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U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
People are our most important resource.
This Census Bureau survey collects
information about education,
employment, income, and housing—
information your community uses to
plan and fund programs. Your response
is important, and we keep your
answers confidential.
Start Here
This form asks for three types of information:
• basic information about the people who are living or staying at
the address on the mailing label above
• specific information about this house, apartment, or mobile
home
• more detailed information about each person living or staying
here
➜
What is your name? Please PRINT the name of the person who
is filling out this form. Include the telephone number so we can
contact you if there is a question, and today’s date.
Last Name
First Name
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
Area Code + Number
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(2005), Page 1, Base (Black)
MI
Date (Month/Day/Year)
➜
How many people are living or staying at this address?
Number of people
➜
Please turn to the next page to continue.
ACS-1(2005)
FORM
(5-19-2005)
OMB No. 0607-0810
ACS-1(2005), Page 1, GREEN Pantone 354 (20% and 100%)
List of Residents
READ THESE
INSTRUCTIONS
FIRST
1 What
is this
person’s
sex?
2 What is this person’s
age and what is this
person’s date of birth?
Print numbers in boxes.
• LIST everyone who is
living or staying here for
more than 2 months.
• LIST anyone else staying
here who does not have
another usual place to
stay.
• DO NOT LIST anyone who
is living somewhere else
for more than 2 months,
such as a college student
living away.
X Person 1
Age (in years)
Last Name (Please print)
First Name
MI
Female
Month Day
Year of birth
IF YOU ARE NOT SURE
WHOM TO LIST, CALL
1–800–354–7271.
Husband or wife
Son or daughter
Brother or sister
Age (in years)
Last Name (Please print)
Male
First Name
MI
Female
Month Day
Year of birth
Age (in years)
Last Name (Please print)
Husband or wife
Son or daughter
Brother or sister
Male
First Name
MI
Female
Month Day
Year of birth
Other nonrelative
Father or mother
Grandchild
In-law
Roomer, boarder
Housemate,
roommate
Unmarried partner
Foster child
Other nonrelative
Other relative
Person 4
Relationship of Person 4 to Person 1.
Husband or wife
Son or daughter
Brother or sister
Age (in years)
Last Name (Please print)
Male
MI
Father or mother
Female
Month Day
Year of birth
Grandchild
In-law
Other relative
Roomer, boarder
Housemate,
roommate
Unmarried partner
Foster child
Other nonrelative
Relationship of Person 5 to Person 1.
Person 5
Age (in years)
Last Name (Please print)
Male
Female
First Name
➜
Father or mother
Grandchild
In-law
Other relative
Roomer, boarder
Housemate,
roommate
Unmarried partner
Foster child
Relationship of Person 3 to Person 1.
First 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.)
Relationship of Person 2 to Person 1.
Person 2
Person 3
If this place is a
vacation home or a
temporary residence
where no one in this
household stays for more
than 2 months, do not
list any names in the List
of Residents. Complete
only pages 4, 5, and 6
and return the form.
to Person 1?
Person 1
Male
Please fill out this form
as soon as possible after
receiving it in the mail.
3 How is this person related
MI
Month Day
Year of birth
Husband or wife
Son or daughter
Brother or sister
Roomer, boarder
Housemate,
roommate
Father or mother
Grandchild
In-law
Unmarried partner
Foster child
Other nonrelative
Other relative
If there are more than
five people, list them
here. We may call you
for more information
about them.
Person 6
Person 7
Person 8
Last Name (Please print)
Last Name (Please print)
Last Name (Please print)
After you’ve created
the List of Residents,
answer the questions
across the top of the
page for the first five
people on the list.
First Name
MI
First Name
MI
First Name
MI
2
ACS-1(2005), Page 2, Base (Black)
ACS-1(2005), Page 2, GREEN Pantone 354 (10%, 20% and 100%)
4 What is this
person’s
marital
status?
NOTE: Please answer BOTH Questions 5 and 6.
5 Is this person Spanish/
Hispanic/Latino?
Mark (X) the "No" box if
not Spanish/Hispanic/Latino.
Now married
Widowed
Divorced
Separated
Never married
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am.,
Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino — Print group.
Now married
Widowed
Divorced
Separated
Never married
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am.,
Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino — Print group.
Now married
Widowed
Divorced
Separated
Never married
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am.,
Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino — Print group.
Now married
Widowed
Divorced
Separated
Never married
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am.,
Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino — Print group.
Now married
Widowed
Divorced
Separated
Never married
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am.,
Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino — Print group.
6 What is this person’s race? Mark (X) one or more races to indicate what this
person considers himself/herself to be.
White
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian –
Print race.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race below.
Some other race – Print race below.
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian –
Print race.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race below.
Some other race – Print race below.
White
Asian Indian
Black or African American
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian –
Print race.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race below.
Black or African American
American Indian or Alaska
Native – Print name of enrolled
or principal tribe.
White
Black or African American
American Indian or Alaska
Native – Print name of enrolled
or principal tribe.
American Indian or Alaska
Native – Print name of enrolled
or principal tribe.
White
Some other race – Print race below.
Native Hawaiian
Asian Indian
Chinese
Black or African American
American Indian or Alaska
Native – Print name of enrolled
or principal tribe.
Filipino
Japanese
Korean
Vietnamese
Other Asian –
Print race.
White
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian –
Print race.
Black or African American
American Indian or Alaska
Native – Print name of enrolled
or principal tribe.
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race below.
Some other race – Print race below.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race below.
