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 imprisoned for any disclosure of your answers.
The same law that protects the confidentiality of your answers requires that you provide the information asked in this survey to the best of your knowledge.
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 1 and 3. An interviewer will 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 elderly person or the price for which your house would sell. Ask someone else in your household; if no one knows, give your best estimate.
Follow the steps through the questionnaire and read the instructions. Instructions for completing the individual questions begin on page 5 of this guide. 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 OF RESIDENTS. 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 page 2 of the form. If you are still not sure, call 1-800-354-7271 for help.
In the space labeled Person 1, print the name of the household member living or staying here in whose name the house or apartment is owned, being bought, or rented.
If there is no such person, any adult household member can be Person 1 on the List of Residents.
If there are more than five people in your household, please list the names of the additional people on the lines at the bottom of pages 2 and 3. Complete this form for the five people listed on the List of Residents, and mail it back in the enclosed envelope as soon as possible. An interviewer will telephone to obtain the information for the additional persons.
3.Mark the appropriate category to describe the relationship of each person to Person 1. If the person is related to Person 1 by birth, marriage, or adoption, but is not the Husband or wife, Son or daughter, Brother or sister, Father or mother, Grandchild, or In-law, of Person 1, mark the "Other relative" box. Therefore, a niece or nephew of Person 1 would be categorized as "Other relative." A parent in-law or son/daughter in-law of Person 1 would be categorized as an "in law."
If a person is a stepchild or an adopted child of Person 1, mark the "Son or daughter" box.
If a person is not related to Person 1, mark the applicable box. A "Roomer or boarder" is someone renting a room/space in the house. 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 18 who is involved in the formal foster care system. For all other people who are not related to person 1 mark "Other nonrelative".
4.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.
5. A person is of Spanish/Hispanic/Latino 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, other Spanish/Hispanic/Latino" box, print the name of the specific group.
If a person is not of Spanish/Hispanic/Latino origin, answer this question by marking the "No, not Spanish/Hispanic/Latino" box.
This question should be answered for ALL persons, regardless of citizenship status.
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" or the "Other Pacific Islander" 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 Burmese, Hmong, Indonesian, Laotian, Pakistani, Thai, Cambodian, Sri Lankan, and so on.
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 for ALL persons, regardless of citizenship status.
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.
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.
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.
7. Count only whole rooms in your house, apartment, or mobile home used for living purposes, such as living rooms, dining rooms, kitchens, bedrooms, finished recreation rooms, family rooms, etc. DO NOT count bathrooms, kitchenettes, strip or pullman kitchens, utility rooms, foyers, halls, half-rooms, porches, balconies, unfinished attics, unfinished basements, or other unfinished space used for storage.
9. If you have all of the facilities listed, mark the "Yes, has all three facilities" box. All facilities must be in your house, apartment, or mobile home, but not necessarily in the same room. Consider that you have hot water even if you have it only part of the time. If any of the three facilities is not present, mark the "No" box.
11. Mark the "Yes" box if 1) there is a telephone in working order, and you receive service at your house, apartment, or mobile home. If service has been discontinued because of nonpayment or any other reason, mark the "No" box.
12. Count company cars (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 cars or trucks permanently out of working order.
13. Mark the category for the fuel used most to heat your 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 14a and 14b, report last month's costs. For items 14c and 14d, 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 14c and 14d.
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 14a and mark the "Included in electricity payment entered above" box in item 14b.
17.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 19a 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?" 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?" 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 for cash rent?" box.
If the unit is not owned or being bought by the occupants and if money rent is not paid or contracted, mark the "Occupied without payment of cash 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
By the week ......4
Every other week .....2
If rent is paid: Divide rent by:
4 times a year......3
2 times a year ......6
Once a year .......12
22. Mark the box that corresponds to the value of the property. 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. If you rent the land, estimate the value of the rented land and add it to the value of the mobile home.
23. 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 26b. Report payments on installment loans for mobile homes in items 27b.
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 24.
26a.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.
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 19a to change it to a monthly amount. Include payments on all second or junior mortgages or home equity loans.
27b.Report an amount even if your bills are unpaid or paid by someone else. Include payments for personal property taxes, land or site rent, registration fees and license fees. DO NOT include real estate taxes already reported in 23. 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.
28a. Answer this question if you have listed at least one person on page 2 of the form. Mark the "Yes" box if all of the persons listed on pages 2 and 3 of the form live or stay year round at the address on the front of the form. Then continue with the questions on page 7.
