Questionnaire Text

Questionnaire form view entire document: text image

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

b) Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships. Report NET income after business expenses

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

Questionnaire instructions view entire document: text image

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.

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.