Census Survey

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Today's Date

Last Name

First Name

Middle Initial

Phone Number

Address

How many people are living or staying at this address? ● INCLUDE everyone who is living or staying here for more than 2 months. ● INCLUDE yourself if you are living here for more than 2 months. ● INCLUDE anyone else staying here who does not have another place to stay, even if they are here for 2 months or less. ● DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

How many people are living or staying at this address?

1. • 0
2. • 1
3. • 2
4. • 3
5. • 4
6. • 5
7. • 6
8. • 7
9. • 8
10. • 9
11. • 10
12. • 11
13. • 12
14. • 13 or more

How many people are living or staying at this address?

Person 1

Last name

First name

Middle Initial

What is Person 1's sex?

1. • Male
2. • Female

What is Person 1’s age?

What is Person 1’s date of birth?

Is Person 1 of Hispanic, Latino, or Spanish origin?

1. • No, not of Hispanic, Latino, or Spanish origin
2. • Yes, Mexican, Mexican Am., Chicano
3. • Yes, Puerto Rican
4. • Yes, Cuban
5. • Yes, another Hispanic, Latino, or Spanish origin

Enter Hispanic, Latino, or Spanish origin

What is Person 1’s race?

1. • White
2. • Black, African Am., or Negro
3. • American Indian or Alaska Native
4. • Asian Indian
5. • Chinese
6. • Filipino
7. • Other Asian
8. • Japanese
9. • Korean
10. • Vietnamese
11. • Native Hawaiian
12. • Guamanian or Chamorro
13. • Samoan
14. • Other Pacific Islander
15. • Some other race

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 2

Last name

First name

Middle Initial

How is this person related to Person 1?

1. • Husband or wife
2. • Biological son or daughter
3. • Adopted son or daughter
4. • Stepson or stepdaughter
5. • Brother or sister
6. • Father or mother
7. • Grandchild
8. • Parent-in-law
9. • Son-in-law or daughter-in-law
10. • Other relative
11. • Roomer or boarder
12. • Housemate or roommate
13. • Unmarried partner
14. • Foster child
15. • Other nonrelative

What is Person 2's sex?

1. • Male
2. • Female

What is Person 2's age?

What is Person 2's date of birth?

Is Person 2 of Hispanic, Latino, or Spanish origin?

1. • No, not of Hispanic, Latino, or Spanish origin
2. • Yes, Mexican, Mexican Am., Chicano
3. • Yes, Puerto Rican
4. • Yes, Cuban
5. • Yes, another Hispanic, Latino, or Spanish origin

Enter Hispanic, Latino, or Spanish origin

What is Person 2's race?

1. • White
2. • Black, African Am., or Negro
3. • American Indian or Alaska Native
4. • Asian Indian
5. • Chinese
6. • Filipino
7. • Other Asian
8. • Japanese
9. • Korean
10. • Vietnamese
11. • Native Hawaiian
12. • Guamanian or Chamorro
13. • Samoan
14. • Other Pacific Islander
15. • Some other race

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 3

Last name

First name

Middle initial

How is this person related to Person 1?

1. • Husband or wife
2. • Biological son or daughter
3. • Adopted son or daughter
4. • Stepson or stepdaughter
5. • Brother or sister
6. • Father or mother
7. • Grandchild
8. • Parent-in-law
9. • Son-in-law or daughter-in-law
10. • Other relative
11. • Roomer or boarder
12. • Housemate or roommate
13. • Unmarried partner
14. • Foster child
15. • Other nonrelative

What is Person 3's sex?

1. • Male
2. • Female

What is Person 3's age?

What is Person 3's date of birth?

Is Person 3 of Hispanic, Latino, or Spanish origin?

1. • No, not of Hispanic, Latino, or Spanish origin
2. • Yes, Mexican, Mexican Am., Chicano
3. • Yes, Puerto Rican
4. • Yes, Cuban
5. • Yes, another Hispanic, Latino, or Spanish origin

Enter Hispanic, Latino, or Spanish origin

What is Person 3's race?

1. • White
2. • Black, African Am., or Negro
3. • American Indian or Alaska Native
4. • Asian Indian
5. • Chinese
6. • Filipino
7. • Other Asian
8. • Japanese
9. • Korean
10. • Vietnamese
11. • Native Hawaiian
12. • Guamanian or Chamorro
13. • Samoan
14. • Other Pacific Islander
15. • Some other race

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 4

Last name

First name

Middle Initial

How is this person related to Person 1?