If at least one of the persons listed on page 2 or 3 lives somewhere else during the year, mark the "No" box and continue with question 28b.
28b. Indicate the number of persons who live somewhere else during the year. Mark the "All persons listed" if all persons listed on pages 2 and 3 live somewhere else. If only some of the persons listed on pages 2 and 3 live somewhere else, enter the count of persons who live somewhere else during the year. For example, if there are 4 persons listed on page 2 of the form and 2 of those persons live somewhere else during the year, enter 2 in the space provided.
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 area where the person was born. Use current boundaries, not boundaries at the time of the person's birth. 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 (for example, Jamaica, not West Indies).
8.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 (or at sea) and has at least one American parent, mark the "Yes, born abroad of American parent or parents" box. Mark the "Yes, U.S. citizen by naturalization" box only if the person has completed the naturalization process and is now a United States citizen.
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.
Report schooling completed in foreign or ungraded schools as the equivalent level of schooling in the regular American school system.
For persons who completed high school by passing an equivalency test, such as the General Educational Development (GED) examination, and did not attend college, mark the "High School Graduate" box.
Some of the examples of Professional school degrees include medicine, dentistry, chiropractic, optometry, osteopathic medicine, pharmacy, podiatry, veterinary medicine, law, and theology.
DO NOT include certificates, diplomas or degrees for training on specific trades such as computer and electronics technology, auto repair, medical assistant, cosmetology, and other fields at vocational, technical or business schools.
DO NOT include honorary degrees awarded by colleges and universities to individuals for their accomplishments. Include only "earned" degrees.
12.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.
Persons who have more than one origin and cannot identify with a single ancestry group may report two ancestry groups (for example, German-Irish).
Do not report a religious group as a person's ancestry.
If the person lived in the same house or apartment one year ago, mark the "Yes, this house" box and then go to instruction F.
If the person did not live in the United States one year ago, mark the "No, outside the United States" box and print the name of the foreign country, or Puerto Rico, Guam, etc., where the person lived. Be specific when printing the name of foreign countries, 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 go to instruction F.
If the person lived somewhere else in the United States one year ago, mark the "No, different house in the United States" box. Then in items 13b and 13c, provide the city, county, state and ZIP code where the person lived one year ago.
13c.Mark the "Yes" box if the city or town is now inside the city/town limits even if it was not inside the limits one year ago; that is, if the area was annexed by the city/town during the last year.
If the person lived in Louisiana, print the parish name in the "Name of county" 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 county" space blank.
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.
14b.Print the name of the language spoken at home. If this person speaks more than one non-English language and cannot determine which is spoken more often, report the one the person first learned to speak.
17.Answer this question if the person is a female who is at least 15 years old and younger than 51 years old. 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 step children.
18b. Answer this question if the person has at least one of his or her own grandchildren living in the house, apartment, or mobile home. Mark the "Yes" box if the person is currently responsible for the basic needs of the grandchild or grandchildren.
19.For a person with service in the National Guard or military Reserves, 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).
- Work in own business, professional practice, or farm.
- 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.
- Housework or yard work at home.
- Unpaid volunteer work.
- School work done as a student.
- Work done as a resident of an institution.
23. 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 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 and then go to question24.
24.If the person usually used more than one type of transportation to get to work (for example, drove to public transportation), mark the category of the one method of transportation that he or she used for most of the distance during the trip.
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.
29.Mark Yes 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 employment office, went to a job interview, placed or answered 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" box.
31.Refer to the instructions for question 22 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.
32. Refer to the instructions for question 23 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.
Employees of foreign governments, the United Nations, and other international organizations should mark the "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?" box for a county-run community college or a city-run public school.
If the person works in a gambling casino owned or operated by American Indians, mark the "a local GOVERNMENT employee" box.
35. 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 worked for. If the person worked in his or her own un-named business, print "self-employed."
36.Print one or more words to describe the business, industry, or individual employer named in question 35. If there is more than one activity, desciribe 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: Metal furniture manufacturing, Retail grocery store, Petroleum refining, Cattle ranch. Do not enter: Furniture company, Grocery store, Oil company, Ranch.
Enter descriptions like the following: Registered nurse, Personnel manager, High school teacher.
Do not enter single words such as: Nurse, Manager, Teacher.
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 the List of Residents.
40a. 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.
40b. Include NONFARM profit (or loss) from self-employment in sole proprietorships and partnerships. Exclude profit (or loss) of incorporated businesses you own. 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 40b above. Include regular payments from an estate or trust fund.
40f. 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.
40g. 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.
40h. 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.
- 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
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.
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.