H12. If you pay rent for your living quarters -
What is the monthly rent?
If rent is not paid by the month, see the instruction guide on how to figure a monthly rent.[] Less than $50 [] $160 to $169
[] $50 to $59 [] $170 to $179
[] $60 to $69 [] $180 to $189
[] $70 to $79 [] $190 to $199
[] $80 to $89 [] $200 to $224
[] $90 to $99 [] $225 to $249
[] $100 to $109 [] $250 to $274
[] $110 to $119 [] $275 to $299
[] $120 to $129 [] $300 to $349
[] $130 to $139 [] $350 to $399
[] $140 to $149 [] $400 to $499
[] $150 to $159 [] $500 or more
"Report the rent agreed to or contracted for, even if the rent is unpaid or paid by someone else. If rent is not paid by the month, change the rent to a monthly amount; and then fill the appropriate circle in question H12.
"If rent is paid: Multiply rent by:
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
H22. What are the costs of utilities and fuels for your living quarters?
"If your living quarters are rented, enter the costs for utilities and fuels only if you pay for them in addition to the rent entered in H12. If already included in rent, fill the appropriate circle. The amounts to be reported should be for the past 12 months, that is, for electricity and gas, the monthly averagefor the past 12 months; for water and other fuels, the totalamount for the past 12 months. Estimate as closely as possible when exact costs are not known. 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 own living quarters. If gas and electricity are billed together, enter the combined amount on the electricity line and bracket ( { ) the two utilities."
a. Electricity
$ __________________.00 OR[] Included in rent or no charge
Average monthly cost[] Electricity not used
b. Gas$ __________________.00 OR[] Included in rent or no charge
Average monthly cost[] Gas not used
c. Water$ __________________.00 OR[] Included in rent or no charge
Yearly cost
d. Oil, coal, kerosene, wood, etc.$ __________________.00 OR[] Included in rent or no charge
Yearly cost [] These fuels not used