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.

a) Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items
[ ] Yes --> $____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No
Questionnaire instructions view entire document:  text  image
14a. If the person is a baby under one year of age, mark the "Person is under 1 year old" box. Then skip to the questions for the next person. Do not complete any more questions for the baby.

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 14b and 14c, provide the city, county, state and ZIP code where the person lived one year ago.