The American Community Survey 2003-2007

U.S. Department of Commerce
Economics and Statistics Administration
U.S. Census Bureau

People are our most important resource. This Census Bureau survey collects information about education, employment, income, and housing--information your community uses to plan and fund programs. Your response is important, and we keep your answers confidential.

If you need help or have questions about completing this form, please call 1-800-354-7271. The telephone call is free.

NECESITA AYUDA? Si usted habla espanol y necesita ayuda para completar su cuestionario, llame sin cargo alguno al 1-800-354-7271.

For more information about the American Community Survey, visit our web site at: http://www.census.gov/acs/www/.

Start Here

This form asks for three types of information:

1. What is your name?

Last Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
First Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ] MI [ ]
Area Code + Number [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
Date(Month/Day/Year) [ ][ ][ ][ ][ ][ ][ ][ ]

2. How many people are living or staying at this address?

Number of people [ ][ ]

Please turn to the next page to continue

List of Residents

READ THESE INSTRUCTIONS FIRST

Please fill out this form as soon as possible after receiving it in the mail

If this place is a vacation home or a temporary residence where no one in this household stays for more than 2 months, do not list any names in the List of Residents. Complete only pages 4, 5, and 6 and return the form.

If you are not sure whom to list, call 1-800-354-7271.

After you've created the List of Residents, answer the questions across the top of the page for the first five people on the list.

Person 1 - [repeated for up to 5 household members]
Last Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
First Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ] MI [ ]

Person 1

1. What is this person's sex?
O Male
O Female

2. What is this person's date of birth and what is this person's age?
Print numbers in boxes
Age (in years)[ ][ ][ ]
Month[ ][ ] Day[ ][ ]Year of Birth[ ][ ]

3. How is this person related to Person 1?
[response for Person Number 1 is premarked as Head of Household, following options contained in Section 3 for all other residents:]

O Husband or wife O Roomer, boarder
O Son or daughter O Housemate, Roommate
O Brother or Sister O Unmarried Partner
O Grandchild O Foster Child
O In-law O Other nonrelative
O Other relative

Person 1 -[for 6-8 additional household members]
Last Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
First Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ] MI [ ]

4. What is this person's marital status?

O Now Married
O Widowed
O Divorced
O Separated
O Never married

NOTE: Please answer BOTH Questions 5 and 6.

5. Is this person Spanish/Hispanic/Latino?
Mark (X) the "No" box if not Spanish/Hispanic/Latino

O No, not Spanish/Hispanic/Latino
O Yes, Mexican, Mexican Am., Chicano
O Yes, Puerto Rican
O Yes, Cuban
O Yes, other Spanish/Hispanic/Latino -- Print group -->
__________________

6. What is this person's race? Mark (X) one or more races to indicate what this person considers himself/herself to be

[ ] White
[ ] Asian Indian [ ] Native Hawaiian
[ ] Filipino [ ] Samoan
[ ] Guamanian or Chamorro
[ ] Other Pacific Islander
[ ] Black or African American
[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe -->
____________________
____________________
[ ] Chinese
[ ] Japanese
[ ] Korean [ ] Vietnamese
[ ] Other Asian - Print race -->
____________________
[] Some other race - Print race below -->
____________________

Housing

Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

1. Which best describes this building? Include all apartments, flats, etc., even if vacant
[ ] A mobile home
[ ] A one-family house detached from any other house
[ ] A one-family house attached to one or more houses
[ ] A building with 2 apartments
[ ] A building with 3 or 4 apartments
[ ] A building with 5 to 9 apartments
[ ] A building with 10 to 19 apartments
[ ] A building with 20-49 apartments
[ ] A building with 50 or more apartments
[ ] Boat, RV, van, etc.

