ACS-1 (Sequential American Community Survey

13198015

DC

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

THE

American Community Survey

Please complete this form and return
it as soon as possible after receiving
it in the mail.
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.

Start Here
➜

Please print today’s date.
Year
Month Day

➜

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

First Name

MI

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.

—

➜

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.
Number of people

➜

Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.

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/

USCENSUSBUREAU

ACS-1(2008)KFI

FORM
(06-05-2007)

OMB No. 0607-0810

§.4q0¤
ACS-1(2008)KFI, Page 1, Base (Black)

ACS-1(2008)KFI, Page 1, Green Pantone 354 (20 and 40%)

13198023

Person 1

Person 2
1 What is Person 2’s name?

(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)

First Name

MI

2 How is this person related to Person 1? Mark (X) ONE box.

1

What is Person 1’s name?
Last Name (Please print)

2

First Name

MI

How is this person related to Person 1?
X

3

Person 1

4

Female

Month

Day

Year of birth

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster Child

Grandchild

Other nonrelative

Female

4 What is Person 2’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Day

Year of birth

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.

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

No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

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

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

6 What is Person 2’s race? Mark (X) one or more boxes.

What is Person 1’s race? Mark (X) one or more boxes.
White

White

Black, African Am., or Negro

Black, African Am., or Negro

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

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

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.

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

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

Some other race – Print race.

2

Roomer or boarder

Stepson or stepdaughter

Age (in years)

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

6

Adopted son or daughter

Male

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.

5

Other relative

3 What is Person 2’s sex? Mark (X) ONE box.

What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Son-in-law or daughter-in-law

Biological son or daughter

Parent-in-law

What is Person 1’s sex? Mark (X) ONE box.
Male

Husband or wife

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.

Some other race – Print race.

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13198031

Person 3
1

1 What is Person 4’s name?

What is Person 3’s name?
Last Name (Please print)

2

Person 4

First Name

MI

How is this person related to Person 1? Mark (X) ONE box.

Husband or wife

Son-in-law or daughter-in-law

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Brother or sister

Unmarried partner

Father or mother

Foster Child

Father or mother

Foster Child

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Parent-in-law

3 What is Person 4’s sex? Mark (X) ONE box.

What is Person 3’s sex? Mark (X) ONE box.
Female

Male

What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Day

Year of birth

Female

4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.

6

2 How is this person related to Person 1? Mark (X) ONE box.

Son-in-law or daughter-in-law

Age (in years)

5

MI

Biological son or daughter

Male

4

First Name

Husband or wife

Parent-in-law

3

Last Name (Please print)

Month

Day

Year of birth

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.

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

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

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

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

6 What is Person 4’s race? Mark (X) one or more boxes.

What is Person 3’s race? Mark (X) one or more boxes.
White

White

Black, African Am., or Negro

Black, African Am., or Negro

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

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

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.

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

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

Some other race – Print race.

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.

Some other race – Print race.

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13198049

Person 5
1

➜

What is Person 5’s name?
Last Name (Please print)

First Name

MI

If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.

Person 6
Last Name (Please print)

2

First Name

MI

How is this person related to Person 1? Mark (X) ONE box.
Husband or wife

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster Child

Grandchild

Other nonrelative

Sex

Male

Female

Age (in years)

Person 7
Last Name (Please print)

First Name

MI

Parent-in-law

3

What is Person 5’s sex? Mark (X) ONE box.
Male

4

Sex

Female

Month

Day

Age (in years)

Last Name (Please print)

First Name

MI

Year of birth

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.

5

Female

Person 8

What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Male

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

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

First Name

MI

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Sex

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

Male

Female

Person 10
Last Name (Please print)

6

Age (in years)

First Name

MI

What is Person 5’s race? Mark (X) one or more boxes.
White
Sex

Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.

Male

Female

Person 11
Last Name (Please print)

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

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

Sex

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.

Age (in years)

Male

First Name

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race.
Sex

4

Male

Female

Age (in years)

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ACS-1(2008)KFI, Page 4, Base (Black)

MI

ACS-1(2008)KFI, Page 4, Green Pantone 354 (20 and 40%)

MI

13198056

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

Housing
➜

1

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

A

8 Does this house, apartment, or mobile

Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.

home have –

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.

a. hot and cold running water?