Some other race – Print race below.
Person 9
Person 10
Person 11
Person 12
Last Name (Please print)
Last Name (Please print)
Last Name (Please print)
Last Name (Please print)
First Name
First Name
MI
MI
First Name
MI
First Name
➜ When you are finished, turn the page and continue with the Housing section.
ACS-1(2005), Page 3, Base (Black)
MI
3
ACS-1(2005), Page 3, GREEN Pantone 354 (10%, 20% and 100%)
Housing information helps your community
plan for police and fire protection.
Housing
➜
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
Answer questions 4–6 ONLY if this is a
one-family house or a mobile home;
otherwise, SKIP to question 7.
8
How many bedrooms are in this house,
apartment, or mobile home; that is, how
many bedrooms would you list if this
house, apartment, or mobile home were
on the market for sale or rent?
No bedroom
1
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
4
2
5
IN THE PAST 12 MONTHS, what were
the actual sales of all agricultural
products from this property?
None
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more
3 bedrooms
4 bedrooms
5 or more bedrooms
9
When did PERSON 1 (listed in the List
of Residents on page 2) move into this
house, apartment, or mobile home?
Month
Year
6
10
Is there a business (such as a store or
barber shop) or a medical office on
this property?
Yes
No
7
room
rooms
rooms
rooms
rooms
rooms
rooms
rooms
or more rooms
Does this house, apartment, or mobile
home have COMPLETE kitchen facilities;
that is, 1) a sink with piped water, 2) a
stove or range, and 3) a refrigerator?
Yes, has all three facilities
No
11
How many rooms are in this house,
apartment, or mobile home? Do NOT count
bathrooms, porches, balconies, foyers, halls, or
half-rooms.
1
2
3
4
5
6
7
8
9
Does this house, apartment, or mobile
home have COMPLETE plumbing facilities;
that is, 1) hot and cold piped water, 2) a
flush toilet, and 3) a bathtub or shower?
Yes, has all three facilities
No
About when was this building first built?
2005 or later
2000 to 2004
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
3
2 bedrooms
Less than 1 acre → SKIP to question 6
1 to 9.9 acres
10 or more acres
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.
1 bedroom
How many acres is this house or
mobile home on?
Is there telephone service available in this
house, apartment, or mobile home from
which you can both make and receive
calls?
Yes
No
12
How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
None
1
2
3
4
5
6 or more
4
ACS-1(2005), Page 4, Base (Black)
ACS-1(2005), Page 4, GREEN Pantone 354 (10%, 20%, and 100%)
Housing (continued)
13
Which FUEL is used MOST for heating this
house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
No fuel used
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.
$
.00
Monthly amount – Dollars
Yes → What was the value of the
Food Stamps received
during the past 12 months?
Past 12 months’ value – Dollars
$
OR
16
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.
Last month’s cost – Dollars
.00
OR
Monthly amount – Dollars
Included in rent or condominium fee
Included in electricity payment
entered above
No charge or gas not used
$
.00
OR
None
No
Past 12 months’ cost – Dollars
$
.00
OR
Included in rent or condominium fee
No charge
Yes
No
C
.00
Is this house, apartment, or mobile home
part of a condominium?
17
Is this house, apartment, or mobile
home –
Owned by you or someone in this
household with a mortgage or
loan?
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented for cash rent?
Occupied without payment of cash
rent? → SKIP to C
.00
b. Does the monthly rent include any
meals?
No
Included in rent or condominium fee
No charge or electricity not used
c. IN THE PAST 12 MONTHS, what was the
cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
$
At any time DURING THE PAST
12 MONTHS, did anyone in this
household receive Food Stamps?
.00
$
a. What is the monthly rent for this
house, apartment, or mobile home?
Included in rent or condominium fee
No charge or these fuels not used
Last month’s cost – Dollars
b. LAST MONTH, what was the cost of
gas for this house, apartment, or
mobile home?
18
OR
a. LAST MONTH, what was the cost of
electricity for this house,
apartment, or mobile home?
$
Answer questions 18a and b ONLY IF you
PAY RENT for this house, apartment,
or mobile home. Otherwise, SKIP to
question 19.
Past 12 months’ cost – Dollars
15
14
B
19
Answer questions 19–23 ONLY IF you or
someone else in this household OWNS or
IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E on
the next page.
What is the value of this property; that
is, how much do you think this house
and lot, apartment, or mobile home and
lot, would sell for if it were for sale?
Less than $10,000
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 to $199,999
$200,000 to $249,999
$250,000 or more – Specify
$
.00
5
ACS-1(2005), Page 5, Base (Black)
ACS-1(2005), Page 5, GREEN Pantone 354 (10%, 20%, and 100%)
Housing (continued)
20
What are the annual real estate taxes on
THIS property?
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
Annual amount – Dollars
$
.00
Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance
OR
None
21
What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
23
Annual amount – Dollars
$
25
a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?
None
Answer questions 25a–c ONLY IF you
listed at least one person on page 2.
Otherwise, SKIP to page 24 for the
mailing instructions.
a. Do you or any member of this
household live or stay at this address
year round?
Yes → SKIP to the questions for Person 1
on the next page
No
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home
equity loan
No → SKIP to D
.00
OR
22
E
b. How many months a year do members
of this household stay at this address?
Months
a. Do you or any member of this
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
No → SKIP to question 23a
Monthly amount – Dollars
$
c. What is the main reason members of this
household are staying at this address?
