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.

f) Any public assistance or welfare payments from the state or local welfare office.

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

Questionnaire instructions view entire document: text image

47f. Include any public assistance or welfare payments the person receives from the state or county welfare office. Do not include assistance received from private charities. Do not include assistance to pay heating or cooling costs.