4 How many acres is this house or

c. a bathtub or shower?

mobile home on?
Less than 1 acre ➔ SKIP to question 6

d. a sink with a faucet?

1 to 9.9 acres

e. a stove or range?

10 or more acres

f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.

5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
None

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

$1 to $999
$1,000 to $2,499
$2,500 to $4,999

None

$5,000 to $9,999

1

$10,000 or more

2

About when was this building first built?
2000 or later – Specify year

3

6 Is there a business (such as a store or

4

barber shop) or a medical office on
this property?

5
6 or more

Yes
1990 to 1999

No

1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

3

No

b. a flush toilet?
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home

2

Yes

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

10 Which FUEL is used MOST for heating this
7 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms

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

Year

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".

No fuel used

Number of bedrooms

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13198064

Housing (continued)
11 a. LAST MONTH, what was the cost

12 In THE PAST 12 MONTHS, did anyone in

of electricity for this house,
apartment, or mobile home?

this household receive Food Stamps or
a Food Stamp benefit card?

Last month’s cost – Dollars
$

Yes
No

.00

,
OR

Included in rent or condominium fee

part of a condominium?

16 About how much do you think this

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

b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
Last month’s cost – Dollars
.00

,

Answer questions 16 – 20 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.

13 Is this house, apartment, or mobile home

No charge or electricity not used

$

C

$

OR

.00

,

Included in rent or condominium fee

Amount – Dollars
$

.00

,

,

17 What are the annual real estate taxes on
THIS property?

OR

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

house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?

Annual amount – Dollars

None
$

No

.00

,
OR

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.

14 Is this house, apartment, or mobile home –
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.

Past 12 months’ cost – Dollars
$

Owned by you or someone in this
household free and clear (without a
mortgage or loan)?

.00

,
OR

Rented?

No charge

18 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$

Occupied without payment of
rent? ➔ SKIP to C

Included in rent or condominium fee

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.

None

Mark (X) ONE box.

.00

,
OR
None

B

Answer questions 15a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 16.

Past 12 months’ cost – Dollars
$

.00

,

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

OR

Monthly amount – Dollars

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

$

,

.00

b. Does the monthly rent include any
meals?
Yes
No

6

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ACS-1(2008)KFI, Page 6, Base (Black)

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13198072

Housing (continued)
19 a. Do you or any member of this

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

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

E

Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.

Yes, home equity loan

Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase

Yes, second mortgage
Yes, second mortgage and home
equity loan
No ➔ SKIP to D

No ➔ SKIP to question 20a

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

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

Monthly amount – Dollars
$

,

.00
$

OR

OR

No regular payment required ➔ SKIP to
question 20a
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

.00

,

No regular payment required

D

Answer question 21 if this is a MOBILE
HOME. Otherwise, SKIP to E .

21 What are the total annual costs for
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

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

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ACS-1(2008)KFI, Page 7, Base (Black)

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13198080

Person 1
➜

14 a. Did this person live in this house or apartment
Please copy the name of Person 1 from Page 2, 11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
then continue answering questions below.
1 year ago?
If currently enrolled, mark the previous grade or
highest degree received.

Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12

Nursery school

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15

Kindergarten

7

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

HIGH SCHOOL GRADUATE

Regular high school diploma

8

GED or alternative credential

Is this person a citizen of the United States?

COLLEGE OR SOME COLLEGE

Yes, born in the United States ➔ SKIP to 10a

Some college credit, but less than 1 year of
college credit

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

1 or more years of college credit, no degree

Name of city, town, or post office

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Name of U.S. state or
Puerto Rico

ZIP Code
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
No, not a U.S. citizen
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
9 When did this person come to live in the
15 Is this person CURRENTLY covered by any of the
United States? Print numbers in boxes.
following types of health insurance or health
Doctorate degree (for example: PhD, EdD)
Year
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
12 What is this person’s ancestry or ethnic origin?
Yes No
a. Insurance through a current or
former employer or union (of this
10 a. At any time IN THE LAST 3 MONTHS, has this
person or another family member)
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
b. Insurance purchased directly from
school, home school, and schooling which leads
(For example: Italian, Jamaican, African Am.,
an insurance company (by this
to a high school diploma or a college degree.
Cambodian, Cape Verdean, Norwegian, Dominican,
person or another family member)
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

13 a. Does this person speak a language other than

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool

English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?

c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

g. Indian Health Service
For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

h. Any other type of health insurance
or health coverage plan – Specify

Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

8

Well
Not well
Not at all

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13198098

Person 1 (continued)
16 a. Is this person deaf or does he/she have
serious difficulty hearing?

