The law, Title 13, Sections 141, 193, and 221 of the U.S. Code, authorizing the American Community Survey, also provides that your answers are confidential. No one except Census Bureau employees may see your completed form and they can be fined and/or imprisoned for any disclosure of your answers.
Make sure you answer questions for each person in this household. If anyone in the household, such as a roomer or boarder, does not want to give you his or her personal information, print at least the person's name and answer questions 2 and 3. An interviewer may telephone to get the information from that person.
There may be a question you cannot answer exactly. For example, you may not know the age of an older person or the price for which your house would sell. Ask someone else in your household; if no one knows, give your best estimate.
Read these instructions and also follow the instructions provided throughout the questionnaire. These instructions will help you understand the questions and to answer them correctly. If you need assistance, call 1-800-354-7271. The telephone call is free.
List the name of each person who lives at this address. If you are not sure if you should list a person, see the guidelines on the front page of the form. If you are still not sure, call 1-800-354-7271 for help.
If there are more than five people in your household, please provide the name of each additional person on page 4. For each additional person, you should also provide this person's sex and age. Complete this form for the first five people listed on pages 2, 3, and 4, and mail it back in the enclosed envelope as soon as possible. An interviewer will telephone to obtain the information for the additional persons.
2. If the person is related to Person 1 by birth, marriage, or adoption, but is not the Husband or wife, 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, of Person 1, mark the "Other relative" box. Therefore, a niece or nephew of Person 1 would be categorized as "Other relative."
If a person is not related to Person 1, mark the applicable box. A "Roomer or boarder" is someone who occupies room(s) and makes cash or non-cash payment(s). A "Housemate or roommate" is someone sharing the house/apartment (but who is not romantically involved) with Person 1. An "Unmarried partner," also known as a domestic partner, is a person who shares a close personal relationship with Person 1. A "Foster child" is someone under the age of 21 who is involved in the formal foster care system. For all other people who are not related to person 1, mark the "Other nonrelative" box.
4. For each person, print this person's age and month, day, and year of birth. Print the age at the last birthday. Do not round the age up if this person is close to having a birthday. If the exact age is not known, provide an estimate. Print "0" for babies less than 1 year old.
5. A person is of Hispanic, Latino, or Spanish origin if the person's origin (ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban, Argentinean, Colombian, Costa Rican, Dominican, Ecuadoran, Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other Spanish-speaking countries of the Caribbean or Central or South America, or from Spain.
The term Mexican Am. refers to persons of Mexican-American origin or ancestry.
If you mark the "Yes, another Hispanic, Latino, or Spanish origin" box, print the name of the specific origin.
If a person is not of Hispanic, Latino, or Spanish origin, answer this question by marking the "No, not of Hispanic, Latino, or Spanish origin" box.
This question should be answered by ALL persons.
The concept of race, as used by the Census Bureau, reflects self-identification by individuals according to the race or races with which they identify.
The instruction before question 5, "For this survey, Hispanic origins are not races" reflects the federal government's treatment of Hispanic origin and race as separate and distinct concepts. People who identify their origin as Hispanic, Latino, or Spanish may be of any race.
People may choose to provide two or more races either by marking two or more race response boxes, by providing multiple write-in responses, or by some combination of marking boxes and writing in responses.
If you mark the "American Indian or Alaska Native" box, also print the name of the tribe(s) in which the person is enrolled. If the person is not enrolled in a tribe, print the name of the principal tribe.
If you mark the "Other Asian" box, print the name of the specific race(s) or group(s) in the space provided. The category "Other Asian" includes persons who identify themselves as Laotian, Thai, Pakistani, Cambodian, Sri Lankan, and so on.
If you mark the "Other Pacific Islander" box, print the name of the specific race(s) or group(s) in the space provided. The category "Other Pacific Islander" includes persons who identify themselves as Fijian, Tongan, Polynesian, Tahitian and so on.
If you mark the "Some other race" box, print the race(s) or group(s) in the space provided.
This question should be answered by ALL persons.
Count both occupied and vacant apartments in the house or building. Do not count stores or office space.
