Questionnaire Text

Questionnaire form view entire document: text image

47. 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.

d) Social Security or Railroad Retirement

[ ] Yes -->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

Questionnaire instructions view entire document: text image

41d.Include amounts, before Medicare deductions, of Social Security and/or Railroad Retirement payments to retired persons, to dependents of deceased insured workers, and to disabled workers.