20 In the PAST 12 MONTHS did this person get –
Yes

Yes

b. Widowed?
c. Divorced?

21 How many times has this person been married?

Yes

Once

No

F

Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

No, never served in the military ➔ SKIP to
question 28a

22 In what year did this person last get married?

26 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.
September 2001 or later

H

Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.

August 1990 to August 2001 (including Persian
Gulf War)
September 1980 to July 1990
May 1975 to August 1980

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

Vietnam era (August 1964 to April 1975)
March 1961 to July 1964

Yes

Yes

February 1955 to February 1961

No

No

Korean War (July 1950 to January 1955)

c. Does this person have difficulty dressing or
bathing?
Yes
No

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

Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

18 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?
Yes
No

19 What is this person’s marital status?

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

Yes
No ➔ SKIP to question 25

G

Yes, on active duty in the past, but not
during the last 12 months

Three or more times

No
b. Does this person have serious difficulty
walking or climbing stairs?

Yes, on active duty during
the last 12 months, but not now

No, training for Reserves or National Guard
only ➔ SKIP to question 27a

17 a. Because of a physical, mental, or emotional

Yes

Yes, now on active duty

Two times

Year

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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.

a. Married?

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

25 Has this person ever served on active duty in the

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 25
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.

Now married

Less than 6 months

Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➔ SKIP to H

5 or more years

27 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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13198106

Person 1 (continued)
28 a. LAST WEEK, did this person work for pay
at a job (or business)?

I

Yes ➔ SKIP to question 29

Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

35 During the LAST 4 WEEKS, has this person been

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

Yes
No ➔ SKIP to question 34a

36 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

29 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.

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

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

No, because of all other reasons (in school, etc.)

37 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 40

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

b. Name of city, town, or post office

Minutes

Over 5 years ago or never worked ➔ SKIP to
question 46

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

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

Yes ➔ SKIP to question 39

J

Yes
No, outside the city/town limits

Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.

d. Name of county

34 a. LAST WEEK, was this person on layoff from
a job?
e. Name of U.S. state or foreign country

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks

Yes ➔ SKIP to question 34c

40 to 47 weeks

No

27 to 39 weeks
14 to 26 weeks

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

f. ZIP Code

30 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.

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35

13 weeks or less

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

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?

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Yes ➔ SKIP to question 36

Subway or elevated

No

Railroad

Worked at
home ➔ SKIP
to question 38a

Ferryboat

Other method

Taxicab

10

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13198114

Person 1 (continued)
K

Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.

44 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

40 – 45 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.

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?

41 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

42 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)

activities or duties? (For example: patient care,

Yes ➔

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

No

Mark (X) one box.
manufacturing?

$

.00

,

TOTAL AMOUNT for past
12 months

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

46 INCOME IN THE PAST 12 MONTHS.
Yes ➔

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.)

No

Yes ➔

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

No

,

$

.00

,

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.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
$

.00

,

TOTAL AMOUNT for past
12 months

No

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 ➔

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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

Yes ➔

.00

$

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 47 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 46a
proprietorships and partnerships. Report NET
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
income after business expenses.
the dollar amount.

Yes ➔

$

No

43 Is this mainly –

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).

Mark (X) ONE box.

an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?

.00

,

45 What were this person’s most important

40 Was this person –
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

,

.00

TOTAL AMOUNT for past
12 months

None OR $
Loss

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.

wholesale trade?
retail trade?

Yes ➔

other (agriculture, construction, service,
government, etc.)?

No

$

,

.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 on page 2,
SKIP to page 28 for mailing instructions.

