex unmarried partner
[ ] Same-sex husband/wife/spouse
[ ] Same-sex unmarried partner
[ ] Biological son or daughter
[ ] Adopted son or daughter
[ ] Stepson or stepdaughter
[ ] Brother or sister
[ ] Father or mother
[ ] Grandchild
[ ] Parent-in-law
[ ] Son-in-law or daughter-in-law
[ ] Other relative
[ ] Roommate or housemate
[ ] Foster child
[ ] Other nonrelative

3. What is Person X's sex? Mark (X) ONE box.

[ ] Male
[ ] Female

4. What is Person X's age and what is Person X's date of birth? For babies less than 1 year old, do not write the age in months. Write 0 as the age.

Print numbers in boxes.
Age (in years) [ ][ ][ ]

Month [ ][ ]
Day [ ][ ]
Year of birth [ ][ ][ ][ ]

-- NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.

5. Is Person X of Hispanic, Latino, or Spanish origin?

6. What is Person X's race? Mark (X) one or more boxesAND print origins.

[ ] White - Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. --___________________________

[ ] Black or African Am. -Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. --_________________________

[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. -- ______________________
[ ] Chinese
[ ] Vietnamese
[ ] Native Hawaiian
[ ] Filipino
[ ] Korean
[ ] Samoan
[ ] Asian Indian
[ ] Japanese
[ ] Chamorro
[ ] Other Asian -- Print, for example, Pakistani, Cambodian, Hmong, etc. -- _____________________
[ ] Other Pacific Islander ? Print, for example, Tongan, Fijian, Marshallese, etc. --______________________
[ ] Some other race -- Print race or origin. --
____________________________________________________

If there are more than five people living or staying here, print their names in the spaces for Person 6 through Person 12. We may call you for more information about them.

[Repeat for Persons Y = 6 - 12.]

Person Y

Last Name (Please print) ______________________

First Name _____________________

MI___

Sex

[ ] Male
[ ] Female

Age (in years)[ ][ ][ ]

Housing

Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

1. Which best describes this building? Include all apartments, flats, etc., even if vacant.

[ ] A mobile home
[ ] A one-family house detached from any other house
[ ] A one-family house attached to one or more houses
[ ] A building with 2 apartments
[ ] A building with 3 or 4 apartments
[ ] A building with 5 to 9 apartments
[ ] A building with 10 to 19 apartments
[ ] A building with 20 to 49 apartments
[ ] A building with 50 or more apartments
[ ] Boat, RV, van, etc.

2. About when was this building first built?

[ ] 2020 or later -- Specify year -- [ ][ ][ ][ ]
[ ] 2010 to 2019
[ ] 2000 to 2009
[ ] 1990 to 1999
[ ] 1980 to 1989
[ ] 1970 to 1979
[ ] 1960 to 1969
[ ] 1950 to 1959
[ ] 1940 to 1949
[ ] 1939 or earlier

3. When did PERSON 1 (listed on page 2) move into this house, apartment, or mobile home?

Month [ ][ ]

Year [ ][ ][ ][ ]

[A] - Answer questions 4-5 if this is a HOUSE OR A MOBILE HOME; otherwise, SKIP to question 6a.

4. How many acres is this house or mobile home on?

[ ] Less than 1 acre -- SKIP to question 6
[ ] 1 to 9.9 acres
[ ] 10 or more acres

5. IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?

[ ] None
[ ] $1 to $999
[ ] $1,000 to $2,499
[ ] $2,500 to $4,999
[ ] $5,000 to $9,999
[ ] $10,000 or more

a. How many separate rooms are in this house, apartment, or mobile home? Rooms must be separated by built-in archways or walls that extend out at least 6 inches and go from floor to ceiling.

INCLUDE bedrooms, kitchens, etc. EXCLUDE bathrooms, porches, balconies, foyers, halls, or unfinished basements.

Number of rooms
[ ][ ]

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this house, apartment, or mobile home were for sale or rent. If this is an efficiency/studio apartment, print "0".

Number of bedrooms
[ ][ ]

7. Does this house, apartment, or mobile home have --

a. hot and cold running water?