2. About when was this building first built?
[ ] 2005 or later
[ ] 2000 to 2004
[ ] 1995 to 1999
[ ] 1990 to 1994
[ ] 1980 to 1989
[ ] 1970 to 1979
[ ] 1960 to 1969
[ ] 1950 to 1959
[ ] 1940 to 1949
[ ] 1939 or earlier
Note: The first response selections were modified in 2005. The first category became "2005 or later" and an additional one was added after it which was "2000 to 2004."

3. When did PERSON 1 (listed in the List of Residents on page 2) move into this house, apartment, or mobile home?
Month [ ][ ] Year [ ][ ][ ][ ]

[A] - Answer questions 4-6 ONLY if this is a one-family house or a mobile home; otherwise, SKIP to question 7.

4. How many acres is this house or mobile home on?
[ ] Less than 1 acre -->SKIP to question 6
[ ] 1 to 9.9 acres
[ ] 10 or more acres

5. IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?
[ ] None
[ ] $1 to $999
[ ] $1,000 to $2,499
[ ] $2,500 to $4,999
[ ] $5,000 to $9,999
[ ] $10,000 or more

6. Is there a business (such as a store or barber shop) or a medical office on this property?
[ ] Yes
[ ] No

7. How many rooms are in this house, apartment, or mobile home?Do NOT count bathrooms, porches, balconies, foyers, halls, or half-rooms.
[ ] 1 room
[ ] 2 rooms
[ ] 3 rooms
[ ] 4 rooms
[ ] 5 rooms
[ ] 6 rooms
[ ] 7 rooms
[ ] 8 rooms
[ ] 9 or more rooms

8. How many bedrooms are in this house, apartment, or mobile home; that is, how many bedrooms would you list if this house, apartment or mobile home were on the market for sale or rent?
[ ] No bedroom
[ ] 1 bedroom
[ ] 2 bedrooms
[ ] 3 bedrooms
[ ] 4 bedrooms
[ ] 5 or more bedrooms

9. Does this house, apartment, or mobile home have COMPLETE plumbing facilities; that is, 1) hot and cold piped water, 2) a flush toilet, and 3) a bathtub or shower?
[ ] Yes, has all three facilities
[ ] No

10. Does this house, apartment, or mobile home have COMPLETE kitchen facilities: that is, 1) hot and cold piped water, 2) a flush toilet, and 3) a bathtub or shower?
[ ] Yes, has all three facilities
[ ] No

11. Does this house, apartment, or mobile home have COMPLETE kitchen facilities; that is, 1) a sink with piped water, 2) a stove or range, and 3) a refrigerator?
[ ] Yes
[ ] No

12. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?
[ ] None
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6 or more

13. Which FUEL is used MOST for heating this house, apartment or mobile home?
[ ] Gas: from underground pipes serving the neighborhood
[ ] Gas: bottled, tank or LP
[ ] Electricity
[ ] Fuel oil, kerosene, etc.
[ ] Coal or coke
[ ] Wood
[ ] Solar energy
[ ] Other fuel
[ ] No fuel used

14. a) LAST MONTH, what was the cost of electricity for this house, apartment, or mobile home?
Last month's cost - Dollars
$________________.00
OR
[ ] Included in rent or condominium fee
[ ] No charge or electricity not used

b) LAST MONTH, what was the cost of gas for this house, apartment or mobile home?
Last month's cost - Dollars
$________________.00
OR
[ ] Included in rent or condominium fee
[ ] Included in electricity payment entered above
[ ] No charge or gas not used

c) IN THE PAST 12 MONTHS, what was the cost of water and sewer for this house, apartment, or mobile home?
If you have listed here less than 12 months, estimate the cost.
Past 12 months' cost - Dollars
$________________.00
OR
[ ] Included in rent or condominium fee
[ ] No charge

d) IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?
If you have lived here less than 12 months, estimate the cost
Past 12 month's cost - Dollars
$________________.00
OR
[ ] Included in rent or condominium fee
[ ] No charge or these fuels not used