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13198122

Person 2
➜

14 a. Did this person live in this house or apartment
Please copy the name of Person 2 from page 2, 11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
then continue answering questions below.
1 year ago?
If currently enrolled, mark the previous grade or
highest degree received.

Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12

Nursery school

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15

Kindergarten

7

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

HIGH SCHOOL GRADUATE

Regular high school diploma

8

GED or alternative credential

Is this person a citizen of the United States?

COLLEGE OR SOME COLLEGE

Yes, born in the United States ➔ SKIP to 10a

Some college credit, but less than 1 year of
college credit

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

1 or more years of college credit, no degree

Name of city, town, or post office

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Name of U.S. state or
Puerto Rico

ZIP Code
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
No, not a U.S. citizen
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
9 When did this person come to live in the
15 Is this person CURRENTLY covered by any of the
United States? Print numbers in boxes.
following types of health insurance or health
Doctorate degree (for example: PhD, EdD)
Year
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
12 What is this person’s ancestry or ethnic origin?
Yes No
a. Insurance through a current or
former employer or union (of this
10 a. At any time IN THE LAST 3 MONTHS, has this
person or another family member)
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
b. Insurance purchased directly from
school, home school, and schooling which leads
(For example: Italian, Jamaican, African Am.,
an insurance company (by this
to a high school diploma or a college degree.
Cambodian, Cape Verdean, Norwegian, Dominican,
person or another family member)
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

13 a. Does this person speak a language other than

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool

English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?

c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

g. Indian Health Service
For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

h. Any other type of health insurance
or health coverage plan – Specify

Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

12

Well
Not well
Not at all

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13198130

Person 2 (continued)
16 a. Is this person deaf or does he/she have
serious difficulty hearing?

20 In the PAST 12 MONTHS did this person get –
Yes

Yes

b. Widowed?
c. Divorced?

21 How many times has this person been married?

Yes

Once

No

F

Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

No, never served in the military ➔ SKIP to
question 28a

22 In what year did this person last get married?

26 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.
September 2001 or later

H

Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.

August 1990 to August 2001 (including Persian
Gulf War)
September 1980 to July 1990
May 1975 to August 1980

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

Vietnam era (August 1964 to April 1975)
March 1961 to July 1964

Yes

Yes

February 1955 to February 1961

No

No

Korean War (July 1950 to January 1955)

c. Does this person have difficulty dressing or
bathing?
Yes
No

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

Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

18 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?
Yes
No

19 What is this person’s marital status?

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

Yes
No ➔ SKIP to question 25

G

Yes, on active duty in the past, but not
during the last 12 months

Three or more times

No
b. Does this person have serious difficulty
walking or climbing stairs?

Yes, on active duty during
the last 12 months, but not now

No, training for Reserves or National Guard
only ➔ SKIP to question 27a

17 a. Because of a physical, mental, or emotional

Yes

Yes, now on active duty

Two times

Year

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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.

a. Married?

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

25 Has this person ever served on active duty in the

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 25
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.

Now married

Less than 6 months

Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➔ SKIP to H

5 or more years

27 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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13198148

Person 2 (continued)
28 a. LAST WEEK, did this person work for pay
at a job (or business)?

I

Yes ➔ SKIP to question 29

Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

35 During the LAST 4 WEEKS, has this person been

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

Yes
No ➔ SKIP to question 34a

36 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

29 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.

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

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

No, because of all other reasons (in school, etc.)

37 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 40

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

b. Name of city, town, or post office

Minutes

Over 5 years ago or never worked ➔ SKIP to
question 46

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

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

Yes ➔ SKIP to question 39

J

Yes
No, outside the city/town limits

Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.

d. Name of county

34 a. LAST WEEK, was this person on layoff from
a job?
e. Name of U.S. state or foreign country

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks

Yes ➔ SKIP to question 34c

40 to 47 weeks

No

27 to 39 weeks
14 to 26 weeks

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

f. ZIP Code

30 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.

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35

13 weeks or less

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

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?

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Yes ➔ SKIP to question 36

Subway or elevated

No

Railroad

Worked at
home ➔ SKIP
to question 38a

Ferryboat

Other method

Taxicab

14

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13198155

Person 2 (continued)
K

Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.

44 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

40 – 45 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.

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?