[ ] Yes
[ ] No

b. a bathtub or shower?

[ ] Yes
[ ] No

c. a sink with a faucet?

[ ] Yes
[ ] No

d. a stove or range?

[ ] Yes
[ ] No

e. a refrigerator?

[ ] Yes
[ ] No

8. Can you or any member of this household both make and receive phone calls when at this house, apartment, or mobile home? Include calls using cell phones, land lines, or other phone devices..

[ ] Yes
[ ] No

9. At this house, apartment, or mobile home - do you or any member of this household own or use any of the following types of computers?

a. Desktop or laptop

[ ] Yes
[ ] No

b. Smartphone

[ ] Yes
[ ] No

c. Tablet or other portable wireless computer

[ ] Yes
[ ] No

d. Some other type of computer Specify --__________________

[ ] Yes
[ ] No

10. At this house, apartment, or mobile home - do you or any member of this household have access to the Internet?

[ ] Yes, by paying a cell phone company or Internet service provider
[ ] Yes, without paying a cell phone company or Internet service provider - SKIP to question 12
[ ] No access to the Internet at this house, apartment, or mobile home - SKIP to question 12

11. Do you or any member of this household have access to the Internet using a -

a. cellular data plan for a smartphone or other mobile device?

[ ] Yes
[ ] No

b. broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed in this household?

[ ] Yes
[ ] No

c. satellite Internet service installed in this household?

[ ] Yes
[ ] No

d. dial-up Internet service installed in this household?

[ ] Yes
[ ] No

e. Some other service? Specify service --________________

[ ] Yes
[ ] No

12. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?

[ ] None
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6 or more

13. Which FUEL is used MOST for heating this house, apartment or mobile home?

[ ] Gas: from underground pipes serving the neighborhood
[ ] Gas: bottled, tank or LP
[ ] Electricity
[ ] Fuel oil, kerosene, etc.
[ ] Coal or coke
[ ] Wood
[ ] Solar energy
[ ] Other fuel
[ ] No fuel used

14.

a. LAST MONTH, what was the cost of electricity for this house, apartment, or mobile home?

Last month's cost - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge or electricity not used

b. LAST MONTH, what was the cost of gas for this house, apartment or mobile home?

Last month's cost - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] Included in electricity payment entered above
[ ] No charge or gas not used

c. IN THE PAST 12 MONTHS, what was the cost of water and sewer for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost.

Past 12 months' cost - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge

d. IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost.

Past 12 months' cost - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge or these fuels not used

15. IN THE PAST 12 MONTHS, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks.

[ ] Yes
[ ] No

16. Is this house, apartment, or mobile home part of a condominium?

[ ] Yes - What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box.

Monthly Amount - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] None

[ ] No

17. Is this house, apartment, or mobile home -- Mark (X) ONE box.

[ ] Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
[ ] Owned by you or someone in this household free and clear (without a mortgage or loan)?
[ ] Rented?
[ ] Occupied without payment of rent? - Skip to C on the next page

[B] - Answer questions 18a and b if this house, apartment, or mobile home is RENTED. Otherwise, SKIP to question 19.

18. a. What is the monthly rent for this house, apartment, or mobile home?

Monthly amount - Dollars
$[ ][ ],[ ][ ][ ].00

b. Does the monthly rent include any meals?

[ ] Yes
[ ] No

[C] - Answer questions 19-23 if you or any member of this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to E.

19. About how much do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale?

Amount - Dollars
$[ ],[ ][ ][ ],[ ][ ][ ].00

20. What are the annual real estate taxes on THIS property?

Annual amount - Dollars
$[ ][ ],[ ][ ][ ].00
OR
[ ] None

21. What is the annual payment for fire, hazard, and flood insurance on THIS property?

Annual amount - Dollars
$[ ],[ ][ ][ ].00
OR
[ ] None

22.

a. Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?

[ ] Yes, mortgage, deed of trust, or similar debt
[ ] Yes, contract to purchase
[ ] No - SKIP to question 23a

b. How much is the regular monthly mortgage payment on THIS property? Include payment only on FIRST mortgage or contract to purchase.

