Questionnaire Text

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d) Social Security or Railroad Retirement
[ ] Yes -->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No
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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.

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.