41 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

42 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)

activities or duties? (For example: patient care,

Yes ➔

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

No

Mark (X) one box.
manufacturing?

$

.00

,

TOTAL AMOUNT for past
12 months

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

46 INCOME IN THE PAST 12 MONTHS.
Yes ➔

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.)

No

Yes ➔

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

No

,

$

.00

,

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.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
$

.00

,

TOTAL AMOUNT for past
12 months

No

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 ➔

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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

Yes ➔

.00

$

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 47 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 46a
proprietorships and partnerships. Report NET
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
income after business expenses.
the dollar amount.

Yes ➔

$

No

43 Is this mainly –

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).

Mark (X) ONE box.

an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?

.00

,

45 What were this person’s most important

40 Was this person –
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

,

.00

TOTAL AMOUNT for past
12 months

None OR $
Loss

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.

wholesale trade?
retail trade?

Yes ➔

other (agriculture, construction, service,
government, etc.)?

No

$

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Continue with the questions for Person 3 on the
next page. If only 2 people arelisted on page 2,
SKIP to page 28 formailing instructions.

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13198163

Person 3
➜

14 a. Did this person live in this house or apartment
Please copy the name of Person 3 from page 3, 11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
then continue answering questions below.
1 year ago?
If currently enrolled, mark the previous grade or
highest degree received.

Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12

Nursery school

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15

Kindergarten

7

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

HIGH SCHOOL GRADUATE

Regular high school diploma

8

GED or alternative credential

Is this person a citizen of the United States?

COLLEGE OR SOME COLLEGE

Yes, born in the United States ➔ SKIP to 10a

Some college credit, but less than 1 year of
college credit

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

1 or more years of college credit, no degree

Name of city, town, or post office

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Name of U.S. state or
Puerto Rico

ZIP Code
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
No, not a U.S. citizen
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
9 When did this person come to live in the
15 Is this person CURRENTLY covered by any of the
United States? Print numbers in boxes.
following types of health insurance or health
Doctorate degree (for example: PhD, EdD)
Year
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
12 What is this person’s ancestry or ethnic origin?
Yes No
a. Insurance through a current or
former employer or union (of this
10 a. At any time IN THE LAST 3 MONTHS, has this
person or another family member)
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
b. Insurance purchased directly from
school, home school, and schooling which leads
(For example: Italian, Jamaican, African Am.,
an insurance company (by this
to a high school diploma or a college degree.
Cambodian, Cape Verdean, Norwegian, Dominican,
person or another family member)
No, has not attended in the last 3
months ➔SKIP to question 11
Yes, public school, public college

French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

13 a. Does this person speak a language other than

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool

English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?

c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

g. Indian Health Service
For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

h. Any other type of health insurance
or health coverage plan – Specify

Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

16

Well
Not well
Not at all

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Person 3 (continued)
16 a. Is this person deaf or does he/she have
serious difficulty hearing?

20 In the PAST 12 MONTHS did this person get –
Yes

Yes

a. Married?

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

b. Widowed?
c. Divorced?

21 How many times has this person been married?

Yes

Once

No

F

Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

No

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, never served in the military ➔ SKIP to
question 28a

22 In what year did this person last get married?

26 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.
September 2001 or later

H

Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.

August 1990 to August 2001 (including Persian
Gulf War)
September 1980 to July 1990
May 1975 to August 1980

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

Vietnam era (August 1964 to April 1975)
March 1961 to July 1964

Yes

Yes

February 1955 to February 1961

No

No

Korean War (July 1950 to January 1955)

c. Does this person have difficulty dressing or
bathing?
Yes
No

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

Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

18 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?
Yes
No

19 What is this person’s marital status?

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

Yes
No ➔ SKIP to question 25

G

Yes, now on active duty

Three or more times

No
b. Does this person have serious difficulty
walking or climbing stairs?

Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.

No, training for Reserves or National Guard
only ➔ SKIP to question 27a

17 a. Because of a physical, mental, or emotional

Yes

U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the

Two times

Year

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 Has this person ever served on active duty in the

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 25
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.

Now married

Less than 6 months

Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➔ SKIP to H

5 or more years

27 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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Person 3 (continued)
28 a. LAST WEEK, did this person work for pay
at a job (or business)?