Detached means there is open space on all sides, or the house is joined only to a shed or garage. Attached means that the house is joined to another house or building by at least one wall that goes from ground to roof. An example of A one-family house attached to one or more houses is a house in a row of houses attached to one another, sometimes referred to as a townhouse.
A mobile home that has had one or more rooms added or built onto it should be considered as A one-family house detached from any other house. If only a porch or shed has been added to a mobile home, it should be considered as a mobile home.
Towable RVs, such as travel trailers or fifth-wheel trailers, should be considered as A mobile home. Self-propelling RVs or motorhomes should be considered as a Boat, RV, van, etc.
If the building was first built in 2000 or later, enter the exact year it was built.
If you live on a boat or in a mobile home, enter the year corresponding to the model year in which it was manufactured.
If you do not know the year the building was first built, enter your best estimate.
The number of acres is the acreage on which the house or mobile home is located; include adjoining land you rent for your use.
5. IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?
[ ] $1 to $999
[ ] $1,000 to $2,499
[ ] $2,500 to $4,999
[ ] $5,000 to $9,999
[ ] $10,000 or more
6. Complete this question only if you live in a one-family house or mobile home. A business, such as a grocery store or barber shop, is easily recognized from the outside and usually has a separate entrance. A medical office is a doctor's or dentist's office regularly visited by patients.
7b. Include all rooms intended to be used as bedrooms in this house, apartment, or mobile home, even if they are currently being used for other purposes.
Print "0" for an efficiency or studio apartment that does not have a separate bedroom. Your response to this question (7b) should be smaller than the number of rooms reported in question 7a.
8g. Mark "Yes"to "telephone service..." if (1) there is a telephone in working order, and someone receives service at this house, apartment, or mobile home; or (2) if someone has a cell phone from which you can both make and receive calls. If service has been discontinued because of nonpayment or any other reason, mark the "No" box.
9. Include company cars, vans or SUVs (including police cars and taxicabs) and company trucks of one-ton (2,000 pounds) capacity or less that are regularly kept at home and used by household members for nonbusiness purposes. DO NOT count (1) cars or trucks permanently out of working order, or (2) motorcycles or other recreational vehicles.
10.Mark ONE category for the fuel used MOST to heat this house, apartment, or mobile home. In buildings containing more than one apartment, you may obtain this information from the owner, manager, or janitor.
Solar energy is provided by a system that collects, stores, and distributes heat from the sun. Other fuel includes any fuel not listed separately, such as purchased steam, fuel briquettes, and waste material.
If your house, apartment, or mobile home is rented, enter the costs for utilities and fuels only if you pay for them in addition to the monthly rent.
If you live in a condominium, enter the costs for utilities and fuels only if you pay for them in addition to your condominium fee.
If your fuel and utility costs are included in your rent or condominium fee, mark the "Included in rent or in condominium fee" box. DO NOT enter any dollar amounts.
For items 11a and 11b, report LAST MONTH'S COSTS. For items 11c and 11d, report total costs for the PAST 12 MONTHS.
Estimate as closely as possible if you do not know exact costs. If you have lived in this house, apartment, or mobile home less than one year, estimate the costs for the PAST 12 MONTHS in 11c and 11d.
Report amounts even if your bills are unpaid or paid by someone else. If the bills include utilities or fuel used also by another apartment or a business establishment, estimate the amounts for your house or apartment only. If gas and electricity are billed together, enter the combined amount in 11a and mark the "Included in electricity payment entered above" box in item 11b.
12. On October 1, 2008, the federal Food Stamp Program was renamed SNAP (Supplemental Nutrition Assistance Program). Some states may have their own specific name for this program. If you received benefits from the government to buy food for your family using a benefit card, mark the "Yes" box.
13. A condominium is housing in which the apartments, houses, or mobile homes in a building or development are individually owned, but the common areas, such as lobbies and halls, are jointly owned. Occupants of a cooperative should mark the "No" box.
A condominium fee is normally assessed by the condominium owners' association for the purpose of improving and maintaining the common areas. Enter a monthly amount even if it is unpaid or paid by someone else. If the amount is paid on some other periodic basis, see the instruction for question 15a below on how to change it to a monthly amount.