Monthly amount - Dollars
$[ ][ ],[ ][ ][ ].00
OR
[ ] No regular payment required - SKIP to question 23a

c. Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?

[ ] Yes, taxes included in mortgage payment
[ ] No, taxes paid separately or taxes not required

d. Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property?

[ ] Yes, insurance included in mortgage payment
[ ] No, insurance paid separately or no insurance

23.
a) Do you or any member of this household have a second mortgage or a home equity loan on THIS property?

[ ] Yes, home equity loan
[ ] Yes, second mortgage
[ ] Yes, second mortgage and home equity loan
[ ] No - SKIP to [D]

b) How much is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property?

Monthly amount - Dollars
$[ ][ ],[ ][ ][ ].00
OR
[ ] No regular payment required

[D] - Answer question 24 if this is a MOBILE HOME. Otherwise, SKIP to [E]

24. What are the total annual costs for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site? Exclude real estate taxes.

Annual costs - Dollars
$[ ][ ],[ ][ ][ ].00

[E] - Answer questions about PERSON 1 on the next page. If no one is listed as PERSON 1on page 2, SKIP to page 48 for mailing instructions.

Person 1
[This form repeats for each person listed]

Please copy the name of Person 1 from page 2, then continue answering questions below.
Last Name
_____________________________
First Name
_____________________________
MI
____

7. Where was this person born?

[ ] In the United States - Print name of state._______________________
[ ] Outside the United States - Print name of foreign country, or Puerto Rico, Guam, etc.__________________________

8. Is this person a citizen of the United States?

[ ] Yes, born in the United States - SKIP to question 10a
[ ] Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas
[ ] Yes, born abroad of U.S. citizen parent or parents
[ ] Yes, U.S. citizen by naturalization -- Print year of naturalization --
[ ][ ][ ][ ]
[ ] No, not a U.S. citizen

9. When did this person come to live in the United States? If this person came to live in the United States more than once, print latest year.

Year [ ][ ][ ][ ]

10.

a. At any time IN THE LAST 3 MONTHS, has this person attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.

[ ] No, has not attended in the last 3 months - SKIP to question 11
[ ] Yes, public school, public college
[ ] Yes, private school, private college, home school

b. What grade or level was this person attending? Mark (X) ONE box.

[ ] Nursery school, preschool
[ ] Kindergarten
[ ] Grade 1 through 12 -- Specify grade 1-12 -- [ ][ ]
[ ] College undergraduate years (freshman to senior)
[ ] Graduate or professional school beyond a bachelor's degree (for example: MA or PhD program, or medical or law school)

11. What is the highest degree or level of school this person has COMPLETED? Mark (X) ONE box. If currently enrolled, mark the previous grade or highest degree received.

NO SCHOOLING COMPLETED

[ ] No schooling completed

NURSERY OR PRESCHOOL THROUGH GRADE 12

[ ] Nursery school
[ ] Kindergarten
[ ] Grade 1 through 11 -- Specify grade 1-11 -- [ ][ ]
[ ] 12th grade -- NO DIPLOMA

HIGH SCHOOL GRADUATE

[ ] Regular high school diploma
[ ] GED or alternative credential

COLLEGE OR SOME COLLEGE

[ ] Some college credit, but less than 1 year of college credit
[ ] 1 or more years of college credit, no degree
[ ] Associate's degree (for example: AA, AS)
[ ] Bachelor's degree (for example: BA, BS)

AFTER BACHELOR'S DEGREE

[ ] Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)
[ ] Professional degree beyond a bachelor's degree (for example: MD, DDS, DVM, LLB, JD)
[ ] Doctorate degree (for example: PhD, EdD)

[F] - Answer question 12 if this person has a bachelor's degree or higher. Otherwise, SKIP to question 13.

12. This question focuses on this person's BACHELOR'S DEGREE. Please print below the specific major(s) of any BACHELOR'S DEGREES this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology)
_______________________________
_______________________________
_______________________________

13. What is this person's ancestry or ethnic origin?
_______________________________
_______________________________
(For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

14.

a. Does this person speak a language other than English at home?