.00
This is their permanent address
This is their seasonal or vacation address
To be close to work
To attend school or college
Looking for permanent housing
Other reason(s)– Specify
OR
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
No regular payment required
Monthly amount – Dollars
.00
$
D
Answer question 24 ONLY IF this is a
MOBILE HOME. Otherwise, SKIP to E .
OR
No regular payment required → SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes not
required
➜
24
What are the total annual costs for
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
Continue with the questions about
PERSON 1 on the next page.
Annual costs – Dollars
$
.00
6
ACS-1(2005), Page 6, Base (Black)
ACS-1(2005), Page 6, GREEN Pantone 354 (10%, 20%, and 100%)
Your answers are important! Every person
in the American Community Survey counts.
Person 1
➜
11
Please copy the name of Person 1 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
14
Person is under 1 year old → SKIP to the
questions for Person 2 on page 10.
Yes, this house → SKIP to F
No schooling completed
First Name
Nursery school to 4th grade
MI
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F
5th grade or 6th grade
7th grade or 8th grade
7
a. Did this person live in this house or
apartment 1 year ago?
9th grade
Where was this person born?
In the United States – Print name of state.
10th grade
No, different house in the United States
11th grade
12th grade – NO DIPLOMA
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Name of city, town, or post office
Some college credit, but less than 1 year
1 or more years of college, no degree
8
Associate degree (for example: AA, AS)
Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Bachelor’s degree (for example: BA, AB, BS)
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Yes, born abroad of American parent or parents
Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Yes, U.S. citizen by naturalization
10
When did this person come to live in the
United States? Print numbers in boxes.
Year
12
Name of county
Name of state
13
ZIP Code
F
Answer questions 15 and 16 ONLY IF this person
is 5 years old or over. Otherwise, SKIP to the
questions for PERSON 2 on page 10.
15
Does this person have any of the following
long-lasting conditions:
a. Does this person speak a language other
than English at home?
Yes, public school, public college
Yes
Yes, private school, private college
No → SKIP to question 14
b. What grade or level was this person
attending? Mark (X) ONE box.
No, outside the city/town limits
What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes
Doctorate degree (for example: PhD, EdD)
No, not a citizen of the United States
9
c. Did this person live inside the limits of the
city or town?
a. Blindness, deafness, or a severe
vision or hearing impairment?
Yes
No
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?
b. What is this language?
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
For example: Korean, Italian, Spanish, Vietnamese 16
c. How well does this person speak English?
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Very well
Well
Not well
Not at all
a. Learning, remembering, or
concentrating?
Yes
No
b. Dressing, bathing, or getting around
inside the home?
7
ACS-1(2005), Page 7, Base (Black)
ACS-1(2005), Page 7, GREEN Pantone 354 (10%, 20%, and 100%)
Person 1 (continued)
G
Answer question 17 ONLY IF this person is
15 years old or over. Otherwise, SKIP to the
questions for PERSON 2 on page 10.
17
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Going outside the home alone to
shop or visit a doctor’s office?
Yes
21
When did this person serve on active duty in
the U.S. Armed Forces? Mark (X) a box for EACH
period in which this person served, even if just for
part of the period.
25 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X) the
box of the one used for most of the distance.
September 2001 or later
Car, truck, or van
Motorcycle
August 1990 to August 2001 (including
Persian Gulf War)
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at home →
SKIP to question 33
Ferryboat
Other method
September 1980 to July 1990
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
b. Working at a job or business?
Taxicab
February 1955 to February 1961
H
Korean War (July 1950 to January 1955)
Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.
January 1947 to June 1950
I
World War II (December 1941 to December 1946)
Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.
November 1941 or earlier
18
Has this person given birth to any children in
the past 12 months?
22
Yes
a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
23
No → SKIP to question 20
b. Is this grandparent currently responsible for
most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
No → SKIP to question 20
c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
Person(s)
LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.
24
At what location did this person work LAST WEEK?
If this person worked at more than one location, print
where he or she worked most last week.
6 to 11 months
b. Name of city, town, or post office
a.m.
p.m.
28 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
J
Answer questions 29–32 ONLY IF this person
did NOT work last week. Otherwise, SKIP to
question 33.
a job?
c. Is the work location inside the limits of that
city or town?
Yes
d. Name of county
f. ZIP Code
No
Yes, on vacation, temporary illness, labor
dispute, etc. → SKIP to question 32
No → SKIP to question 30
e. Name of U.S. state or foreign country
Yes, on active duty in the past, but not
during the last 12 months
Yes → SKIP to question 29c
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No, outside the city/town limits
Yes, now on active duty
No, training for Reserves or National Guard
only → SKIP to question 23
No, never served in the military → SKIP to
question 23
Minute
.
.
29 a. LAST WEEK, was this person on layoff from
3 or 4 years
Yes, on active duty during
the last 12 months, but not now
Hour
a. Address (Number and street name)
Less than 6 months
Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
go to work LAST WEEK?
No → SKIP to question 29
1 or 2 years
20
27 What time did this person usually leave home to
Yes
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
5 or more years
usually rode to work in the car, truck, or van
LAST WEEK?
2 years or more
Yes
Yes
26 How many people, including this person,
Less than 2 years
No
19
In total, how many years of active-duty
military service has this person had?
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes → SKIP to question 31
No
8
ACS-1(2005), Page 8, Base (Black)
ACS-1(2005), Page 8, GREEN Pantone 354 (10%, 20%, and 100%)
Person 1 (continued)
30
Has this person been looking for work during
the last 4 weeks?
36
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
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.
