Form ACS-1(X)Pro American Community Survey

13191010

DC

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

Start Here
This form asks for information
about the people who are living or
staying at the address on the
mailing label and about the house,
apartment, or mobile home
located at the address on the
mailing label.

➜

➜

PLEASE COMPLETE THIS FORM AND RETURN IT AS SOON AS
POSSIBLE AFTER RECEIVING IT IN THE MAIL.
Please print today’s date.
Month Day
Year

Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name

MI

First Name

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

–

➜

Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y necesita ayuda
para completar su cuestionario, llame sin cargo alguno al
1–877–833–5625. Usted también puede pedir un cuestionario
en español o completar su entrevista por teléfono con un
entrevistador que habla español.
For more information about the American Community Survey,
visit our web site at: http://www.census.gov/acs/www/

How many people are living or staying at this address?
• INCLUDE everyone who is living or staying here for more than 2 months.
• INCLUDE anyone else staying here who does not have another usual
place to live.
• EXCLUDE anyone who is living somewhere else for more than 2 months,
such as a college student living away.
Number of people

➜

Fill out pages 2 and 3 for EVERYONE who is living or staying at this
address, including yourself.

If no one is living or staying here for more than 2 months, complete only
pages 4, 5, and 6 and return this questionnaire.

USCENSUSBUREAU

§.4++¤

FORM

ACS-1(X)Pro (8-25-2006)

OMB No. 0607-XXXX

13191028

1
●

List of Residents
Person 1

2
●

How is this person related
to Person 1?

Male
Female

X Person 1
First Name

MI

Person 2

First Name

MI

Last Name (Please print)

First Name

MI

Person 4

Son-in-law, daughter-in-law

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

Male
Female

Husband or wife

Parent-in-law

Biological son or daughter

Son-in-law, daughter-in-law

Adopted son or daughter

Other relative

Male

Stepson or stepdaughter

Roomer or boarder

Female

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

First Name

MI

Person 5

Husband or wife

Parent-in-law

Biological son or daughter

Son-in-law, daughter-in-law

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

First Name

MI

➜

Husband or wife

Parent-in-law

Biological son or daughter

Son-in-law, daughter-in-law

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

If there are more than five people, list them here.
We may call you for more information about them.

MI

Male
Female

Male
Female

Person 7

§.4+=¤

Please report babies as age 0 when
the child is less than 1 year old.
Age (in years)

Print numbers in boxes.
Month Day
Year of birth

Please report babies as age 0 when
the child is less than 1 year old.
Age (in years)

Person 8
Last Name (Please print)

Last Name (Please print)

First Name

Please report babies as age 0 when
the child is less than 1 year old.
Age (in years)

Print numbers in boxes.
Month Day
Year of birth

Relationship of Person 5 to Person 1.

Last Name (Please print)

Please report babies as age 0 when
the child is less than 1 year old.
Age (in years)

Print numbers in boxes.
Month Day
Year of birth

Relationship of Person 4 to Person 1.

Last Name (Please print)

2

Parent-in-law

Biological son or daughter

Relationship of Person 3 to Person 1.

Person 3

First Name

Husband or wife

Please report babies as age 0 when
the child is less than 1 year old.
Age (in years)

Print numbers in boxes.
Month Day
Year of birth

Relationship of Person 2 to Person 1.

Last Name (Please print)

Person 6

What is this person’s date of
birth and what is this
person’s age?
Print numbers in boxes.
Month Day
Year of birth

Person 1 is the person living or staying here in whose name this house or
apartment is owned, being bought, or rented. If there is no such person,
start with the name of any adult living or staying here.

Last Name (Please print)

Last Name (Please print)

3
●

What
is this
person’s
sex?

MI

First Name

MI

13191036

4
●

NOTE: Please answer BOTH Question 4 about Hispanic origin and Question 5 about race.
For this survey, Hispanic origins are not races.
Is this person of Hispanic, Latino, or
Spanish origin?

5
●

What is this person’s race? Mark (X) one or more boxes.

No, not of Hispanic, Latino, or Spanish origin

White

Asian Indian

Native Hawaiian

Yes, Mexican, Mexican Am., Chicano

Black, African Am., or Negro

Chinese

Guamanian or Chamorro

Yes, Puerto Rican

American Indian or Alaska
Native — Print name of enrolled
or principal tribe.

Filipino

Samoan

Japanese

Other Pacific Islander — Print race, for
example, Fijian, Tongan, and so on.
Some other race — Print race.

Yes, Cuban

Korean

Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Columbian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.
White

Asian Indian

Native Hawaiian

Yes, Mexican, Mexican Am., Chicano

Black, African Am., or Negro

Chinese

Guamanian or Chamorro

Yes, Puerto Rican

American Indian or Alaska
Native — Print name of enrolled
or principal tribe.