If the house, apartment, or mobile home is mortgaged or there is a contract to purchase, mark the "Owned by you or someone in this household with a mortgage or loan? Include home equity loans. " box. If there is no mortgage or other debt, mark the "Owned by you or someone in this household free and clear (without a mortgage or loan)?" box. If the house, apartment, or mobile home is owned but the land is rented, mark one of the "owned" categories. If the mobile home is owned without an installment loan, but there is a mortgage on the land, mark the "Owned by you or someone in this household with a mortgage or loan? Include home equity loans." box.
If any money rent is paid, even if the rent is paid by people who are not members of your household, or paid by a federal, state, or local government agency, mark the "Rented?" box.
If the unit is not owned or being bought by a member of this household and if money rent is not paid or contracted, mark the "Occupied without payment of rent?" box. The unit may be owned by friends or relatives who live elsewhere and who allow you to occupy this house, apartment, or mobile home without charge. A house or apartment may be provided as part of wages or salary. Examples are: caretaker's or janitor's house or apartment; parsonages; tenant farmer or sharecropper houses for which the occupants do not pay cash rent; or military housing.
By the day........ 30 4 times a year...... 3
By the week ...... 4 2 times a year ...... 6
Every other week ..... 2 Once a year ....... 12
16. Enter your best estimate of the value of the property; that is, how much you think the property would sell for if it were on the market. If this is a house, include the value of the house, the land it is on, and any other structures on the same property. If the house is owned but the land is rented, estimate the combined value of the house and the land. If this is a condominium unit, estimate the value for the condominium, including your share of the common elements. If this is a mobile home, include the value of the mobile home and the value of the land only if you own the land.
17. Report taxes for all taxing jurisdictions (city or town, county, state, school district, etc.) even if they are included in your mortgage payment, not yet paid or paid by someone else, or are delinquent. DO NOT include taxes past due from previous years.
Include payments on first mortgages and contracts to purchase only. Report payments for second or junior mortgages and home equity loans in 20b.
If this is a mobile home, report payments on installment loans but DO NOT include personal property taxes, site rent, registration fees, and license fees on the mobile home and site. Report these fees in item 21.
20a. A second mortgage or home equity loan is also secured by real estate. You must have a first mortgage in order to have a second mortgage. You may have a home equity loan and other mortgages on the property or the home equity loan may be the only mortgage.
20b. Enter a monthly amount even if it is unpaid or paid by someone else. If the amount is paid on some other periodic basis, see instructions for 15a to change it to a monthly amount. Include payments on all second or junior mortgages or home equity loans.
Include payments for personal property taxes, land or site rent, registration fees and license fees. DO NOT include real estate taxes already reported in 17. Report the total annual amount even if you make it in two or more installments. Estimate as closely as possible when you don't know exact costs.
Mark the "In the United States" box and then print the name of the state in which the person was born. If the person was born in Washington, D.C., print "District of Columbia."
For people born outside the United States:
Mark the "Outside the United States" box, and then print the name of the foreign country or Puerto, Rico, Guam, etc. where the person was born. Use current boundaries, not boundaries at the time of the person's birth. For example, specify either Northern Ireland or the Republic of Ireland (Eire); North or South Korea; England, Scotland, or Wales (not Great Britain or United Kingdom). Specify the particular country or island in the Caribbean (for example, Jamaica, not West Indies).
8. If the person was born in the United States (50 states and the District of Columbia), mark the "Yes, born in the United States" box. If the person was born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas, mark the "Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas" box. If the person was born outside the United States (50 states and the District of Columbia) or at sea and had at least one parent who was a U.S. citizen at the time of the person's birth, mark the "Yes, born abroad of U.S. citizen parent or parents" box. Mark the "Yes, U.S. citizen by naturalization" box only if this person was born outside the United States (50 states and the District of Columbia) and has completed the naturalization process and is now a United States citizen. In the boxes below "Print year of naturalization," print the four-digit year this person completed the formal naturalization process. If this person is not a U.S. citizen, mark the "No, not a U.S. citizen" box. Legal Permanent Residents (LPRs) or "green card" holders, or other non-naturalized immigrants or visitors to the U.S. are not citizens of the United States and therefore should mark the "No, not a U.S. citizen" box.