Yes
No → SKIP to question 32
Yes →
Name of company, business, or other employer
31
LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
32
No
37
Yes →
No
Within the past 12 months
38
Over 5 years ago or never worked → SKIP to
question 41
33
Weeks
34
K
Answer questions 35–40 ONLY IF this person
worked in the past 5 years. Otherwise, SKIP
to question 41.
35–40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
week, give information for his/her last job or business.
35
Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
wholesale trade?
Yes →
retail trade?
No
other (agriculture, construction, service,
government, etc.)?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
.00
Loss
$
.00
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).
39
What kind of work was this person doing? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
Yes →
No
40
41
What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes →
No
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
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes →
No
42
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
No
$
.00
TOTAL AMOUNT for past
12 MONTHS
$
.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.
Mark (X) the "No" box to show types of income
NOT received.
$
.00
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
INCOME IN THE PAST 12 MONTHS.
Yes →
$
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
.00
$
.00
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
$
TOTAL AMOUNT for past
12 MONTHS
d. Social Security or Railroad Retirement.
During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Loss
Is this mainly – Mark (X) one box.
manufacturing?
During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
.00
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
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)
When did this person last work, even for a
few days?
1 to 5 years ago → SKIP to question 35
$
TOTAL AMOUNT for past
12 MONTHS
None OR
$
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
TOTAL AMOUNT for past
12 MONTHS
➜
Continue with the questions for Person 2 on the
next page. If only 1 person is listed in the List of
Residents, SKIP to page 24 for mailing instructions.
9
ACS-1(2005), Page 9, Base (Black)
ACS-1(2005), Page 9, GREEN Pantone 354 (10%, 20%, and 100%)
Survey information helps your community
get financial assistance for roads, hospitals,
schools, and more.
Person 2
➜
11
Please copy the name of Person 2 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
14
Person is under 1 year old → SKIP to the
questions for Person 3 on page 13.
Yes, this house → SKIP to F
No schooling completed
First Name
Nursery school to 4th grade
MI
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F
5th grade or 6th grade
7
7th grade or 8th grade
9th grade
Where was this person born?
In the United States – Print name of state.
a. Did this person live in this house or
apartment 1 year ago?
10th grade
No, different house in the United States
11th grade
12th grade – NO DIPLOMA
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Name of city, town, or post office
Some college credit, but less than 1 year
1 or more years of college, no degree
8
Associate degree (for example: AA, AS)
Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Bachelor’s degree (for example: BA, AB, BS)
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Yes, born abroad of American parent or parents
Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Yes, U.S. citizen by naturalization
10
When did this person come to live in the
United States? Print numbers in boxes.
Year
12
13
Name of county
Name of state
Yes
Yes, private school, private college
No → SKIP to question 14
ZIP Code
F
Answer questions 15 and 16 ONLY IF this person
is 5 years old or over. Otherwise, SKIP to the
questions for PERSON 3 on page 13.
15
Does this person have any of the following
long-lasting conditions:
a. Does this person speak a language other
than English at home?
Yes, public school, public college
b. What grade or level was this person
attending? Mark (X) ONE box.
No, outside the city/town limits
What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes
Doctorate degree (for example: PhD, EdD)
No, not a citizen of the United States
9
c. Did this person live inside the limits of the
city or town?
a. Blindness, deafness, or a severe
vision or hearing impairment?
Yes
No
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?
b. What is this language?
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all
16
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Learning, remembering, or
concentrating?
Yes
No
b. Dressing, bathing, or getting around
inside the home?
10
ACS-1(2003), Page 10, Base (Black)
ACS-1(2003), Page 10, GReen Pantone 354 (10%, 20%, and 100% tone)
Person 2 (continued)
G
Answer question 17 ONLY IF this person is
15 years old or over. Otherwise, SKIP to the
questions for PERSON 3 on page 13.
17
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Going outside the home alone to
shop or visit a doctor’s office?
Yes
21
When did this person serve on active duty in
the U.S. Armed Forces? Mark (X) a box for EACH
period in which this person served, even if just for
part of the period.
25 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X) the
box of the one used for most of the distance.
September 2001 or later
Car, truck, or van
Motorcycle
August 1990 to August 2001 (including
Persian Gulf War)
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at home →
SKIP to question 33
Ferryboat
Other method
September 1980 to July 1990
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
b. Working at a job or business?
Taxicab
February 1955 to February 1961
H
Korean War (July 1950 to January 1955)
Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.
January 1947 to June 1950
I
World War II (December 1941 to December 1946)
Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.
November 1941 or earlier
18
Has this person given birth to any children in
the past 12 months?
22
Yes
a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
23
No → SKIP to question 20
b. Is this grandparent currently responsible for
most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
No → SKIP to question 20
c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
Person(s)
LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.
24
At what location did this person work LAST WEEK?
If this person worked at more than one location, print
where he or she worked most last week.
6 to 11 months
b. Name of city, town, or post office
a.m.
p.m.
28 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
J
Answer questions 29–32 ONLY IF this person
did NOT work last week. Otherwise, SKIP to
question 33.
a job?
c. Is the work location inside the limits of that
city or town?
Yes
d. Name of county
f. ZIP Code
No
Yes, on vacation, temporary illness, labor
dispute, etc. → SKIP to question 32
No → SKIP to question 30
e. Name of U.S. state or foreign country
Yes, on active duty in the past, but not
during the last 12 months
Yes → SKIP to question 29c
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No, outside the city/town limits
Yes, now on active duty
No, training for Reserves or National Guard
only → SKIP to question 23
No, never served in the military → SKIP to
question 23
Minute
.
