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.

h) Any such 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
Questionnaire instructions view entire document:  text  image
41h. 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.

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