ACS-1(X)Seq American Community Survey

13247010

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.
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

USCENSUSBUREAU

ACS-1(X)Seq

FORM
(12-19-2006)

OMB No. 0607-0936
Approval Expires 12/31/2009

§.9g+¤
ACS-1(X)Seq, Page 1, Base (Black)

ACS-1(X)Seq, Page 1, GREEN Pantone 354 (20 and 40%)

13247028

Person 1

Person 2
1

(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)

2
1

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

2

First Name

MI

How is this person related to Person 1?
X Person 1

3

Male

4

3

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

Month

Day

4

Year of birth

5

6

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

Parent-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

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

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.
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.

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

6

What is Person 2’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

MI

Husband or wife

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.

First Name

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

Male

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)

What is Person 2’s name?

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

Some other race – Print race.

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ACS-1(X)Seq, Page 2, Base (Black)

ACS-1(X)Seq, Page 2, GREEN Pantone 354 (20 and 40%)

13247036

Person 3
1

1

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

2

3

First Name

MI

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

Last Name (Please print)

2

MI

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

Parent-in-law

Husband or wife

Parent-in-law

Son-in-law or daughter-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Adopted son or daughter

Other relative

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Father or mother

Unmarried partner

Grandchild

Other nonrelative

Grandchild

Other nonrelative

3

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

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

4

Year of birth

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

Female

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

First Name

Biological son or daughter

Age (in years)

5

What is Person 4’s name?

Husband or wife

Male

4

Person 4

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?

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.

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

6

What is Person 4’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.

§.9gE¤
ACS-1(X)Seq, Page 3, Base (Black)

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

Some other race – Print race.

3
ACS-1(X)Seq, Page 3, GREEN Pantone 354 (20 and 40%)

13247044

Person 5
1

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

2

3

First Name

MI

Husband or wife

Parent-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Grandchild

Other nonrelative

Person 6
Last Name (Please print)

First Name

Sex

Age (in years)

MI

Male

Female

Person 7
Last Name (Please print)

First Name

Sex

Age (in years)

MI

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

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

Male

Female

Person 8
Last Name (Please print)

First Name

Sex

Age (in years)

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

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.

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

Male

4

➜

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

Male

Female

Person 9
Last Name (Please print)

First Name

Sex

Age (in years)

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.

6

Male

Female

Person 10
Last Name (Please print)

First Name

Sex

Age (in years)

MI

What is Person 5’s race? Mark (X) one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.

Male

Female

Person 11
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.

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

Last Name (Please print)

First Name

Sex

Age (in years)

Male

Female

MI

Person 12
Last Name (Please print)

First Name

Sex

Age (in years)

MI

Some other race – Print race.

4

Male

Female

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13247051

Housing
➜

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

1

Which best describes this building?
Include all apartments, flats, etc., even if
vacant.

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

A

Answer questions 4–6 ONLY if this is a
one-family house or a mobile home;
otherwise, SKIP to question 7.

4

How many acres is this house or
mobile home on?

2

IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
None
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more

9

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

Year

§.9gT¤
ACS-1(X)Seq, Page 5, Base (Black)

6

Does this house, apartment, or mobile
home have COMPLETE plumbing facilities;
that is, 1) hot and cold piped water, 2) a
flush toilet, and 3) a bathtub or shower?
Yes, has all three facilities
No

10

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

3

5

How many bedrooms are in this house,
apartment, or mobile home; that is, how
many bedrooms would you list if this
house, apartment, or mobile home were
on the market for sale or rent?
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 or more bedrooms

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

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

8

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

Does this house, apartment, or mobile
home have COMPLETE kitchen facilities;
that is, 1) a sink with piped water, 2) a
stove or range, and 3) a refrigerator?
Yes, has all three facilities
No

Yes
No

11
7

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

room
rooms
rooms
rooms
rooms
rooms
rooms
rooms
or more rooms

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

5
ACS-1(X)Seq, Page 5, GREEN Pantone 354 (10, 20, 40, and 50%)

13247069

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

d. IN THE PAST 12 MONTHS, what was the
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
home? If you have lived here less than 12
months, estimate the cost.
Past 12 months’ cost – Dollars

house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
No fuel used

$

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

Monthly amount – Dollars

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

14 a. LAST MONTH, what was the cost

$

house, apartment, or mobile home?