15. At any time DURING THE PAST 12 MONTHS, did anyone in this household receive Food Stamps?
[ ] Yes -> What was the value of the Food Stamps received during the past 12 months?
Past 12 month's value - Dollars
$________________.00
[ ] No

16. Is this house, apartment, or mobile home part of a condominium?
[ ] Yes -> What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box.
Monthly Amount - Dollars
$________________.00
OR
__None
[ ] No

17. Is this house, apartment, or mobile home
[ ] Owned by you or someone in this household with a mortgage or loan?
[ ] Owned by you or someone in this household free and clear (without a mortgage or loan)?
[ ] Rented for cash rent?
[ ] Occupied without payment of cash rent? -> Skip to C

[B] - Answer questions 19a-21 ONLY IF you PAY RENT for house apartment, or mobile home. Otherwise, SKIP to question 22.

18. a) What is the monthly rent for this house, apartment, or mobile home?
Monthly amount - Dollars
$_________________.00
b) Does this monthly rent include any meals?
[ ] Yes
[ ] No

[C] - Answer questions 19-23 ONLY IF you or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to [E] on the next page.

19. What is the value of this property; that is, how much do you think this house and lot, apartment, or mobile home and lot, would sell for if it were for sale?
[ ] Less than $10,000
[ ] 10,000 to 14,999
[ ] 15,000 to 19.999
[ ] 20,000 to 24,999
[ ] 25,000 to 29,999
[ ] 30,000 to 34,999
[ ] 35,000 to 39,999
[ ] 40,000 to 49,999
[ ] 50,000 to 59,999
[ ] 60,000 to 69,999
[ ] 70,000 to 79,999
[ ] 80,000 to 89,999
[ ] 90,000 to 99,999
[ ] 100,000 to 124,999
[ ] 125,000 to 149,999
[ ] 150,000 to 174,999
[ ] 175,000 to 199,999
[ ] 200,000 to 249,999
[ ] 250,000 or more - Specify ->
$__________________.00

20. What are the annual real estate taxes on THIS property?
Annual amount - Dollars
$__________________.00
OR
[ ] None

21. What is the annual payment for fire, hazard, and flood insurance on THIS property?
Annual amount - Dollars
$__________________.00
OR
[ ] None

22. a) Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?
[ ] Yes, mortgage, deed of trust, or similar debt
[ ] Yes, contract to purchase
[ ] No -> SKIP to question 23a

b) How much is the regular monthly mortgage payment on THIS property? Include payments only on FIRST mortgage or contract to purchase
Monthly amount - Dollars
$_________________.00
OR
[ ] No regular payment required -> SKIP to question 23a

c) Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?
[ ] Yes, taxes included in mortgage payment
[ ] No, taxes paid separately or taxes not required

d) Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property?
[ ] Yes, insurance included in mortgage payment
[ ] No, insurance paid separately or no insurance

23. a) Do you or any member of this household have a second mortgage or a home equity loan on THIS property?
[ ] Yes, home equity loan
[ ] Yes, second mortgage
[ ] Yes, second mortgage and home equity loan
[ ] No -> SKIP to [D]

b) How much is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property?
Monthly amount - Dollars
$_________________.00
OR
[ ] No regular payment required

[D] - Answer question 24 ONLY IF this is a MOBILE HOME. Otherwise, SKIP to [E]

24. What are the total annual costs for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site? Exclude real estate taxes
Annual costs - Dollars
$_________________.00

[E] - Answer questions 25a-c ONLY IF you listed at least one person on page 2. Otherwise, SKP to page 24 for the mailing instructions.

