Questionnaire Text

Questionnaire form view entire document:  text  image
48. What was this person's total income during the PAST 12 MONTHS? Add entries in questions 47a to 47h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.
[ ] None OR $_______________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] Loss
Questionnaire instructions view entire document:  text  image
ANSWER PERSON QUESTIONS 47 THROUGH 48 ONLY IF THIS PERSON IS 15 YEARS OLD OR OVER.

Mark the "Yes" or "No" box for each type of income, and enter the amount received IN THE PAST 12 MONTHS for each "Yes" response.

If income from any source was received jointly by household members, report, if possible, the appropriate share for each person; otherwise, report the whole amount for only one person and mark the "No" box for the other person.

When reporting income received jointly, DO NOT include the amount for a person not listed on pages 2, 3, or 4.

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
47a. Include wages and salaries before deductions from ALL jobs. Be sure to include any tips, commissions, or bonuses. Owners of incorporated businesses should enter their salary here. Military personnel should include base pay plus cash housing and/or subsistence allowance, flight pay, uniform allotments, reenlistment bonuses.

47b. Include NONFARM profit (or loss) from self-employment in sole proprietorships and partnerships. Exclude profit (or loss) of incorporated businesses the person owns.

Include FARM profit (or loss) from self-employment in sole proprietorships and partnerships. Exclude profit (or loss) of incorporated farm businesses you own. Also exclude amounts from land rented for cash but include amounts from land rented for shares.

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.

47d. 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.

47e. Include Supplemental Security Income (SSI) received by elderly, blind, or disabled persons.

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.

47g. Include retirement, survivor or disability benefits received from companies and unions, Federal, state, and local governments, and the U.S. military. Include regular income from annuities and IRA or KEOGH retirement plans.

47h. 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.