10a. A public school is any school or college that is controlled and supported primarily by a local, county, state, or federal government. Schools are private if supported and controlled primarily by religious organizations or other private groups. Home school applies to parental guided education outside of a public or private school for grades 1-12.
Report schooling completed in foreign or ungraded schools as the equivalent level of schooling in the regular American school system.
Mark the "GED or alternative credential" box for persons who did not receive a regular high school diploma but completed high school by receiving a GED or other formal recognition of high school completion from a school or governmental authority.
If the person has not completed any college courses for credit, mark the highest level completed below the college level. If the person has not completed enough credit to be counted as a sophomore, mark the "Some college credit, but less than 1 year of college credit" box.
For the "Professional degree beyond a bachelor's degree" category, DO NOT include certificates or diplomas for training in specific trades or occupations such as computer and electronics technology, medical assistant, or cosmetology. DO NOT include post-bachelor's certificates that are related to occupational training in such fields as teaching, accounting, or engineering.
12. Answer this question only if the person has a bachelor's degree or higher and print the specific major of this person's bachelor's degree. If this person has more than one bachelor's degree or more than one major, print the names of the specific majors for all of this person's bachelor's degree(s).
13. Print the ancestry group(s). Ancestry refers to the person's ethnic origin or descent, "roots," or heritage. Ancestry also may refer to the country of birth of the person or the person's parents or ancestors before their arrival in the United States. Answer this question for ALL persons, regardless of citizenship status.
Do not report a religious group as a person's ancestry.
Persons who have more than one origin and cannot identify with a single ancestry group may report two ancestry groups (for example, German, Irish).
Mark the "No" box if the person speaks only English, or if a non-English language is spoken only at school or is limited to a few expressions or slang.
15a. If the person did not live in the United States one year ago, mark the "No, outside the United States and Puerto Rico" box and print the name of the foreign country, or U.S. Virgin Islands, Guam, etc., where the person lived. Be specific when printing the name of foreign country, for example, specify whether Northern Ireland or the Republic of Ireland (Eire); North or South Korea; England, Scotland or Wales (not Great Britain or United Kingdom). Specify the particular country or island in the Caribbean (not, for example, West Indies). Then SKIP to question 16.
If the person lived somewhere else in the United States one year ago, mark the "No, different house in the United States" box.
15b. Include the house or structure number; street name; street type (for example, St., Road, Ave.); and the street direction (if a direction such as "North" is part of the address). For example, print 1239 N. Main St. or 1239 Main St., N.W., not just 1239 Main. If the person lived in Puerto Rico, the address should also include the name of the development or condominium.
If the only known address is a post office box, give a description of the residence location. For example, print the name of the building where the person lived, the nearest intersection, the name of a military base or installation, or the nearest street where the residence was located, etc. DO NOT GIVE A POST OFFICE BOX NUMBER.
Print the name of the U.S. county or the name of the municipio if in Puerto Rico. If the person lived in Louisiana, print the parish name in the "Name of U.S. county or municipio in Puerto Rico" space. If the person lived in Alaska, print the borough or census area name, if known. If the person lived in New York City and the county name is not known, print the borough name. If the person lived in an independent city (not in any county) or in Washington, D.C., leave the "Name of U.S. county or municipio in Puerto Rico" space blank.
If the person reports any other type of coverage plan in 15h, specify the type of coverage or name of the plan in the write-in box. DO NOT include plans that cover only one type of health care (such as dental plans) or plans that only cover a person in case of an accident or disability.
20. Mark the "Now married" box for a married person regardless of whether his or her spouse is living in the household unless they are separated. If the person's only marriage was annulled, mark the "Never married" box.
24. Mark the "Yes" box if the person has given birth to at least one child born alive in the past 12 months, even if the child died or no longer lives with the mother. Do not consider miscarriages, or stillborn children, or any adopted, foster, or stepchildren.