25. a) Do you or any member of this household live or stay at this address year round?
[ ] Yes -> SKIP to the questions for Person 1 on the next page
[ ] No

b) How many months a year do members of this household stay at this address?
Months
_______

c) What is the main reason members of this household are staying at this address?
[ ] This is their permanent address
[ ] This is their seasonal or vacation address
[ ] To be close to work
[ ] To attend school or college
[ ] Looking for permanent housing
[ ] Other reason(s)- Specify -> ____________________________

Continue with the questions about PERSON 1 on the next page

Person 1

[This form repeats for each person listed]

Please copy the name of Person 1 from the List of Residents on page 2, then continue answering questions below.
Last Name _____________________________
First Name _____________________________ MI ____

7. Where was this person born?
[ ] In the United States - Print name of state._______________________
[ ] Outside the United States - Print name of foreign country, or Puerto Rico, Guam, etc.__________________________

8. Is this person a CITIZEN of the United States?
[ ] Yes, born in the United States -> SKIP to 10a
[ ] Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Nothern Marianas
[ ] Yes, born abroad of American parent or parents
[ ] Yes, U.S. citizen by naturalization
[ ] No, not a citizen of the United States

9. When did this person come to live in the United States?
Print numbers in boxes.
Year [ ][ ][ ][ ]

10. a) At any time IN THE LAST 3 MONTHS, has this person attended regular school or college?
Include only nursery or preschool, kindergarten, elementary school, and schooling which leads to a high school diploma or a college degree.
[ ] No, has not attended in the last 3 months -> SKIP to question 11
[ ] Yes, public school, public college
[ ] Yes, private school, private college

b) What grade or level was this person attending?
Mark (X) ONE box.
[ ] Nursery school, preschool
[ ] Kindergarten
[ ] Grade 1 to grade 4
[ ] Grade 5 to grade 8
[ ] Grade 9 to grade 12
[ ] College undergraduate years (freshman to senior)
[ ] Graduate or professional school (for example: medical, dental or law school)

11. What is the highest degree or level of school this person has COMPLETED?
Mark (X) ONE box. If currently enrolled, mark the previous grade or highest degree received.
[ ] No schooling completed
[ ] Nursery school to 4th grade
[ ] 5th grade or 6th grade
[ ] 7th grade or 8th grade
[ ] 9th grade
[ ] 10th grade
[ ] 11th grade
[ ] 12th grade - NO DIPLOMA
[ ] HIGH SCHOOL GRADUATE - high school DIPLOMA or the equivalent (for example: GED)
[ ] Some college credit, but less than 1 year
[ ] 1 or more years of college, no degree
[ ] Associate degree (for example: AA, AS)
[ ] Bachelor's degree (for example: BA, AB, BS)
[ ] Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)
[ ] Professional degree (for example: MD, DDS, DVM, LLB, JD)
[ ] Doctorate degree (for example: PhD, EdD)

12. What is this person's ancestry or ethnic origin?
_______________________________
_______________________________
(for example: Italian, Jamaican, African Am., Cambodian, etc.)

13. a) Does this person speak a language other than English at home?
[ ] Yes
[ ] No -> SKIP to question 14

b) What is this language?
______________________________
For example: Korean, Italian, Spanish, Vietnamese

c) How well does this person Speak English?
[ ] Very well
[ ] Well
[ ] Not well
[ ] Not at all

14. a) Did this person live in this house or apartment 1 year ago?
[ ] Person is under 1 year old -> SKIP to the questions for Person 2 on page 10.
[ ] Yes, this house ->SKIP to [F] in the next column
[ ] No, outside the United States - Print name of foreign country, Or Puerto Rico, Guam, etc., below; then SKIP to [F] in next column.
______________________________
[ ] No, different house in the United States

b) Where did this person live 1 year ago?
Name of city, town, or post office
______________________________

c) Did this person live inside the limits of the city or town?
[ ] Yes
[ ] No, outside the city/town limits
Name of county ___________________________
Name of State_________________________ ZIP Code [ ][ ][ ][ ][ ]

[F] - Answer questions 15 and 16 ONLY IF this person is 5 years old or over. Otherwise, SKIP to the questions for PERSON 2 on page 10.