Filipino

Samoan

Japanese

Other Pacific Islander — Print race, for
example, Fijian, Tongan, and so on.
Some other race — Print race.

No, not of Hispanic, Latino, or Spanish origin

Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Columbian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

Korean
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.

No, not of Hispanic, Latino, or Spanish origin

White

Asian Indian

Native Hawaiian

Yes, Mexican, Mexican Am., Chicano

Black, African Am., or Negro

Chinese

Guamanian or Chamorro

Yes, Puerto Rican

American Indian or Alaska
Native — Print name of enrolled
or principal tribe.

Filipino

Samoan

Japanese

Other Pacific Islander — Print race, for
example, Fijian, Tongan, and so on.
Some other race — Print race.

Yes, Cuban

Korean

Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Columbian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Columbian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.
White
Black, African Am., or Negro

Asian Indian

Native Hawaiian

Chinese

Guamanian or Chamorro

American Indian or Alaska
Native — Print name of enrolled
or principal tribe.

Filipino

Samoan

Japanese

Other Pacific Islander — Print race, for
example, Fijian, Tongan, and so on.
Some other race — Print race.

Korean
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Columbian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

White

Asian Indian

Native Hawaiian

Black, African Am., or Negro

Chinese

Guamanian or Chamorro

American Indian or Alaska
Native — Print name of enrolled
or principal tribe.

Filipino

Samoan

Japanese

Other Pacific Islander — Print race, for
example, Fijian, Tongan, and so on.
Some other race — Print race.

Korean
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.

Person 9

Person 10

Last Name (Please print)

First Name

Person 11
Last Name (Please print)

Last Name (Please print)

MI

First Name

Person 12

MI

Last Name (Please print)

First Name

§.4+E¤

MI

➜

First Name

When you are finished, turn the page
and continue with the Housing section.

MI

3

13191044

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.

Housing information helps your community
plan for police and fire protection.
A

Answer questions 4–6 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?

2

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

4

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

9

Year

6

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

About when was this building first built?
2005 or later
2000 to 2004
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

3

5

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

Less than 1 acre ➔ SKIP to question 6
1 to 9.9 acres
10 or more acres

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 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.

8

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

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, has all three facilities
No

Yes
No

11
7

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

room
rooms
rooms
rooms
rooms
rooms
rooms
rooms
or more rooms

§.4+M¤

Is there telephone service available in this
house, apartment, or mobile home from
which you can both make and receive
calls?
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

13191051

Housing (continued)
13 Which FUEL is used MOST for heating this

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 months’ cost – Dollars

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

$

electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars
,
,

Monthly amount – Dollars

Included in rent or condominium fee
No charge or these fuels not used

14 a. LAST MONTH, what was the cost of

$

house, apartment, or mobile home?

OR

15

$

OR
Included in rent or condominium fee
No charge or electricity not used

$

Yes
No

C

.00

,

.00

,

b. Does the monthly rent include any
meals?

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 months’ value – Dollars

.00

Answer questions 18a and b if you
PAY RENT for this house, apartment,
or mobile home. Otherwise, SKIP to
question 19.

18 a. What is the monthly rent for this

.00

,

B

Answer questions 19–23 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.

No

19 What is the value of this property; that
b. LAST MONTH, what was the cost of
gas for this house, apartment, or
mobile home?
Last month’s cost – Dollars
$

,

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.

.00

OR

Monthly amount – Dollars

Included in rent or condominium fee
Included in electricity payment
entered above
No charge or gas not used

$

,

.00

OR
None

c. IN THE PAST 12 MONTHS, what was the
cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
Past 12 months’ cost – Dollars
$

,
OR

.00

Included in rent or condominium fee
No charge

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?
Occupied without payment of
rent? ➔ SKIP to C

§.4+T¤

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

5

13191069

Housing (continued)
20

What are the annual real estate taxes on
THIS property?

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

Annual amount – Dollars
$

.00

,

Answer questions 25a—c if you
listed at least one person on page 2.
Otherwise, SKIP to page 24 for the
mailing instructions.

Yes, insurance included in mortgage
payment

OR

No, insurance paid separately or no
insurance

None

25

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

23

Annual amount – Dollars
$

E

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

.00

,

Yes ➔ SKIP to the questions for Person 1
on the next page

Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home
equity loan

OR
None

No
b. How many months a year do members
of this household stay at this address?

No ➔ SKIP to D

22 a. Do you or any member of this

Months

b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?

household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?

a. Do you or any member of this
household live or stay at this address
year round?

c. What is the main reason members of this
household are staying at this address?