1. • Husband or wife
2. • Biological son or daughter
3. • Adopted son or daughter
4. • Stepson or stepdaughter
5. • Brother or sister
6. • Father or mother
7. • Grandchild
8. • Parent-in-law
9. • Son-in-law or daughter-in-law
10. • Other relative
11. • Roomer or boarder
12. • Housemate or roommate
13. • Unmarried partner
14. • Foster child
15. • Other nonrelative

What is Person 4's sex?

1. • Male
2. • Female

What is Person 4's age?

What is Person 4's date of birth?

Is Person 4 of Hispanic, Latino, or Spanish origin?

1. • No, not of Hispanic, Latino, or Spanish origin
2. • Yes, Mexican, Mexican Am., Chicano
3. • Yes, Puerto Rican
4. • Yes, Cuban
5. • Yes, another Hispanic, Latino, or Spanish origin

Enter Hispanic, Latino, or Spanish origin

What is Person 4's race?

1. • White
2. • Black, African Am., or Negro
3. • American Indian or Alaska Native
4. • Asian Indian
5. • Chinese
6. • Filipino
7. • Other Asian
8. • Japanese
9. • Korean
10. • Vietnamese
11. • Native Hawaiian
12. • Guamanian or Chamorro
13. • Samoan
14. • Other Pacific Islander
15. • Some other race

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 5

Last name

First name

Middle initial

How is this person related to Person 1?

1. • Husband or wife
2. • Biological son or daughter
3. • Adopted son or daughter
4. • Stepson or stepdaughter
5. • Brother or sister
6. • Father or mother
7. • Grandchild
8. • Parent-in-law
9. • Son-in-law or daughter-in-law
10. • Other relative
11. • Roomer or boarder
12. • Housemate or roommate
13. • Unmarried partner
14. • Foster child
15. • Other nonrelative

What is Person 5's sex?

1. • Male
2. • Female

What is Person 5's age?

What is Person 5's date of birth?

Is Person 5 of Hispanic, Latino, or Spanish origin?

1. • No, not of Hispanic, Latino, or Spanish origin
2. • Yes, Mexican, Mexican Am., Chicano
3. • Yes, Puerto Rican
4. • Yes, Cuban
5. • Yes, another Hispanic, Latino, or Spanish origin

Enter Hispanic, Latino, or Spanish origin

What is Person 5's race?

1. • White
2. • Black, African Am., or Negro
3. • American Indian or Alaska Native
4. • Asian Indian
5. • Chinese
6. • Filipino
7. • Other Asian
8. • Japanese
9. • Korean
10. • Vietnamese
11. • Native Hawaiian
12. • Guamanian or Chamorro
13. • Samoan
14. • Other Pacific Islander
15. • Some other race

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

If there are more than five people living or staying here, you may receive a call for more information about them.

Person 6

Last name

First name

Middle initial

What is Person 6's sex?

1. • Male
2. • Female

What is Person 6's age?

Person 7

Last name

First name

Middle initial

What is Person 7's sex?

1. • Male
2. • Female

What is Person 7's age?

Person 8

Last name

First name

Middle initial

What is Person 8's sex?

1. • Male
2. • Female

What is Person 8's age?

Person 9

Last name

First name

Middle initial

What is Person 9's sex?

1. • Male
2. • Female

What is Person 9's age?

Person 10

Last name

First name

Middle initial

What is Person 10's sex?

1. • Male
2. • Female

What is Person 10's age?

Person 11

Last name

First name

Middle initial

What is Person 11's sex?

1. • Male
2. • Female

What is Person 11's age?

Person 12

Last name

First name

Middle initial

What is Person 12's sex?

1. • Male
2. • Female

What is Person 12's age?

Housing

Which best describes this building?

1. • A mobile home
2. • A one-family house detached from any other house
3. • A one-family house attached to one or more houses
4. • A building with 2 apartments
5. • A building with 3 or 4 apartments
6. • A building with 5 to 9 apartments
7. • A building with 10 to 19 apartments
8. • A building with 20 to 49 apartments
9. • A building with 50 or more apartments
10. • Boat, RV, van, etc.

