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pdfPerson 1
Person 2
(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.)
1
What is Person 2’s name?
Last Name (Please print)
2
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
First Name
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
How is this person related to Person 1? Mark (X) ONE box.
Grandchild
Other nonrelative
X Person 1
Parent-in-law
3
2
What is Person 1’s sex? Mark (X) ONE box.
4
2
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)
Month
Day
Year of birth
Male
Female
3
2
What is Person 2’s sex? Mark (X) ONE box.
4
2
What is Person 2’s age and what is Person 2’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)
Month
Day
Year of birth
Male
Female
MI
Person 4
Person 3
1
What is Person 3’s name?
Last Name (Please print)
2
1
First Name
How is this person related to Person 1? Mark (X) ONE box.
MI
What is Person 4’s name?
Last Name (Please print)
2
First Name
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
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
Parent-in-law
3
2
What is Person 3’s sex? Mark (X) ONE box.
4
2
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.
Age (in years)
Month
Day
Year of birth
Male
Female
3
2
What is Person 4’s sex? Mark (X) ONE box.
4
2
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)
Month
Day
Year of birth
Male
Female
MI
Person 5
1
What is Person 5’s name?
Last Name (Please print)
2
First Name
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
Parent-in-law
3
2
What is Person 5’s sex? Mark (X) ONE box.
4
2
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)
Month
Day
Year of birth
Male
Female
MI
Person 1
Person 2
(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.)
20
What is this person’s marital status?
20
What is this person’s marital status?
Now married
Now married
Widowed
Widowed
Divorced
Divorced
Separated
Separated
Never married SKIP to ___
Never married SKIP to ___
| File Type | application/pdf |
| Author | tomasino-Rosales_l |
| File Modified | 2010-01-22 |
| File Created | 2010-01-22 |