I

Yes ➔ SKIP to question 29

Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

35 During the LAST 4 WEEKS, has this person been

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

Yes
No ➔ SKIP to question 34a

36 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

29 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.

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

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

No, because of all other reasons (in school, etc.)

37 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 40

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

b. Name of city, town, or post office

Minutes

Over 5 years ago or never worked ➔ SKIP to
question 46

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

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

Yes ➔ SKIP to question 39

J

Yes
No, outside the city/town limits

Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.

d. Name of county

34 a. LAST WEEK, was this person on layoff from
a job?
e. Name of U.S. state or foreign country

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks

Yes ➔ SKIP to question 34c

40 to 47 weeks

No

27 to 39 weeks
14 to 26 weeks

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

f. ZIP Code

30 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.

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35

13 weeks or less

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

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?

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Yes ➔ SKIP to question 36

Subway or elevated

No

Railroad

Worked at
home ➔ SKIP
to question 38a

Ferryboat

Other method

Taxicab

18

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13198197

Person 3 (continued)
K

Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.

44 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

40 – 45 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.

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?

41 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

42 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)

activities or duties? (For example: patient care,

Yes ➔

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

No

Mark (X) one box.
manufacturing?

$

.00

,

TOTAL AMOUNT for past
12 months

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

46 INCOME IN THE PAST 12 MONTHS.
Yes ➔

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.)

No

Yes ➔

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

No

,

$

.00

,

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.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
$

.00

,

TOTAL AMOUNT for past
12 months

No

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 ➔

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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

Yes ➔

.00

$

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 47 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 46a
proprietorships and partnerships. Report NET
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
income after business expenses.
the dollar amount.

Yes ➔

$

No

43 Is this mainly –

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).

Mark (X) ONE box.

an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?

.00

,

45 What were this person’s most important

40 Was this person –
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

,

.00

TOTAL AMOUNT for past
12 months

None OR $
Loss

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.

wholesale trade?
retail trade?

Yes ➔

other (agriculture, construction, service,
government, etc.)?

No

$

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Continue with the questions for Person 4 on the
next page. If only 3 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.

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13198205

Person 4
➜

14 a. Did this person live in this house or apartment
Please copy the name of Person 4 from page 3, 11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
then continue answering questions below.
1 year ago?
If currently enrolled, mark the previous grade or
highest degree received.

Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12

Nursery school

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15

Kindergarten

7

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

HIGH SCHOOL GRADUATE

Regular high school diploma

8

GED or alternative credential

Is this person a citizen of the United States?

COLLEGE OR SOME COLLEGE

Yes, born in the United States ➔ SKIP to 10a

Some college credit, but less than 1 year of
college credit

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

1 or more years of college credit, no degree

Name of city, town, or post office

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Name of U.S. state or
Puerto Rico

ZIP Code
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
No, not a U.S. citizen
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
9 When did this person come to live in the
15 Is this person CURRENTLY covered by any of the
United States? Print numbers in boxes.
following types of health insurance or health
Doctorate degree (for example: PhD, EdD)
Year
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
12 What is this person’s ancestry or ethnic origin?
Yes No
a. Insurance through a current or
former employer or union (of this
10 a. At any time IN THE LAST 3 MONTHS, has this
person or another family member)
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
b. Insurance purchased directly from
school, home school, and schooling which leads
(For example: Italian, Jamaican, African Am.,
an insurance company (by this
to a high school diploma or a college degree.
Cambodian, Cape Verdean, Norwegian, Dominican,
person or another family member)
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

13 a. Does this person speak a language other than

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool

English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?

c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

g. Indian Health Service
For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

h. Any other type of health insurance
or health coverage plan – Specify

Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

20

Well
Not well
Not at all

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Person 4 (continued)
16 a. Is this person deaf or does he/she have
serious difficulty hearing?

20 In the PAST 12 MONTHS did this person get –
Yes

Yes

b. Widowed?

21 How many times has this person been married?
Once

No

F

Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

Yes, now on active duty

c. Divorced?

Yes

Three or more times

No, never served in the military ➔ SKIP to
question 28a

22 In what year did this person last get married?

26 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.
September 2001 or later

H

Yes

Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.