Monthly amount – Dollars

Yes, mortgage, deed of trust, or similar
debt

$

Yes, contract to purchase
No ➔SKIP to question 23a

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

.00

,
OR

No regular payment required

b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
Monthly amount – Dollars
$

,

.00

D

Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .

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

6

ACS-1(X)Pro(3), Page 6, Base (Black)

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

§.4+f¤

Continue with the questions about
PERSON 1 on the next page.

13191077

Person 1
➜

11

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

First Name

7

Your answers are important! Every person
in the American Community Survey counts.

MI

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 Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

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.

14

Person is under 1 year old ➔ SKIP to the
questions for Person 2 on page 10.
F
Yes, this house ➔ SKIP to
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

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)

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

Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Doctorate degree (for example: PhD, EdD)

Name of county

What is this person’s ancestry or ethnic origin?
Name of state

When did this person come to live in the
United States? Print numbers in boxes.
Year
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)

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)

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

13

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

F

15

Yes
No ➔ SKIP to question 14

c. How well does this person speak English?
Very well
Well
Not well
Not at all

§.4+n¤

Answer questions 15 and 16 if this person
is 5 years old or over. Otherwise, SKIP to the
questions for PERSON 2 on page 10.

Does this person have any of the following
long-lasting conditions:

a. Blindness, deafness, or a severe vision
or hearing impairment?
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?

b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese

ZIP Code

16

Yes

No

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:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

7

13191085

Person 1 (continued)
G

Answer questions 17 and 18 if this person is
15 years old or over. Otherwise, SKIP to the
questions for PERSON 2 on page 10.

22

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 (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

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:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?

b. Working at a job or business?

18 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
Never married

H

Answer question 19 if this person is female
and 15–50 years old. Otherwise, SKIP to
question 20a.

23

24

the past 12 months?

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

I

25

Other method

Answer question 27 if you marked "Car,
truck, or van" in question 26. Otherwise,
SKIP to question 28.

usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

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
28
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.

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)

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 34

27 How many people, including this person,

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

Yes
No ➔ SKIP to question 30a

Yes
No

grandchildren under the age of 18 living in
this house or apartment?

In total, how many years of active-duty
military service has this person had?

26 How did this person usually get to work LAST

Less than 2 years
2 years or more

19 Has this person given birth to any children in

20 a. Does this person have any of his/her own

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, even if just for
part of the period.

Minute

:

a.m.
p.m.

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

Yes
No ➔ SKIP to question 21
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 21

21 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 the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 24
No, never served in the military ➔ SKIP to
question 24

8

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

J

Answer questions 30–33 if this person did
NOT work last week. Otherwise, SKIP to
question 34.

30 a. LAST WEEK, was this person on layoff from a
job?
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county

Yes ➔ SKIP to question 30c
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 33
No ➔ SKIP to question 31

e. Name of U.S. state or foreign country

f. ZIP Code

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 32
No

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13191127

Person 1 (continued)
31

Has this person been looking for work during
the last 4 weeks?

37

Yes
No ➔ SKIP to question 33

32

Name of company, business, or other employer

Yes ➔ $

.00
Loss
,
No
TOTAL AMOUNT for past
12 MONTHS
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

38

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)

Yes ➔ $

When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 36
Over 5 years ago or never worked ➔ SKIP to
question 42

34

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

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.)

33

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.

39

Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

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

40

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

41

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)

35 During the PAST 12 MONTHS, in the WEEKS

36

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?

42

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

43

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
Yes ➔
No

,

.00

TOTAL AMOUNT for past
12 MONTHS

§.4,<¤

Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any 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.

Mark (X) the "No" box to show types of income
NOT received.

$

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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.)

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.

Yes ➔ $

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.

Answer questions 36–41 if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.
36–41 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.

Loss

,
No
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).

WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK

K

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
d. Social Security or Railroad Retirement.

,
No
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; 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 $
Loss

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

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.

9

13191077

Survey information helps your community
get financial assistance for roads, hospitals,
schools, and more.

Person 2

The balance of the questionnaire
has questions for Person 2,
Person 3, Person 4, and Person 5.
The questions are the same as
the questions for Person 1.

10

§.4+n¤

13191077

§.4+n¤

11

13191242

Mailing
Instructions
➜ Please make sure you have..

• put all names on the List of Residents and answered
the questions across the top of the page
• answered all Housing questions
• answered all Person questions for each person on the
List of Residents.
➜ Then...

• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

JIC1

JIC2

TELEPHONE CLERK

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 38 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-XXXX, U.S. Census Bureau,
4700 Silver Hill Road, Stop 1500, Washington, D.C.
20233-1500. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(X)Pro (8-25-2006)

24

§.4-K¤