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.

c) Interest, dividends, net rental income, royalty income, or income from estates and trusts. Report even small amounts credited to an account

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

Questionnaire instructions view entire document: text image

47c. Include interest received or credited to checking and saving accounts, money market funds, certificates of deposit (CDs), IRAs, KEOGHs, and government bonds.

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 47b above. Include regular payments from an estate or trust fund.