About when was this building first built?

1. • 2012
2. • 2011
3. • 2010
4. • 2009
5. • 2008
6. • 2007
7. • 2006
8. • 2005
9. • 2004
10. • 2003
11. • 2002
12. • 2001
13. • 2000
14. • 1990 to 1999
15. • 1980 to 1989
16. • 1970 to 1979
17. • 1960 to 1969
18. • 1950 to 1959
19. • 1940 to 1949
20. • 1939 or earlier

When did PERSON 1 move into this house, apartment, or mobile home?

How many acres is this house or mobile home on?

1. • Less than 1 acre
2. • 6 1 to 9.9 acres
3. • 10 or more acres

IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?

1. • None
2. • $1 to $999
3. • $1,000 to $2,499
4. • $2,500 to $4,999
5. • $5,000 to $9,999
6. • $10,000 or more

Is there a business (such as a store or barber shop) or a medical office on this property?

1. • Yes
2. • No

How many separate rooms are in this house, apartment, or mobile home?

1. • 1
2. • 2
3. • 3
4. • 4
5. • 5
6. • 6
7. • 7
8. • 8
9. • 9
10. • 10
11. • 11
12. • 12
13. • 13
14. • 14
15. • 15
16. • 16
17. • 17
18. • 18
19. • 19
20. • 20

How many of these rooms are bedrooms?

1. • 0
2. • 1
3. • 2
4. • 3
5. • 4
6. • 5
7. • 6

Does this house, apartment, or mobile home have -

1. • Hot and cold running water?
2. • A flush toilet?
3. • A bathtub or shower?
4. • A sink with a faucet?
5. • A stove or range?
6. • A refrigerator?
7. • Telephone service from which you can both make and receive calls? Include cell phones.

How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?

1. • None
2. • 1
3. • 2
4. • 3
5. • 4
6. • 5
7. • 6 or more

Which FUEL is used MOST for heating this house, apartment, or mobile home?

1. • Gas: from underground pipes serving the neighborhood
2. • Gas: bottled, tank, or LP
3. • Electricity
4. • Fuel oil, kerosene, etc.
5. • Coal or coke
6. • Wood
7. • Solar energy
8. • Other fuel
9. • No fuel used

LAST MONTH, were you charged for electricity for this house, apartment, or mobile home?

1. • Yes
2. • No, the cost was Included in rent or condominium fee
3. • No charge or electricity not used

LAST MONTH, what was the cost (in USD) of electricity for this house, apartment, or mobile home?

LAST MONTH, were you charged for gas for this house, apartment, or mobile home?

1. • Yes
2. • No, the cost was included in rent or condominium fee
3. • No, the cost was included in electricity payment entered above
4. • No charge or gas not used

LAST MONTH, what was the cost (in USD) of gas for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, were you charged for water and sewer for this house, apartment, or mobile home?

1. • Yes
2. • No, the cost was included in rent or condominium fee
3. • No charge

IN THE PAST 12 MONTHS, what was the cost (in USD) of water and sewer for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, were you charged for oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?

1. • Yes
2. • No, the cost is included in rent or condominium fee
3. • No charge or these fuels not used

IN THE PAST 12 MONTHS, what was the cost (in USD) of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, did anyone in this household receive Food Stamps or a Food Stamp benefit card?

1. • Yes
2. • No

Is this house, apartment, or mobile home part of a condominium?

1. • Yes, and I DO pay a separate condominium fee
2. • Yes, but I do NOT pay a separate condominium fee
3. • No, this house, apartment, or mobile home is not part of a condominium

What is the monthly condominium fee (in USD)?

Is this house, apartment, or mobile home –

1. • Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
2. • Owned by you or someone in this household free and clear (without a mortgage or loan)?
3. • Rented?
4. • Occupied without payment of rent?

What is the monthly rent for this house, apartment, or mobile home?

Does the monthly rent include any meals?

1. • Yes
2. • No

You or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home

About how much (in USD) do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale?

What are the annual real estate taxes on THIS property?

What is the annual payment for fire, hazard, and flood insurance on THIS property?

Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?

1. • Yes, mortgage, deed of trust, or similar debt
2. • Yes, contract to purchase
3. • No

How much is the regular monthly mortgage payment on THIS property?

Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?

1. • Yes, taxes included in mortgage payment
2. • No, taxes paid separately or taxes not required

Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property?

1. • Yes, insurance included in mortgage payment
2. • No, insurance paid separately or no insurance

Do you or any member of this household have a second mortgage or a home equity loan on THIS property?

1. • Yes, home equity loan
2. • Yes, second mortgage
3. • Yes, second mortgage and home equity loan
4. • No

How much (in USD) is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property?

What are the total annual costs (in USD) for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site?

About Person 1

Where was Person 1 born?

1. • Alabama
2. • Alaska
3. • Arizona
4. • Arkansas
5. • California
6. • Colorado
7. • Connecticut
8. • Delaware
9. • Florida
10. • Georgia
11. • Hawaii
12. • Idaho
13. • Illinois
14. • Indiana
15. • Iowa
16. • Kansas
17. • Kentucky
18. • Louisiana
19. • Maine
20. • Maryland
21. • Massachusetts
22. • Michigan
23. • Minnesota
24. • Mississippi
25. • Missouri
26. • Montana
27. • Nebraska
28. • Nevada
29. • New Hampshire
30. • New Jersey
31. • New Mexico
32. • New York
33. • North Carolina
34. • North Dakota
35. • Ohio
36. • Oklahoma
37. • Oregon
38. • Pennsylvania
39. • Rhode Island
40. • South Carolina
41. • South Dakota
42. • Tennessee
43. • Texas
44. • Utah
45. • Vermont
46. • Virginia
47. • Washington
48. • West Virginia
49. • Wisconsin
50. • Wyoming
51. • Outside of the United States

Print name of foreign country, or Puerto Rico, Guam, etc.

Is this person a citizen of the United States?

1. • Yes, born in the United States
2. • Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas
3. • Yes, born abroad of U.S. citizen parent or parents
4. • Yes, U.S. citizen by naturalization

Enter year of naturalization

When did this person come to live in the United States?

At any time IN THE LAST 3 MONTHS, has this person attended school or college?

1. • No, has not attended in the last 3 months
2. • Yes, public school, public college
3. • Yes, private school, private college, home school

What grade or level was this person attending?

1. • Nursery school, preschool
2. • Kindergarten
3. • Grade 1 through 12
4. • College undergraduate years (freshman to senior)
5. • Graduate or professional school beyond a bachelor’s degree (for example: MA or PhD program, or medical or law school)

Specify grade 1 – 12

1. • 1
2. • 2
3. • 3
4. • 4
5. • 5
6. • 6
7. • 7
8. • 8
9. • 9
10. • 10
11. • 11
12. • 12

What is the highest degree or level of school this person has COMPLETED?

1. • No schooling completed
2. • Nursery school
3. • Kindergarten
4. • Grade 1 through 11
5. • 12th grade – NO DIPLOMA
6. • Regular high school diploma
7. • GED or alternative credential
8. • Some college credit, but less than 1 year of college credit
9. • 1 or more years of college credit, no degree Associate’s degree (for example: AA, AS)
10. • Bachelor’s degree (for example: BA, BS)
11. • Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
12. • Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)
13. • Doctorate degree (for example: PhD, EdD)

Please print below the specific major(s) of any BACHELOR’S DEGREES this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology)

What is this person’s ancestry or ethnic origin?

Does this person speak a language other than English at home?

1. • Yes
2. • No

What language, other than English, is spoken at home

How well does this person speak English?

1. • Very well
2. • Well
3. • Not well
4. • Not at all

Did this person live in this house or apartment 1 year ago?

1. • Yes, this house or apartment
2. • No, outside the United States and Puerto Rico
3. • No, different house in the United States or Puerto Rico

Enter name of foreign country, or U.S. Virgin Islands, Guam, etc. lived in 1 year ago

Where did this person live 1 year ago?

Address (Number and street name)

Name of city, town, or post office

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or Puerto Rico

ZIP code

Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans?

1. • Insurance through a current or former employer or union (of this person or another family member)
2. • Insurance purchased directly from an insurance company (by this person or another family member)
3. • Medicare, for people 65 and older, or people with certain disabilities
4. • Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
5. • TRICARE or other military health care
6. • VA (including those who have ever used or enrolled for VA health care)
7. • Indian Health Service
8. • Any other type of health insurance or health coverage plan

Enter name of other type of health insurance or health coverage plan

Is this person deaf or does he/she have serious difficulty hearing?