No

August 1990 to August 2001 (including Persian
Gulf War)
September 1980 to July 1990
May 1975 to August 1980

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

Vietnam era (August 1964 to April 1975)
March 1961 to July 1964

Yes

Yes

February 1955 to February 1961

No

No

Korean War (July 1950 to January 1955)

c. Does this person have difficulty dressing or
bathing?

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

Yes
No

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

Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

18 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?
Yes
No

19 What is this person’s marital status?

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

Yes
No ➔ SKIP to question 25

G

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 27a

17 a. Because of a physical, mental, or emotional

b. Does this person have serious difficulty
walking or climbing stairs?

Yes, on active duty during
the last 12 months, but not now

Two times

Year

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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.

a. Married?

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

25 Has this person ever served on active duty in the

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 25
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.

Now married

Less than 6 months

Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➔ SKIP to H

5 or more years

27 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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Person 4 (continued)
28 a. LAST WEEK, did this person work for pay
at a job (or business)?

I

Yes ➔ SKIP to question 29

Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

35 During the LAST 4 WEEKS, has this person been

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

Yes
No ➔ SKIP to question 34a

36 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

29 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.

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

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

No, because of all other reasons (in school, etc.)

37 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 40

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

b. Name of city, town, or post office

Minutes

Over 5 years ago or never worked ➔ SKIP to
question 46

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

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

Yes ➔ SKIP to question 39

J

Yes
No, outside the city/town limits

Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.

d. Name of county

34 a. LAST WEEK, was this person on layoff from
a job?
e. Name of U.S. state or foreign country

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks

Yes ➔ SKIP to question 34c

40 to 47 weeks

No

27 to 39 weeks
14 to 26 weeks

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

f. ZIP Code

30 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.

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35

13 weeks or less

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

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?

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Yes ➔ SKIP to question 36

Subway or elevated

No

Railroad

Worked at
home ➔ SKIP
to question 38a

Ferryboat

Other method

Taxicab

22

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13198239

Person 4 (continued)
K

Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.

44 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

40 – 45 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.

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?

41 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

42 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)

activities or duties? (For example: patient care,

Yes ➔

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

No

Mark (X) one box.
manufacturing?

$

.00

,

TOTAL AMOUNT for past
12 months

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

46 INCOME IN THE PAST 12 MONTHS.
Yes ➔

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.)

No

Yes ➔

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

No

,

$

.00

,

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.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
$

.00

,

TOTAL AMOUNT for past
12 months

No

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 ➔

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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

Yes ➔

.00

$

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 47 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 46a
proprietorships and partnerships. Report NET
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
income after business expenses.
the dollar amount.

Yes ➔

$

No

43 Is this mainly –

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).

Mark (X) ONE box.

an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?

.00

,

45 What were this person’s most important

40 Was this person –
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

,

.00

TOTAL AMOUNT for past
12 months

None OR $
Loss

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.

wholesale trade?
retail trade?

Yes ➔

other (agriculture, construction, service,
government, etc.)?

No

$

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Continue with the questions for Person 5 on the
next page. If only 4 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.

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13198247

Person 5
➜

14 a. Did this person live in this house or apartment
Please copy the name of Person 5 from page 4, 11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
then continue answering questions below.
1 year ago?
If currently enrolled, mark the previous grade or
highest degree received.

Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12

Nursery school

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15

Kindergarten

7

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

HIGH SCHOOL GRADUATE

Regular high school diploma

8

GED or alternative credential

Is this person a citizen of the United States?

COLLEGE OR SOME COLLEGE

Yes, born in the United States ➔ SKIP to 10a

Some college credit, but less than 1 year of
college credit

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

1 or more years of college credit, no degree

Name of city, town, or post office

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Name of U.S. state or
Puerto Rico

ZIP Code
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
No, not a U.S. citizen
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
9 When did this person come to live in the
15 Is this person CURRENTLY covered by any of the
United States? Print numbers in boxes.
following types of health insurance or health
Doctorate degree (for example: PhD, EdD)
Year
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
12 What is this person’s ancestry or ethnic origin?
Yes No
a. Insurance through a current or
former employer or union (of this
10 a. At any time IN THE LAST 3 MONTHS, has this
person or another family member)
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
b. Insurance purchased directly from
school, home school, and schooling which leads
(For example: Italian, Jamaican, African Am.,
an insurance company (by this
to a high school diploma or a college degree.
Cambodian, Cape Verdean, Norwegian, Dominican,
person or another family member)
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

13 a. Does this person speak a language other than

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool

English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?

c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

g. Indian Health Service
For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

h. Any other type of health insurance
or health coverage plan – Specify

Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

24

Well
Not well
Not at all

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13198254

Person 5 (continued)
16 a. Is this person deaf or does he/she have
serious difficulty hearing?