OR

15

$

At any time DURING THE PAST
12 MONTHS, did anyone in this
household receive Food Stamps?

$

OR

Yes
No

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

C

.00

,

.00

,

b. Does the monthly rent include any
meals?

Yes ➔ What was the value of the
Food Stamps received
during the past 12 months?
Past 12 months’ value – Dollars

.00

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

18 a. What is the monthly rent for this

.00

,

B

Answer questions 19–23 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.

No

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

,

16

Is this house, apartment, or mobile home
part of a condominium?
Yes ➔ What is the monthly condominium
fee? For renters, answer only if you
pay the condominium fee in addition
to your rent; otherwise, mark the
"None" box.
Monthly amount – Dollars

.00

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

$

,

.00

OR
None

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

,
OR

.00

Included in rent or condominium fee
No charge

6

No

17

Is this house, apartment, or mobile
home –
Owned by you or someone in this
household with a mortgage or
loan?
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented for cash rent?
Occupied without payment of cash
rent? ➔ SKIP to C

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

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ACS-1(X)Seq, Page 6, Base (Black)

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13247077

Housing (continued)
20 What are the annual real estate taxes on

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

THIS property?
Annual amount – Dollars
$

.00

,

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

Yes, insurance included in mortgage
payment

OR

No, insurance paid separately or no
insurance

None

25 a. Do you or any member of this

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

23

Annual amount – Dollars
$

E

.00

,

household live or stay at this address
year round?

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

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

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

OR
None

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

No ➔ SKIP to D

22 a. Do you or any member of this

Months

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

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

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

Monthly amount – Dollars

Yes, mortgage, deed of trust, or similar
debt

$

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

This is their permanent address
This is their seasonal or vacation address
To be close to work
To attend school or college
Looking for permanent housing
Other reason(s) — Specify

.00

,
OR

No regular payment required

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

,

.00

D

Answer question 24 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

§.9gn¤
ACS-1(X)Seq, Page 7, Base (Black)

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

24 What are the total annual costs for
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
Annual costs – Dollars
$

,

.00

7
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13247085

Person 1
➜

11

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

First Name

7

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

MI

Where was this person born?
In the United States – Print name of state.

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

8

Is this person a CITIZEN of the United States?
Yes, born in the United States ➔ SKIP to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

14

person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to
a high school diploma or a college degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)

a. Did this person live in this house or
apartment 1 year ago?
Person is under 1 year old ➔ SKIP to the
questions for Person 2 on page 11.
Yes, this house ➔ SKIP to F
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

No schooling completed
Nursery school to 4th grade
5th grade or 6th grade
7th grade or 8th grade
9th grade
10th grade
11th grade
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, AB, BS)
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)

No, different house in the United States
b. Where did this person live 1 year ago?
Name of city, town, or post office

c. Did this person live inside the limits of the
city or town?
Yes
No, outside the city/town limits

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

Name of county

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

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

10 a. At any time IN THE LAST 3 MONTHS, has this

8

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.

13

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

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 11.

15

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

Yes
No ➔ SKIP to question 14
b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese 16

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

ZIP Code

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

Yes

No

Because of a physical, mental, or emotional
condition lasting 6 months or more, does
this person have any difficulty in doing any
of the following activities:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

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13247093

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 11.

21

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

17 Because of a physical, mental, or emotional

condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?
b. Working at a job or business?

H

Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.

18 Has this person given birth to any children in
the past 12 months?
Yes
No

22

23

Yes
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?
Yes
No ➔ SKIP to question 20

24

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

20 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.

ACS-1(X)Seq, Page 9, Base (Black)

WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab

I

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 33
Other method

Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.

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

LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
27 What time did this person usually leave home
pay in a family business or farm for 15 hours or
to go to work LAST WEEK?
more, or was on active duty in the Armed Forces.
Hour
Minute
Yes
a.m.
No ➔ SKIP to question 29
p.m.
At what location did this person work LAST
28 How many minutes did it usually take this
WEEK? If this person worked at more than one
person to get from home to work LAST WEEK?
location, print where he or she worked most last
week.
Minutes
a. Address (Number and street name)

:

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.

Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 23
No, never served in the military ➔ SKIP to
question 23

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

25 How did this person usually get to work LAST

Less than 2 years
2 years or more

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

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

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.

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office

J

Answer questions 29–32 ONLY IF this
person did NOT work last week. Otherwise,
SKIP to question 33.