.
29 a. LAST WEEK, was this person on layoff from
3 or 4 years
Yes, on active duty during
the last 12 months, but not now
Hour
a. Address (Number and street name)
Less than 6 months
Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
go to work LAST WEEK?
No → SKIP to question 29
1 or 2 years
20
27 What time did this person usually leave home to
Yes
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
5 or more years
usually rode to work in the car, truck, or van
LAST WEEK?
2 years or more
Yes
Yes
26 How many people, including this person,
Less than 2 years
No
19
In total, how many years of active-duty
military service has this person had?
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes → SKIP to question 31
No
11
ACS-1(2005), Page 11, Base (Black)
ACS-1(2005), Page 11, GREEN Pantone 354 (10%, 20%, and 100%)
Person 2 (continued)
30
Has this person been looking for work during
the last 4 weeks?
36
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
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.
Yes
No → SKIP to question 32
Yes →
Name of company, business, or other employer
31
LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
32
No
37
Yes →
No
Within the past 12 months
38
Over 5 years ago or never worked → SKIP to
question 41
33
Weeks
34
K
Answer questions 35–40 ONLY IF this person
worked in the past 5 years. Otherwise, SKIP
to question 41.
35–40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
week, give information for his/her last job or business.
35
Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
wholesale trade?
Yes →
retail trade?
No
other (agriculture, construction, service,
government, etc.)?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
$
.00
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).
39
What kind of work was this person doing? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
Yes →
No
40
41
Yes →
No
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
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes →
No
42
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
No
$
.00
TOTAL AMOUNT for past
12 MONTHS
$
.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.
Mark (X) the "No" box to show types of income
NOT received.
$
.00
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
INCOME IN THE PAST 12 MONTHS.
Yes →
$
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
.00
$
.00
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
$
d. Social Security or Railroad Retirement.
During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Loss
Is this mainly – Mark (X) one box.
manufacturing?
During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
.00
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
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)
When did this person last work, even for a
few days?
1 to 5 years ago → SKIP to question 35
$
TOTAL AMOUNT for past
12 MONTHS
None OR
$
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
TOTAL AMOUNT for past
12 MONTHS
➜
Continue with the questions for Person 3 on the
next page. If only 2 people are listed in the List of
Residents, SKIP to page 24 for mailing instructions.
12
ACS-1(2005), Page 12, Base (Black)
ACS-1(2005), Page 12, GREEN Pantone 354 (10%, 20%, and 100%)
Information about children helps
your community plan for child care,
education, and recreation.
Person 3
➜
11
Please copy the name of Person 3 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
14
Person is under 1 year old → SKIP to the
questions for Person 4 on page 16.
Yes, this house → SKIP to F
No schooling completed
First Name
Nursery school to 4th grade
MI
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F
5th grade or 6th grade
7th grade or 8th grade
7
a. Did this person live in this house or
apartment 1 year ago?
9th grade
Where was this person born?
In the United States – Print name of state.
10th grade
No, different house in the United States
11th grade
12th grade – NO DIPLOMA
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Name of city, town, or post office
Some college credit, but less than 1 year
1 or more years of college, no degree
8
Associate degree (for example: AA, AS)
Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Bachelor’s degree (for example: BA, AB, BS)
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Yes, born abroad of American parent or parents
Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Yes, U.S. citizen by naturalization
10
When did this person come to live in the
United States? Print numbers in boxes.
Year
12
13
Name of county
Name of state
Yes
Yes, private school, private college
No → SKIP to question 14
ZIP Code
F
Answer questions 15 and 16 ONLY IF this person
is 5 years old or over. Otherwise, SKIP to the
questions for PERSON 4 on page 16.
15
Does this person have any of the following
long-lasting conditions:
a. Does this person speak a language other
than English at home?
Yes, public school, public college
b. What grade or level was this person
attending? Mark (X) ONE box.
No, outside the city/town limits
What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes
Doctorate degree (for example: PhD, EdD)
No, not a citizen of the United States
9
c. Did this person live inside the limits of the
city or town?
a. Blindness, deafness, or a severe
vision or hearing impairment?
Yes
No
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?
b. What is this language?
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all
16
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Learning, remembering, or
concentrating?
Yes
No
b. Dressing, bathing, or getting around
inside the home?
13
ACS-1(2005), Page 13, Base (Black)
ACS-1(2005), Page 13, GREEN Pantone 354 (10%, 20%, and 100%)
Person 3 (continued)
G
Answer question 17 ONLY IF this person is
15 years old or over. Otherwise, SKIP to the
questions for PERSON 4 on page 16.
17
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Going outside the home alone to
shop or visit a doctor’s office?
Yes
21
When did this person serve on active duty in
the U.S. Armed Forces? Mark (X) a box for EACH
period in which this person served, even if just for
part of the period.
25
September 2001 or later
Car, truck, or van
Motorcycle
August 1990 to August 2001 (including
Persian Gulf War)
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at home →
SKIP to question 33
Ferryboat
Other method
September 1980 to July 1990
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
b. Working at a job or business?
Taxicab
February 1955 to February 1961
H
Korean War (July 1950 to January 1955)
Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.
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.
January 1947 to June 1950
I
World War II (December 1941 to December 1946)
Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.
November 1941 or earlier
18
Has this person given birth to any children in
the past 12 months?
22
Yes
a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
23
No → SKIP to question 20
b. Is this grandparent currently responsible for
most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
No → SKIP to question 20
c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.