[ ] Yes
[ ] No - SKIP to question 15a

b. What is this language?
______________________________For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

[ ] Very well
[ ] Well
[ ] Not well
[ ] Not at all

15.

a. Did this person live in this house or apartment 1 year ago?

[ ] Person is under 1 year old - SKIP to question 16
[ ] Yes, this house - SKIP to question 16
[ ] No, outside the United States and Puerto Rico - Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then SKIP to question 16
______________________________
[ ] No, different house in the United States or Puerto Rico

b. Where did this person live 1 year ago?

Address (Number and street name)
___________________________________
___________________________________

Name of city, town, or post office
___________________________________

Name of U.S. county or municipio in Puerto Rico
____________________________________
Name of U.S. state or Puerto Rico
____________________________

ZIP Code
[ ][ ][ ][ ][ ]

16. Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans? Mark "Yes" or "No" for EACH type of coverage in items a - h.

a. Insurance through a current or former employer or union (of this person or another family member)

[ ] Yes
[ ] No

b. Insurance purchased directly from an insurance company (by this person or another family member)

[ ] Yes
[ ] No

c. Medicare, for people 65 and older, or people with certain disabilities

[ ] Yes
[ ] No

d. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability

[ ] Yes
[ ] No

e. TRICARE or other military health care

[ ] Yes
[ ] No

f. VA (enrolled for VA health care)

[ ] Yes
[ ] No

g. Indian Health Service

[ ] Yes
[ ] No

h. Any other type of health insurance or health coverage plan

[ ] Yes Specify -- ___________________________________
[ ] No

[G] - Answer question 17a if this person is covered by health insurance. Otherwise, SKIP to question 18a.

17.

a. Is there a premium for this plan? A premium is a fixed amount of money paid on a regular basis for health coverage. It does not include copays, deductibles, or other expenses such as prescription costs.

[ ] Yes
[ ] No -- SKIP to question 18a

b. Does this person or another family member receive a tax credit or subsidy based on family income to help pay the premium?

[ ] Yes
[ ] No

18.

a. Is this person deaf or does he/she have serious difficulty hearing?

[ ] Yes
[ ] No

b. Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

[ ] Yes
[ ] No

[H] - Answer question 19a-c if this person is 5 years old or over. Otherwise, SKIP to the questions for PERSON 2 on page 19.

19.

a. Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

[ ] Yes
[ ] No

b. Does this person have serious difficulty walking or climbing stairs?

[ ] Yes
[ ] No

c. Does this person have difficulty dressing or bathing?

[ ] Yes
[ ] No

[I] - Answer question 20 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 19.

20. Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor's office or shopping?

[ ] Yes
[ ] No

21. What is this person's marital status?

[ ] Now married
[ ] Widowed
[ ] Divorced
[ ] Separated
[ ] Never married -- SKIP to J on the next page

22. In the PAST 12 MONTHS did this person get --

a. Married?

[ ] Yes
[ ] No

b. Widowed?

[ ] Yes
[ ] No

c. Divorced?

[ ] Yes
[ ] No

23. How many times has this person been married?

[ ] Once
[ ] Two times
[ ] Three or more times

24. In what year did this person last get married?

Year
[ ][ ][ ][ ]

[J] Answer question 25 if this person is female and 15-50 years old. Otherwise, SKIP to question 26a.

25. In the PAST 12 MONTHS, has this person given birth to any children?

[ ] Yes
[ ] No

26.

a. Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?

[ ] Yes
[ ] No -- SKIP to question 27

b. Is this grandparent currently responsible for most of the basic needs of any grandchildren under the age of 18 who live in this house or apartment?

[ ] Yes
[ ] No -- SKIP to question 27

c. How long has this grandparent been responsible for these grandchildren? If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time.