20 In the PAST 12 MONTHS did this person get –
Yes

Yes

b. Widowed?

21 How many times has this person been married?
Once

No

F

Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

Yes, now on active duty

c. Divorced?

Yes

Three or more times

No, never served in the military ➔ SKIP to
question 28a

22 In what year did this person last get married?

26 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.
September 2001 or later

H

Yes

Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.

No

August 1990 to August 2001 (including Persian
Gulf War)
September 1980 to July 1990
May 1975 to August 1980

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

Vietnam era (August 1964 to April 1975)
March 1961 to July 1964

Yes

Yes

February 1955 to February 1961

No

No

Korean War (July 1950 to January 1955)

c. Does this person have difficulty dressing or
bathing?

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

Yes
No

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

Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

18 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?
Yes
No

19 What is this person’s marital status?

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

Yes
No ➔ SKIP to question 25

G

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 27a

17 a. Because of a physical, mental, or emotional

b. Does this person have serious difficulty
walking or climbing stairs?

Yes, on active duty during
the last 12 months, but not now

Two times

Year

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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.

a. Married?

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

25 Has this person ever served on active duty in the

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 25
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.

Now married

Less than 6 months

Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➔ SKIP to H

5 or more years

27 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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13198262

Person 5 (continued)
28 a. LAST WEEK, did this person work for pay
at a job (or business)?

I

Yes ➔ SKIP to question 29

Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

35 During the LAST 4 WEEKS, has this person been

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

Yes
No ➔ SKIP to question 34a

36 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

29 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.

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

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

No, because of all other reasons (in school, etc.)

37 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 40

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

b. Name of city, town, or post office

Minutes

Over 5 years ago or never worked ➔ SKIP to
question 46

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

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

Yes ➔ SKIP to question 39

J

Yes
No, outside the city/town limits

Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.

d. Name of county

34 a. LAST WEEK, was this person on layoff from
a job?
e. Name of U.S. state or foreign country

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks

Yes ➔ SKIP to question 34c

40 to 47 weeks

No

27 to 39 weeks
14 to 26 weeks

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

f. ZIP Code

30 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.

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35

13 weeks or less

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

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?

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Yes ➔ SKIP to question 36

Subway or elevated

No

Railroad

Worked at
home ➔ SKIP
to question 38a

Ferryboat

Other method

Taxicab

26

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13198270

Person 5 (continued)
K

Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.

44 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

40 – 45 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.

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?

41 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

42 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)

activities or duties? (For example: patient care,

Yes ➔

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

No

Mark (X) one box.
manufacturing?

$

.00

,

TOTAL AMOUNT for past
12 months

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

46 INCOME IN THE PAST 12 MONTHS.
Yes ➔

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.)

No

Yes ➔

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

No

,

$

.00

,

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.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
$

.00

,

TOTAL AMOUNT for past
12 months

No

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 ➔

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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

Yes ➔

.00

$

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 47 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 46a
proprietorships and partnerships. Report NET
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
income after business expenses.
the dollar amount.

Yes ➔

$

No

43 Is this mainly –

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).

Mark (X) ONE box.

an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?

.00

,

45 What were this person’s most important

40 Was this person –
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

,

.00

TOTAL AMOUNT for past
12 months

None OR $
Loss

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.

wholesale trade?
retail trade?

Yes ➔

other (agriculture, construction, service,
government, etc.)?

No

$

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Now continue with the mailing instructions
on page 28.

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13198288

Mailing
Instructions
➜ Please make sure you have...

• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ 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

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

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 0607-0810, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. 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(2008)KFI (06-05-2007)

28

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