28
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.
Less than 6 months
6 to 11 months
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
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 23
No, never served in the military → SKIP to
question 23
p.m.
How many minutes did it usually take this
person to get from home to work LAST WEEK?
J
f. ZIP Code
Answer questions 29–32 ONLY IF this person
did NOT work last week. Otherwise, SKIP to
question 33.
a. LAST WEEK, was this person on layoff from
a job?
Yes → SKIP to question 29c
No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, labor
dispute, etc. → SKIP to question 32
No → SKIP to question 30
Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
a.m.
Minutes
29
3 or 4 years
Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
Minute
.
.
a. Address (Number and street name)
1 or 2 years
20
What time did this person usually leave home to
go to work LAST WEEK?
Hour
No → SKIP to question 29
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
5 or more years
27
Yes
24
How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
2 years or more
Yes
Yes
26
Less than 2 years
No
19
In total, how many years of active-duty
military service has this person had?
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes → SKIP to question 31
No
14
ACS-1(2003), Page 14, Base (Black)
ACS-1(2003), Page 14, GREEN Pantone 354 (10%, 20%, and 100%)
Person 3 (continued)
30
Has this person been looking for work during
the last 4 weeks?
36
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
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.
Yes
No → SKIP to question 32
Yes →
Name of company, business, or other employer
31
LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
32
No
37
Yes →
No
Within the past 12 months
38
Over 5 years ago or never worked → SKIP to
question 41
33
Weeks
34
K
Answer questions 35–40 ONLY IF this person
worked in the past 5 years. Otherwise, SKIP
to question 41.
35–40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
week, give information for his/her last job or business.
35
Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
wholesale trade?
Yes →
retail trade?
No
other (agriculture, construction, service,
government, etc.)?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
.00
Loss
$
.00
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).
39
What kind of work was this person doing? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
Yes →
No
40
41
What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes →
No
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
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes →
No
42
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
No
$
.00
TOTAL AMOUNT for past
12 MONTHS
$
.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.
Mark (X) the "No" box to show types of income
NOT received.
$
.00
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
INCOME IN THE PAST 12 MONTHS.
Yes →
$
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
.00
$
.00
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
$
TOTAL AMOUNT for past
12 MONTHS
d. Social Security or Railroad Retirement.
During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Loss
Is this mainly – Mark (X) one box.
manufacturing?
During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
.00
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
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)
When did this person last work, even for a
few days?
1 to 5 years ago → SKIP to question 35
$
TOTAL AMOUNT for past
12 MONTHS
None OR
$
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
TOTAL AMOUNT for past
12 MONTHS
➜
Continue with the questions for Person 4 on the
next page. If only 3 people are listed in the List of
Residents, SKIP to page 24 for mailing instructions.
15
ACS-1(2003), Page 15, Base (Black)
ACS-1(2003), Page 15, GREEN Pantone 354 (10%, 20%, and 100%)
Knowing about age, race, and sex helps your
community better meet the needs of everyone.
Person 4
➜
11
Please copy the name of Person 4 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
14
Person is under 1 year old → SKIP to the
questions for Person 5 on page 19.
Yes, this house → SKIP to F
No schooling completed
First Name
Nursery school to 4th grade
MI
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F
5th grade or 6th grade
7th grade or 8th grade
7
a. Did this person live in this house or
apartment 1 year ago?
9th grade
Where was this person born?
In the United States – Print name of state.
10th grade
No, different house in the United States
11th grade
12th grade – NO DIPLOMA
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Name of city, town, or post office
Some college credit, but less than 1 year
1 or more years of college, no degree
8
Associate degree (for example: AA, AS)
Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Bachelor’s degree (for example: BA, AB, BS)
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Yes, born abroad of American parent or parents
Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Yes, U.S. citizen by naturalization
10
When did this person come to live in the
United States? Print numbers in boxes.
Year
12
13
Name of county
Name of state
Yes
Yes, private school, private college
No → SKIP to question 14
ZIP Code
F
Answer questions 15 and 16 ONLY IF this person
is 5 years old or over. Otherwise, SKIP to the
questions for PERSON 5 on page 19.
15
Does this person have any of the following
long-lasting conditions:
a. Does this person speak a language other
than English at home?
Yes, public school, public college
b. What grade or level was this person
attending? Mark (X) ONE box.
No, outside the city/town limits
What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes
Doctorate degree (for example: PhD, EdD)
No, not a citizen of the United States
9
c. Did this person live inside the limits of the
city or town?
a. Blindness, deafness, or a severe
vision or hearing impairment?
Yes
No
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?
b. What is this language?
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all
16
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Learning, remembering, or
concentrating?
Yes
No
b. Dressing, bathing, or getting around
inside the home?
16
ACS-1(2003), Page 16, Base (Black)
ACS-1(2003), Page 16, GREEN Pantone 354 (10%, 20%, and 100%)
Person 4 (continued)
G
Answer question 17 ONLY IF this person is
15 years old or over. Otherwise, SKIP to the
questions for PERSON 5 on page 19.
17
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Going outside the home alone to
shop or visit a doctor’s office?
Yes
21
No
b. Working at a job or business?
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.
25
How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X) the
box of the one used for most of the distance.
September 2001 or later
Car, truck, or van
Motorcycle
August 1990 to August 2001 (including
Persian Gulf War)
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
September 1980 to July 1990
Subway or elevated
May 1975 to August 1980
Railroad
Worked at home →
SKIP to question 33
Vietnam era (August 1964 to April 1975)
Ferryboat
Other method
March 1961 to July 1964
Taxicab
February 1955 to February 1961
H
Korean War (July 1950 to January 1955)
Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.