15. Does this person have any of the following long-lasting conditions:
a) Blindness, deafness, or a severe vision or hearing impairment?
[ ] Yes [ ] No
b) A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting or carrying?
[ ] Yes [ ] No

16. Because of a physical, mental, or emotional condition lasting 6 months or more, does this person have any difficulty in doing any of the following activities:
a) Learning, remembering, or concentrating?
[ ] Yes [ ] No

b) Dressing, bathing, or getting around inside the home?
[ ] Yes [ ] No

[G] - Answer question 17 ONLY IF this person is 15 years old or over. Otherwise, SKIP to the questions for PERSON 2 on page 10.

17. Because of a physical, mental, or emotional condition lasting 6 months or more, does this person have any difficulty in doing any of the following activities:
a) Going outside the home alone to shop or visit a doctors office?
[ ] Yes [ ] No

b) Working at a job or business?
[ ] Yes [ ] No

[H] - Answer question 18 ONLY IF this person is female and 15-50 years old. Otherwise, SKIP to question 19a.

18. Has this person given birth to any children in the past 12 months?
[ ] Yes
[ ] No

19. a) Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?
[ ] Yes
[ ] No -> SKIP to question 20

b) Is this grandparent currently responsible for most of the basic needs of any grandchild(ren) under the age of 18 who live(s) in this house or apartment?
[ ] Yes
[ ] No SKIP to question 20

c) How long has this grandparent been responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time.
[ ] Less than 6 months
[ ] 6 to 11 months
[ ] 1 or 2 years
[ ] 3 or 4 years
[ ] 5 or more years

20. Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
[ ] Yes, now on active duty
[ ] Yes, on active duty during the last 12 months, but not now
[ ] Yes, on active duty in past, but not during the last 12 months
[ ] No, training for Reserves or National Guard only -->SKIP to question 23
[ ] No, never served in the military ->SKIP to question 23

21. When did this person serve on active duty in the U.S. Armed Forces?
Mark (X) a box for EACH period in which this person served.
[ ] September 2001 or later
[ ] August 1990 to August 2001 (including Persian Gulf War)
[ ] September 1980 to July 1990
[ ] May 1975 to August 1980
[ ] Vietnam era (August 1964 to April 1975)
[ ] March 1961 to July 1964
[ ] February 1955 to February 1961
[ ] Korean War (June 1950 to January 1955)
[ ] January 1947 to June 1950
[ ] World War II (December 1941 to December 1946)
[ ] November 1941 or earlier

22. In total, how many years of active-duty military service has this person had?
[ ] Less than 2 years
[ ] 2 years or more

23. LAST WEEK, did this person do ANY work for either pay or profit?
Mark (X) the "Yes" box even if the person worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or was on active duty in the Armed Forces
[ ] Yes
[ ] No -> SKIP to question 29

24. At what location did this person work LAST WEEK?
If this person worked at more than one location, print where he or she worked most last week
a) Address (Number and street name)_________________________________
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection.

b) Name of city, town, or post office_________________________________

c) Is the work location inside the limits of that city or town?
[ ] Yes
[ ] No, outside the city/town limits

d) Name of county_________________________________

e) Name of U.S. state or foreign country_________________________________

f) ZIP Code
[ ][ ][ ][ ][ ]

25. How did this person usually get to work LAST WEEK?
If this person usually used more than one method of transportation during the trip, mark (X) the box of the one used for most of the distance
[ ] Car, truck, or van
[ ] Bus or trolley bus
[ ] Streetcar or trolley car
[ ] Subway or elevated
[ ] Railroad
[ ] Ferryboat
[ ] Taxicab
[ ] Motorcycle
[ ] Bicycle
[ ] Walked
[ ] Worked at home -> SKIP to question 33
[ ] Other method

[I] - Answer question 26 ONLY IF you marked "car, truck or van" in question 25. Otherwise, SKIP to question 27.