[ ] Less than 6 months
[ ] 6 to 11 months
[ ] 1 or 2 years
[ ] 3 or 4 years
[ ] 5 or more years

27. Has this person ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard? Mark (X) ONE box.

[ ] Never served in the military -- SKIP to question 30a
[ ] Only on active duty for training in the Reserves or National Guard -- SKIP to question 29a
[ ] Now on active duty
[ ] On active duty in the past, but not now

28. When did this person serve on active duty in the U.S. Armed Forces?
Mark (X) a box for EACH period in which this person served, even if just for part of the period.

[ ] September 2001 or later
[ ] August 1990 to August 2001 (including Persian Gulf War)
[ ] May 1975 to July 1990
[ ] Vietnam era (August 1964 to April 1975)
[ ] February 1955 to July 1964
[ ] Korean War (July 1950 to January 1955)
[ ] January 1947 to June 1950
[ ] World War II (December 1941 to December 1946)
[ ] November 1941 or earlier

29.

a. Does this person have a VA service-connected disability rating?

[ ] Yes (such as 0%, 10%, 20%, ... , 100%)
[ ] No -- SKIP to question 30a

b. What is this person's service-connected disability rating?

[ ] 0 percent
[ ] 10 or 20 percent
[ ] 30 or 40 percent
[ ] 50 or 60 percent
[ ] 70 percent or higher

30.

a. LAST WEEK, did this person work for pay at a job (or business)?

[ ] Yes -- SKIP to question 31
[ ] No - Did not work (or retired)

b. LAST WEEK, did this person do ANY work for pay, even for as little as one hour?

[ ] Yes
[ ] No ( SKIP to question 36a

31. At what location did this person work LAST WEEK?
If this person worked at more than one location, print where he or she worked most last week

a. Address (Number and street name)
_________________________________
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection.

b. Name of city, town, or post office
_________________________________

c. Is the work location inside the limits of that city or town?

[ ] Yes
[ ] No, outside the city/town limits

d. Name of county
_________________________________

e. Name of U.S. state or foreign country
_________________________________

f. ZIP Code
[ ][ ][ ][ ][ ]

32. How did this person usually get to work LAST WEEK? Mark (X) ONE box for the method of transportation used for most of the distance.

[ ] Car, truck, or van
[ ] Bus
[ ] Subway or elevated rail
[ ] Long-distance train or commuter rail
[ ] Light rail, streetcar, or trolley
[ ] Ferryboat
[ ] Taxicab
[ ] Motorcycle
[ ] Bicycle
[ ] Walked
[ ] Worked from home -- SKIP to question 40a
[ ] Other method

[K] - Answer question 33 if you marked "Car, truck or van" in question 32. Otherwise, SKIP to question 34.

33. How many people, including this person, usually rode to work in the car, truck or van LAST WEEK?

Person(s)
[ ][ ]

34. LAST WEEK, what time did this person?s trip to work usually begin?

Hour Minute
[ ][ ]:[ ][ ]
[ ]a.m.
[ ] p.m.

35. How many minutes did it usually take this person to get from home to work LAST WEEK?

Minutes
[ ][ ][ ]

[L] - Answer questions 36-39 if this person did NOT work last week. Otherwise, SKIP to question 40a.

36.

a. LAST WEEK, was this person on layoff from a job?

[ ] Yes -- SKIP to question 36c
[ ] No

b. LAST WEEK, was this person TEMPORARILY absent from a job or business?

[ ] Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. -- SKIP to question 39
[ ] No -- SKIP to question 37

c. Has this person been informed that he or she will be recalled to work within the next 6 months OR been given a date to return to work?

[ ] Yes -- SKIP to question 38
[ ] No

37. During the LAST 4 WEEKS, has this person been ACTIVELY looking for work?

[ ] Yes
[ ] No -- SKIP to question 39

38. LAST WEEK, could this person have started a job if offered one, or returned to work if recalled?

[ ] Yes, could have gone to work
[ ] No, because of own temporary illness
[ ] No, because of all other reasons (in school, etc.)

39. When did this person last work, even for a few days?

[ ] Within the past 12 months
[ ] 1 to 5 years ago - SKIP to [M]
[ ] Over 5 years ago or never worked - SKIP to question 43

40.

a. During the PAST 12 MONTHS (52 weeks), did this person work EVERY week? Count paid vacation, paid sick leave, and military service as work.