I
January 1947 to June 1950
World War II (December 1941 to December 1946)
Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.
November 1941 or earlier
18
Has this person given birth to any children in
the past 12 months?
22
Yes
a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
23
No → SKIP to question 20
b. Is this grandparent currently responsible for
most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
No → SKIP to question 20
c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if 27
the person worked only 1 hour, or helped without
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.
Yes
No → SKIP to question 29
28
24
At what location did this person work LAST WEEK?
If this person worked at more than one location, print
where he or she worked most last week.
Less than 6 months
6 to 11 months
b. Name of city, town, or post office
1 or 2 years
Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
c. Is the work location inside the limits of that
city or town?
Yes
d. Name of county
a.m.
p.m.
How many minutes did it usually take this
person to get from home to work LAST WEEK?
J
f. ZIP Code
Answer questions 29–32 ONLY IF this person
did NOT work last week. Otherwise, SKIP to
question 33.
a. LAST WEEK, was this person on layoff from
a job?
Yes → SKIP to question 29c
No
Yes, on vacation, temporary illness, labor
dispute, etc. → SKIP to question 32
No → SKIP to question 30
e. Name of U.S. state or foreign country
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 23
No, never served in the military → SKIP to
question 23
Minute
.
.
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No, outside the city/town limits
Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Hour
Minutes
29
3 or 4 years
20
What time did this person usually leave home to
go to work LAST WEEK?
a. Address (Number and street name)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
5 or more years
How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
2 years or more
Yes
Yes
26
Less than 2 years
No
19
In total, how many years of active-duty
military service has this person had?
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes → SKIP to question 31
No
17
ACS-1(2003), Page 17, Base (Black)
ACS-1(2003), Page 17, GREEn Pantone 354 (10%, 20%, and 100%)
Person 4 (continued)
30
Has this person been looking for work during
the last 4 weeks?
36
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
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.
Yes
No → SKIP to question 32
Yes →
Name of company, business, or other employer
31
LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
32
No
37
Yes →
No
Within the past 12 months
38
Over 5 years ago or never worked → SKIP to
question 41
33
Weeks
34
K
Answer questions 35–40 ONLY IF this person
worked in the past 5 years. Otherwise, SKIP
to question 41.
35–40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
week, give information for his/her last job or business.
35
Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
wholesale trade?
Yes →
retail trade?
No
other (agriculture, construction, service,
government, etc.)?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
$
.00
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).
39
What kind of work was this person doing? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
Yes →
No
40
41
Yes →
No
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
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes →
No
42
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
No
$
.00
TOTAL AMOUNT for past
12 MONTHS
$
.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.
Mark (X) the "No" box to show types of income
NOT received.
$
.00
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
INCOME IN THE PAST 12 MONTHS.
Yes →
$
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
.00
$
.00
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
$
d. Social Security or Railroad Retirement.
During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Loss
Is this mainly – Mark (X) one box.
manufacturing?
During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
.00
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
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)
When did this person last work, even for a
few days?
1 to 5 years ago → SKIP to question 35
$
TOTAL AMOUNT for past
12 MONTHS
None OR
$
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
TOTAL AMOUNT for past
12 MONTHS
➜
Continue with the questions for Person 5 on the
next page. If only 4 people are listed in the List of
Residents, SKIP to page 24 for mailing instructions.
18
ACS-1(2003), Page 18, Base (Black)
ACS-1(2003), Page 18, GREEN Pantone 354 (10%, 20%, and 100%)
Your answers help your
community plan for the future.
Person 5
➜
11
Please copy the name of Person 5 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
14
Person is under 1 year old → SKIP to the
mailing instructions on page 24.
Yes, this house → SKIP to F
No schooling completed
First Name
Nursery school to 4th grade
MI
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F
5th grade or 6th grade
7th grade or 8th grade
7
a. Did this person live in this house or
apartment 1 year ago?
9th grade
Where was this person born?
In the United States – Print name of state.
10th grade
No, different house in the United States
11th grade
12th grade – NO DIPLOMA
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Name of city, town, or post office
Some college credit, but less than 1 year
1 or more years of college, no degree
8
Associate degree (for example: AA, AS)
Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Bachelor’s degree (for example: BA, AB, BS)
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Yes, born abroad of American parent or parents
Professional degree (for example: MD, DDS, DVM,
LLB, JD)
Yes, U.S. citizen by naturalization
10
When did this person come to live in the
United States? Print numbers in boxes.
Year
12
13
Name of county
Name of state
Yes
Yes, private school, private college
No → SKIP to question 14
ZIP Code
F
Answer questions 15 and 16 ONLY IF this person
is 5 years old or over. Otherwise, SKIP to the
mailing instructions on page 24.
15
Does this person have any of the following
long-lasting conditions:
a. Does this person speak a language other
than English at home?
Yes, public school, public college
b. What grade or level was this person
attending? Mark (X) ONE box.
No, outside the city/town limits
What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes
Doctorate degree (for example: PhD, EdD)
No, not a citizen of the United States
9
c. Did this person live inside the limits of the
city or town?
a. Blindness, deafness, or a severe
vision or hearing impairment?
Yes
No
b. A condition that substantially limits
one or more basic physical activities
such as walking, climbing stairs,
reaching, lifting, or carrying?
b. What is this language?