26. For a person with service in the military Reserves, or National Guard, mark a Yes category only if the person has ever been called up for active duty other than for training. For a person whose only service was as a civilian employee or civilian volunteer for the Red Cross, USO, Public Health Service, or War or Defense Department, mark the "No, never served in the military" box. Count World War II Merchant Marine service as active duty; DO NOT count other Merchant Marine service as active duty.
- Work for someone else for wages, salary, piece rate, commission, tips, or payments "in kind" (for example, food or lodging received as payment for work performed).
- Any work in a family business or farm, paid or not.
- Any part-time work including babysitting, paper routes, etc.
- Active duty in the Armed Forces.
Do not count as work - Mark the "No" box if this person performed:
- Housework or yard work at home.
- Unpaid volunteer work.
- School work done as a student.
- Work done as a resident of an institution.
30. Include the building or structure number; street name; street type (for example, St., Road, Ave.); and the street direction (if a direction such as "North" is part of the address). For example, print 1239 N. Main St. or 1239 Main St., N.W., not just 1239 Main.
If the only known address is a post office box, give a description of the work location. For example, print the name of the building or shopping center where the person works, the nearest intersection, or the nearest street where the workplace is located, etc. DO NOT GIVE A POST OFFICE BOX NUMBER.
If the person worked at a military installation or military base that has no street address, report the name of the military installation or base, and a description of the work location (such as building number, building name, nearest street or intersection).
If the person worked at several locations, but reported to the same location each day to begin work, print the street address of the location where he or she reported. If the person did not report to the same location each day to begin work, print the address of the location where he or she worked most of the time last week.
If the person's employer operates in more than one location (such as a grocery store chain or public school system), print the street address of the location or branch where the person worked. If the street address of a school is not known, print the name of the school, and a description of the location (such as nearest street or intersection).
If the person worked on a college or university campus and the street address of the workplace is not known, print the name of the building where he or she worked, and a description of the location (such as nearest street or intersection).
If the person worked in a foreign country or Puerto Rico, Guam, etc., print the name of the country on the state or foreign country line.
DO NOT include persons who rode to school or some other nonwork destination in the count of persons who rode in the vehicle.
If the person usually left home to go to work sometime between 12:00 o'clock midnight and 12:00 o'clock noon, mark a.m.
If the person usually left home to go to work sometime between 12:00 o'clock noon and 12:00 o'clock midnight, mark p.m.
34. Travel time is from door to door. Enter a one-way commute time for this person's usual daily commute from home to work last week. Include time waiting for public transportation or picking up passengers in a carpool.
35c. If the person was informed by his or her employer, either formally or informally, that they will be recalled within the next 6 months, mark the "Yes" box. Also mark the "Yes" box if the person has been given, formally or informally, a specific date to return to work, even if that date is more than 6 months away.
36. Mark the "Yes" box if the person tried to get a job or start a business or professional practice at any time in the last 4 weeks; for example, registered at an public or private employment office, went to a job interview, placed or answered employment ads, or did anything toward starting a business or professional practice.
Mark the "No, because of own temporary illness" box only if the person expects to be able to work within 30 days.
If the person could not have gone to work because he or she was going to school, taking care of children, etc., mark the "No, because of all other reasons (in school, etc.)" box.
38. Refer to the instructions for question 29a-29b to determine what to count as work. Mark the "Over 5 years ago or never worked" box if the person: (1) never worked at any kind of job or business, either full or part time, (2) never worked, with or without pay, in a family business or farm, and (3) never served on active duty in the Armed Forces.
39a-39b. Refer to the instructions for question 29a-29b to determine what to count as work. Include paid vacation, paid sick leave, and military service. Count every week in which the person worked at all, even for an hour.
41. Mark the "An employee of a PRIVATE NOT FOR PROFIT, tax-exempt, or charitable organization?" box if the person worked for a cooperative, credit union, mutual insurance company, or similar organization.
Employees of foreign governments, the United Nations, and other international organizations should mark the "a Federal GOVERNMENT employee?" box.
If the person worked at a public school, college or university, mark the appropriate government category; for example, mark the "a state GOVERNMENT employee?" box for a state university, or mark the "a local GOVERNMENT employee (city, county, etc.)?" box for a county-run community college or a city-run public school.