[ ] Yes -- SKIP to question 41
[ ] No

b. During the PAST 12 MONTHS (52 weeks), how many WEEKS did this person work? Include paid time off and include weeks when the person only worked for a few hours

Weeks
[ ][ ]

41. During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did this person usually work each WEEK?

Usual hours worked each WEEK
[ ][ ][ ]

[M] - Answer questions 42a-f if this person worked in the past 5 years. Otherwise, SKIP to question 43.

42. DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment this person had last week.
If this person had more than one job, describe the one at which the most hours were worked. If this person did not work last week, describe the most recent employment in the past five years.

a. Which one of the following best describes this person?s employment last week or the most recent employment in the past 5 years? Mark (X) ONE box

PRIVATE SECTOR EMPLOYEE
[ ] For-profit company or organization
[ ] Non-profit organization (including tax-exempt and charitable organizations)
GOVERNMENT EMPLOYEE
[ ] Local government (for example: city or county school district)
[ ] State government (including state colleges/universities)
[ ] Active duty U.S. Armed Forces or Commissioned Corps
[ ] Federal government civilian employee
SELF-EMPLOYED OR OTHER
[ ] Owner of non-incorporated business, professional practice, or farm
[ ] Owner of incorporated business, professional practice, or farm
[ ] Worked without pay in a for-profit family business or farm for 15 hours or more per week

b. What was the name of this person's employer, business, agency, or branch of the Armed Forces?
___________________________________

c. What kind of business or industry was this? Include the main activity, product, or service provided at the location where employed. (For example: elementary school, residential construction)
___________________________________

d. Was this mainly - Mark (X) ONE box

[ ] manufacturing?
[ ] wholesale trade?
[ ] retail trade?
[ ] other (agriculture, construction, service, government, etc.)?

e. What was this person's main occupation? (For example: 4th grade teacher, entry-level plumber)
_________________________________

f. Describe this person's most important activities or duties. (For example: instruct and evaluate students and create lesson plans, assemble and install pipe sections and review building plans for work details)
_________________________________
_________________________________
_________________________________

43. INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this person received, and give your best estimate of the TOTAL AMOUNT during the PAST 12 MONTHS. (NOTE: The "past 12 months" is the period from today's date one year ago up through today.)

Mark (X) the "No" box to show types of income NOT received.

If net income was a loss, mark the "Loss" box to the right of the dollar amount.

For income received jointly, report the appropriate share for each person - or, if that's not possible, report the whole amount for only one person and mark the "No" box for the other person.

a. Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items

[ ] Yes -- $[ ],[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

b. Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships. Report NET income after business expenses.

[ ] Yes -- $[ ],[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No
[ ] Loss

c) Interest, dividends, net rental income, royalty income, or income from estates and trusts. Report even small amounts credited to an account.

[ ] Yes -- $[ ],[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No
[ ] Loss

d. Social Security or Railroad Retirement

[ ] Yes -- $[ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

e. Supplemental Security Income (SSI)

[ ] Yes -- $[ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

f. Any public assistance or welfare payments from the state or local welfare office.

[ ] Yes -- $[ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

g. Retirement income, pensions, survivor or disability income. Include income from a previous employer or union, or any regular withdrawals or distributions from IRA, Roth IRA, 401(k), 403(b), or other accounts specifically designed for retirement. Do not include Social Security.

[ ] Yes -- $[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

h. Any other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony. .Do NOT include lump sum payments such as money from an inheritance or the sale of a home.

[ ] Yes -- $[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] No

44. What was this person's total income during the PAST 12 MONTHS? Add entries in questions 43a to 43h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.

[ ] None OR $[ ][ ],[ ][ ][ ],[ ][ ][ ].00 (TOTAL AMOUNT for past 12 months)
[ ] Loss

Continue with the questions for Person 2 on the next page. If no one is listed as person 2 on page 3, SKIP to page 48 for mailing instructions.

(DOCUMENT REPEATS THE ABOVE "PERSON" FORM FOR UP TO 5 RESIDENTS)

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