1. • Yes
2. • No

Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

1. • Yes
2. • No

Person is 5 years old or over

Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

1. • Yes
2. • No

Does this person have serious difficulty walking or climbing stairs?

1. • Yes
2. • No

Does this person have difficulty dressing or bathing?

1. • Yes
2. • No

Person is 15 years old or over

Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping?

1. • Yes
2. • No

What is this person’s marital status?

1. • Now married
2. • Widowed
3. • Divorced
4. • Separated
5. • Never married

Currently or was married

In the PAST 12 MONTHS did this person get -

1. • Married?
2. • Widowed?
3. • Divorced?

How many times has this person been married?

1. • Once
2. • Twice
3. • Three or more times

In what year did this person last get married?

Has this person given birth to any children in the past 12 months?

1. • Yes
2. • No

Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?

1. • Yes
2. • No

Is this grandparent currently responsible for most of the basic needs of any grandchildren under the age of 18 who lives in this house or apartment?

1. • Yes
2. • No

How long has this grandparent been responsible for these grandchildren?

1. • Less than 6 months
2. • 6 to 11 months
3. • 1 or 2 years
4. • 3 or 4 years
5. • 5 or more years

Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?

1. • Yes, now on active duty
2. • Yes, on active duty during the last 12 months, but not now
3. • Yes, on active duty in the past, but not during the last 12 months
4. • No, training for Reserves or National Guard only
5. • No, never served in the military

When did this person serve on active duty in the U.S. Armed Forces?

1. • September 2001 or later
2. • August 1990 to August 2001 (including Persian Gulf War)
3. • September 1980 to July 1990
4. • May 1975 to August 1980
5. • Vietnam era (August 1964 to April 1975)
6. • March 1961 to July 1964
7. • February 1955 to February 1961
8. • Korean War (July 1950 to January 1955)
9. • January 1947 to June 1950
10. • World War II (December 1941 to December 1946)
11. • November 1941 or earlier

Does this person have a VA service-connected disability rating?

1. • Yes (such as 0%, 10%, 20%, ... , 100%)
2. • No

What is this person’s service-connected disability rating?

1. • 0 percent
2. • 10 or 20 percent
3. • 30 or 40 percent
4. • 50 or 60 percent
5. • 70 percent or higher

LAST WEEK, did this person work for pay at a job (or business)?

1. • Yes
2. • No – Did not work (or retired)

LAST WEEK, did this person do ANY work for pay, even for as little as one hour?

1. • Yes
2. • No

Person worked last week

At what location did this person work LAST WEEK?

Address (Number and street name)

Name of city, town, or post office

Is the work location inside the limits of that city or town?

1. • Yes
2. • No, outside the city/town limits

Name of county

Name of U.S. state or foreign country

1. • Alabama
2. • Alaska
3. • Arizona
4. • Arkansas
5. • California
6. • Colorado
7. • Connecticut
8. • Delaware
9. • Florida
10. • Georgia
11. • Hawaii
12. • Idaho
13. • Illinois
14. • Indiana
15. • Iowa
16. • Kansas
17. • Kentucky
18. • Louisiana
19. • Maine
20. • Maryland
21. • Massachusetts
22. • Michigan
23. • Minnesota
24. • Mississippi
25. • Missouri
26. • Montana
27. • Nebraska
28. • Nevada
29. • New Hampshire
30. • New Jersey
31. • New Mexico
32. • New York
33. • North Carolina
34. • North Dakota
35. • Ohio
36. • Oklahoma
37. • Oregon
38. • Pennsylvania
39. • Rhode Island
40. • South Carolina
41. • South Dakota
42. • Tennessee
43. • Texas
44. • Utah
45. • Vermont
46. • Virginia
47. • Washington
48. • West Virginia
49. • Wisconsin
50. • Wyoming
51. • Foreign Country, outside of the United States

Name of foreign country, outside of the United States

ZIP Code

How did this person usually get to work LAST WEEK?