42. If the person worked for a company, business, or government agency, print the name of the company, not the name of the person's supervisor. If the person worked for an individual or a business that had no company name, print the name of the individual this person worked for. If the person worked in his or her own un-named business, print "self-employed."
43. Print one or more words to describe the business, industry, or individual employer named in question 42. If there is more than one activity, describe only the major activity at the place where the person worked. Enter what is made, what is sold, or what service is given.
Enter descriptions like the following: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank. Do not enter: newspaper, order house, engine.
Enter descriptions like the following: registered nurse, personnel manager, supervisor of order department, secretary, accountant, high school teacher, etc.
Do not enter single words such as: nurse, manager, teacher, etc.
46. Describe the most important activities or duties the person performed. Enter descriptions like the following: patient care, directing hiring policies, supervising order clerks, typing and filing, reconciling financial records, etc.
If income from any source was received jointly by household members, report, if possible, the appropriate share for each person; otherwise, report the whole amount for only one person and mark the "No" box for the other person.
When reporting income received jointly, DO NOT include the amount for a person not listed on pages 2, 3, or 4.
DO NOT include the following as income in any item:
- Refunds or rebates of any kind
- Withdrawals from savings of any kind
- Capital gains or losses from the sale of homes, shares of stock, etc.
- Inheritances or insurance settlements
- Any type of loan
- Pay in-kind such as food, free rent
47a. Include wages and salaries before deductions from ALL jobs. Be sure to include any tips, commissions, or bonuses. Owners of incorporated businesses should enter their salary here. Military personnel should include base pay plus cash housing and/or subsistence allowance, flight pay, uniform allotments, reenlistment bonuses.
Include FARM profit (or loss) from self-employment in sole proprietorships and partnerships. Exclude profit (or loss) of incorporated farm businesses you own. Also exclude amounts from land rented for cash but include amounts from land rented for shares.
Include dividends received, credited, or reinvested from ownership of stocks or mutual funds.
Include profit (or loss) from royalties and the rental of land, buildings or real estate, or from roomers or boarders. Income received by self-employed persons whose primary source of income is from renting property or from royalties should be included in question 47b above. Include regular payments from an estate or trust fund.
47f. Include any public assistance or welfare payments the person receives from the state or county welfare office. Do not include assistance received from private charities. Do not include assistance to pay heating or cooling costs.
47g. Include retirement, survivor or disability benefits received from companies and unions, Federal, state, and local governments, and the U.S. military. Include regular income from annuities and IRA or KEOGH retirement plans.
47h. Include Veterans' (VA) disability compensation and educational assistance payments (VEAP); unemployment compensation, child support or alimony; and all other regular payments such as Armed Forces transfer payments, assistance from private charities, regular contributions from persons not living in the household.
48. Add the total entries (subtracting losses) for 47a through 47h for the PAST 12 MONTHS and enter that number in the space provided. Mark the "Loss" box if there is a loss. Print the total amount in dollars.
Why are we taking a survey?
The Census Bureau is conducting the American Community Survey to provide more timely data than data we typically collect only once every 10 years during the decennial census.
What does the Census Bureau do with the information you provide?
The American Community Survey will be the source of summarized data that we make available to federal, state, and local governments, and also to the public. The data will enable your community leaders from government, business, and non-profit organizations to plan more effectively.
How was this address selected?
Your address was scientifically selected to represent a cross section of other households in your community. Households in the sample are required to complete the survey form. Please return it in the postage-paid envelope as soon as possible.
Value or rent
Government and planning agencies use answers to these questions in combination with other information to develop housing programs to meet the needs of people at different economic levels.
Plumbing and Kitchen facilities
This question helps provide information on the quality of housing. The data are used with other statistics to show how the "level of living" compares in various areas and how it changes over time.
Answers to the questions about the jobs people hold provide information on the extent and types of employment in different areas of the country. From this information, communities can develop training programs, and business and local governments can determine the need for new employment opportunities.
Income helps determine how well families or persons live. Income information makes it possible to compare the economic levels of different areas, and how economic levels for a community change over time. Funding for many government programs is based on the answers to these questions.