26. How many people, including this person, usually rode to work in the car, truck or van LAST WEEK?
Person(s)
_________

27. What time did this person usually leave home to go to work LAST WEEK?
Hour Minute [ ]a.m.
[ ][ ]:[ ][ ] [ ]p.m.

28. How many minutes did it usually take this person to get from home to work LAST WEEK?
Minutes
_______

[J] - Answer questions 29-32 ONLY IF this person did NOT work last week. Otherwise, SKIP to question 33.

29. a) LAST WEEK, was this person on layoff from a job?
[ ] Yes -> SKIP to question 29c
[ ] No

b) LAST WEEK, was this person TEMPORARILY absent from a job or business?
[ ] Yes, on vacation, temporary illness, labor dispute, etc., -> SKIP to question 32
[ ] No, -> SKIP to question 30

c) Has this person been informed that he or she will be recalled to work within the next 6 months OR been given a date to return to work?
[ ] Yes -> SKIP to question 31
[ ] No

30. Has this person been looking for work during the last 4 weeks?
[ ] Yes
[ ] No -> SKIP to question 32

31. LAST WEEK, could this person have started a job if offered one, or returned to work if recalled?
[ ] Yes, could have gone to work
[ ] No, because of own temporary illness
[ ] No, because of all other reasons (in school, etc.)

32. When did this person last work, even for a few days?
[ ] Within the past 12 months
[ ] 1 to 5 years ago ->SKIP to question 35
[ ] Over 5 years ago or never worked ->SKIP to question 41

33. During the PAST 12 MONTHS, how many WEEKS did this person work?
Count paid vacation, paid sick leave, and military service.
Weeks
_________

34. During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did this person usually work each WEEK?
Usual hours worked each WEEK
_________

[K] - Answer questions 35-40 ONLY IF this person worked in the past 5 years. Otherwise, SKIP to question 41

35-40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person's chief job activity or business last week. If this person had more than one job, describe the one at which this person worked the most hours. If this person had no job or business last week, give information for his/her last job or business.

35. Was this person...
Mark (X) ONE box
[ ] an employee of a PRIVATE FOR PROFIT company or business, or of an individual, for wages, salary, or commissions?
[ ] an employee of a PRIVATE NOT FOR PROFIT, tax-exempt, or charitable organization?
[ ] a local GOVERNMENT employee (city, county, etc.)?
[ ] a state GOVERNMENT employee?
[ ] a Federal GOVERNMENT employee?
[ ] SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm?
[ ] SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm?
[ ] working WITHOUT PAY in family business or farm?

36. For whom did this person work?
If now on active duty in the armed forces, mark (X) this box -> [ ] and print the branch of the Armed Forces
Name of company, business, or other employer
____________________________________

37. What kind of business or industry was this?
Describe the activity at the location where employed. (For example: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank)
____________________________________

38. Is this mainly - Mark (X) one box
[ ] manufacturing?
[ ] wholesale trade?
[ ] retail trade?
[ ] other (agriculture, service, government, etc.)?

39. What kind of work was this person doing?
(For example: registered nurse, personal manager, supervisor of order department, secretary, accountant)
____________________________________

40. What were this person's most important activities or duties?
(For example: patient care, directing hiring policies, supervising order clerks, typing and filing, reconciling financial records)
____________________________________

41. 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.

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

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

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

e) Supplemental Security Income (SSI)
[ ] Yes ->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

f) Any public assistance or welfare payments from the state or local welfare office.
[ ] Yes ->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

g) Retirement, survivor, or disability pensions. Do NOT include Social Security.
[ ] Yes ->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

h) Any such other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money from an inheritance or the sale of a home
[ ] Yes ->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No

42. What was this person's total income during the PAST 12 MONTHS?
Add entries in questions 40a to 40h; 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

Continue with the questions for Person 2 on the next page. If only 1 person is listed in the List of Residents, SKIP to page 24 for mailing instructions.

(DOCUMENT REPEATS THE ABOVE "PERSON" FORM FOR UP TO 5 RESIDENTS)

(end)

Go Back to Enumeration Forms Index

Back to Top