1. • Car, truck, or van
2. • Bus or trolley bus
3. • Streetcar or trolley car
4. • Subway or elevated
5. • Railroad
6. • Ferryboat
7. • Taxicab
8. • Motorcycle
9. • Bicycle
10. • Walked
11. • Worked at home
12. • Other method

Worked outside of the home

How many people, including this person, usually rode to work in the car, truck, or van LAST WEEK?

1. • 1
2. • 2
3. • 3
4. • 4
5. • 5
6. • 6
7. • 7
8. • 8
9. • 9
10. • 10
11. • 11
12. • 12
13. • 13
14. • 14

What time did this person usually leave home to go to work LAST WEEK?

Hour

1. • 01
2. • 02
3. • 03
4. • 04
5. • 05
6. • 06
7. • 07
8. • 08
9. • 09
10. • 10
11. • 11
12. • 12

Minute

1. • 00
2. • 05
3. • 10
4. • 15
5. • 20
6. • 25
7. • 30
8. • 35
9. • 40
10. • 45
11. • 50
12. • 55

a.m. or p.m.

1. • a.m.
2. • p.m.

How many minutes did it usually take this person to get from home to work LAST WEEK

Person did not work last week

LAST WEEK, was this person on layoff from a job?

1. • Yes
2. • No

LAST WEEK, was this person TEMPORARILY absent from a job or business?

1. • Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc.
2. • No

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?

1. • Yes
2. • No

During the LAST 4 WEEKS, has this person been ACTIVELY looking for work?

1. • Yes
2. • No

LAST WEEK, could this person have started a job if offered one, or returned to work if recalled?

1. • Yes, could have gone to work
2. • No, because of own temporary illness
3. • No, because of all other reasons (in school, etc.)

When did this person last work, even for a few days?

1. • Within the past 12 months
2. • 1 to 5 years ago
3. • Over 5 years ago or never worked

During the PAST 12 MONTHS (52 weeks), did this person work 50 or more weeks? Count paid time off as work.

1. • Yes
2. • No

How many weeks DID this person work, even for a few hours, including paid vacation, paid sick leave, and military service?

1. • 50 to 52 weeks
2. • 48 to 49 weeks
3. • 40 to 47 weeks
4. • 27 to 39 weeks
5. • 14 to 26 weeks
6. • 13 weeks or less

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

Current or most recent job activity

Was this person -

1. • an employee of a PRIVATE FOR-PROFIT company or business, or of an individual, for wages, salary, or commissions?
2. • an employee of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or charitable organization?
3. • a local GOVERNMENT employee (city, county, etc.)?
4. • a state GOVERNMENT employee?
5. • a Federal GOVERNMENT employee?
6. • SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm?
7. • SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm?
8. • working WITHOUT PAY in family business or farm?

Is this person on active duty in the Armed Forces?

1. • Yes
2. • No

Enter the branch of the Armed Forces

Name of company, business, or other employer person worked for

What kind of business or industry was this?

Is this mainly –

1. • manufacturing?
2. • wholesale trade?
3. • retail trade?
4. • other (agriculture, construction, service, government, etc.)?

What kind of work was this person doing?

What were this person’s most important activities or duties?

Income in the past 12 months

Select "Yes" 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.) Select "No" to show types of income NOT received. If net income was a loss, select "Yes, loss" and enter 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 select "No" for the other person.

Wages, salary, commissions, bonuses, or tips from all jobs.

1. • Yes
2. • No

Total amount for past 12 months

Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships.

1. • Yes, gain
2. • Yes, loss
3. • No

Total gain amount for past 12 months

Total loss amount for past 12 months

Interest, dividends, net rental income, royalty income, or income from estates and trusts.

1. • Yes, gain
2. • Yes, loss
3. • No

Total gain amount for past 12 months

Total loss amount for past 12 months

Social Security or Railroad Retirement.

1. • Yes
2. • No

Total amount for past 12 months

Supplemental Security Income (SSI).

1. • Yes
2. • No

Total amount for past 12 months

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

1. • Yes
2. • No

Total amount for past 12 months

Retirement, survivor, or disability pensions.

1. • Yes
2. • No

Total amount for past 12 months

Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.

1. • Yes
2. • No

Total amount for past 12 months

Was this person’s total income during the past 12 months a gain or a loss?

1. • Gain
2. • Loss

Total gain amount for past 12 months

Total loss amount for past 12 months