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all
16
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Learning, remembering, or
concentrating?
Yes
No
b. Dressing, bathing, or getting around
inside the home?
19
ACS-1(2003), Page 19, Base (Black)
ACS-1(2003), Page 19, GREEN Pantone 354 (10%, 20% and 100%)
Person 5 (continued)
G
Answer question 17 ONLY IF this person is
15 years old or over. Otherwise, SKIP to the
mailing instructions on page 24.
17
Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
a. Going outside the home alone to
shop or visit a doctor’s office?
Yes
21
When did this person serve on active duty in
the U.S. Armed Forces? Mark (X) a box for EACH
period in which this person served, even if just for
part of the period.
25
September 2001 or later
Car, truck, or van
Motorcycle
August 1990 to August 2001 (including
Persian Gulf War)
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at home →
SKIP to question 33
Ferryboat
Other method
September 1980 to July 1990
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
b. Working at a job or business?
Taxicab
February 1955 to February 1961
H
Korean War (July 1950 to January 1955)
Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.
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.
January 1947 to June 1950
I
World War II (December 1941 to December 1946)
Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.
November 1941 or earlier
18
Has this person given birth to any children in
the past 12 months?
22
Yes
a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
23
No → SKIP to question 20
b. Is this grandparent currently responsible for
most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
No → SKIP to question 20
c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
pay in a family business or farm for 15 hours or more,
or was on active duty in the Armed Forces.
28
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.
Less than 6 months
6 to 11 months
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
Yes
d. Name of county
How many minutes did it usually take this
person to get from home to work LAST WEEK?
J
f. ZIP Code
Answer questions 29–32 ONLY IF this person
did NOT work last week. Otherwise, SKIP to
question 33.
a. LAST WEEK, was this person on layoff from
a job?
Yes → SKIP to question 29c
No
Yes, on vacation, temporary illness, labor
dispute, etc. → SKIP to question 32
No → SKIP to question 30
e. Name of U.S. state or foreign country
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 23
No, never served in the military → SKIP to
question 23
p.m.
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No, outside the city/town limits
Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
a.m.
Minutes
29
3 or 4 years
5 or more years
Minute
.
.
a. Address (Number and street name)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
What time did this person usually leave home to
go to work LAST WEEK?
Hour
No → SKIP to question 29
1 or 2 years
20
27
Yes
24
How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
2 years or more
Yes
Yes
26
Less than 2 years
No
19
In total, how many years of active-duty
military service has this person had?
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes → SKIP to 31
No
20
ACS-1(2003), Page 20, Base (Black)
ACS-1(2003), Page 20, GREEN Pantone 354 (10%, 20% and 100%)
Person 5 (continued)
30
Has this person been looking for work during
the last 4 weeks?
36
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
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.
Yes
No → SKIP to question 32
Yes →
Name of company, business, or other employer
31
LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
32
No
37
Yes →
No
Within the past 12 months
38
Over 5 years ago or never worked → SKIP to
question 41
33
Weeks
34
K
Answer questions 35–40 ONLY IF this person
worked in the past 5 years. Otherwise, SKIP
to question 41.
35–40 CURRENT OR MOST RECENT JOB ACTIVITY.
Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
week, give information for his/her last job or business.
35
Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
wholesale trade?
Yes →
retail trade?
No
other (agriculture, construction, service,
government, etc.)?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
.00
Loss
$
.00
TOTAL AMOUNT for past
12 MONTHS
e. Supplemental Security Income (SSI).
39
What kind of work was this person doing? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
Yes →
No
40
41
What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes →
No
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
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes →
No
42
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.
No
$
.00
TOTAL AMOUNT for past
12 MONTHS
$
.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.
Mark (X) the "No" box to show types of income
NOT received.
$
.00
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
INCOME IN THE PAST 12 MONTHS.
Yes →
$
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
.00
$
.00
TOTAL AMOUNT for past
12 MONTHS
What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
41h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
$
TOTAL AMOUNT for past
12 MONTHS
d. Social Security or Railroad Retirement.
During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Loss
Is this mainly – Mark (X) one box.
manufacturing?
During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
.00
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
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)
When did this person last work, even for a
few days?
1 to 5 years ago → SKIP to question 35
$
TOTAL AMOUNT for past
12 MONTHS
None OR
$
.00
Loss
TOTAL AMOUNT for past
12 MONTHS
TOTAL AMOUNT for past
12 MONTHS
➜
Now continue with the mailing
instructions on page 24.
21
ACS-1(2003), Page 21, Base (Black)
ACS-1(2003), Page 21, Green pantone 354 (10%, 20%, and 100%)
Pages 22 and 23 are intentionally left blank
22
ACS-1(2003), Page 22, Base (Black)
23
ACS-1(2003), Page 23, Base (Black)
Mailing
Instructions
➜ Please make sure you have..
•
put all names on the List of Residents and answered
the questions across the top of the page
•
answered all Housing questions
•
answered all Person questions for each person on the
List of Residents.
➜ Then...
•
put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U. S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
•
make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.
For Census Bureau Use
POP
EDIT CLERK
EDIT
PHONE
JIC1
JIC2
TELEPHONE CLERK
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 38 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810, U.S. Census Bureau,
4700 Silver Hill Road, Stop 1500, Washington, D.C.
20233-1500. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2005) (5-19-2005)
24
ACS-1(2005), Page 24, Base (Black)
ACS-1(2005), Page 24, GREEN Pantone 354 (20% and 100%)
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2005-05-25 |
| File Created | 2005-05-22 |