29 a. LAST WEEK, was this person on layoff from
a job?
c. Is the work location inside the limits of that
city or town?

Yes ➔ SKIP to question 29c
No

Yes
No, outside the city/town limits
d. Name of county

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

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

f. ZIP Code

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 31
No

9
ACS-1(X)Seq, Page 9, GREEN Pantone 354 (10, 20, 40, and 50%)

13247101

Person 1 (continued)
30 Has this person been looking for work during

36

the last 4 weeks?
Yes
No ➔ SKIP to question 32

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.

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

Name of company, business, or other employer

Yes ➔ $

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

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
37
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

32 When did this person last work, even for a

What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank)

Yes ➔ $

few days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 35
Over 5 years ago or never worked ➔ SKIP to
question 41

38

WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
Weeks

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

40
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
41
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?
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?

10

Loss

Is this mainly – Mark (X) one box.
Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

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

manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

33 During the PAST 12 MONTHS, how many

.00

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

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

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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)

INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

,
No
TOTAL AMOUNT for past
If net income was a loss, mark the "Loss" box to
12 MONTHS
the right of the dollar amount.
42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
For income received jointly, report the appropriate
41h; subtract any losses. If net income was a loss, enter
share for each person – or, if that’s not possible,
the amount and mark (X) the "Loss" box .
report the whole amount for only one person and
mark the "No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.

None OR $
Loss

Yes ➔
No

$

,

.00

TOTAL AMOUNT for past
12 MONTHS

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

Continue with the questions for Person 2 on the
next page. If only 1 person is listed on pages 2, 3,
and 4, SKIP to page 24 for mailing instructions.

§.9h"¤

ACS-1(X)Seq, Page 10, Base (Black)

ACS-1(X)Seq, Page 10, GREEN Pantone 354 (10, 20, 40, and 50%)

13247119

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

Person 2
➜

First Name

7

11

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

MI

Where was this person born?
In the United States – Print name of state.

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

8

Is this person a CITIZEN of the United States?
Yes, born in the United States ➔ SKIP to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE
box. If currently enrolled, mark the previous grade
or highest degree received.

14

Person is under 1 year old ➔ SKIP to the
questions for Person 3 on page 14.
Yes, this house ➔ SKIP to F
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

No schooling completed
Nursery school to 4th grade
5th grade or 6th grade
7th grade or 8th grade
9th grade
10th grade
11th grade
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, AB, BS)
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)

No, different house in the United States
b. Where did this person live 1 year ago?
Name of city, town, or post office

c. Did this person live inside the limits of the
city or town?
Yes
No, outside the city/town limits

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

Name of county

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

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to
a high school diploma or a college degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)

§.9h4¤
ACS-1(X)Seq, Page 11, Base (Black)

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

13

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

F

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 14.

15

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

Yes
No ➔ SKIP to question 14
b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese 16

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

ZIP Code

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

Yes

No

Because of a physical, mental, or emotional
condition lasting 6 months or more, does
this person have any difficulty in doing any
of the following activities:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

11
ACS-1(X)Seq, Page 11, GREEN Pantone 354 (10, 20, 40, and 50%)

13247127

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 14.

21

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

17 Because of a physical, mental, or emotional

condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?
b. Working at a job or business?

H

Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.

18 Has this person given birth to any children in
the past 12 months?
Yes
No

22

23

Yes
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?
Yes
No ➔ SKIP to question 20

24

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

20 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.

12

WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab

I

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 33
Other method

Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.

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

LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
27 What time did this person usually leave home
pay in a family business or farm for 15 hours or
to go to work LAST WEEK?
more, or was on active duty in the Armed Forces.
Hour
Minute
Yes
a.m.
No ➔ SKIP to question 29
p.m.
At what location did this person work LAST
28 How many minutes did it usually take this
WEEK? If this person worked at more than one
person to get from home to work LAST WEEK?
location, print where he or she worked most last
week.
Minutes
a. Address (Number and street name)

:

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.

Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 23
No, never served in the military ➔ SKIP to
question 23

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

25 How did this person usually get to work LAST

Less than 2 years
2 years or more

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

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

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.

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office

J

Answer questions 29–32 ONLY IF this
person did NOT work last week. Otherwise,
SKIP to question 33.

29 a. LAST WEEK, was this person on layoff from
a job?
c. Is the work location inside the limits of that
city or town?

Yes ➔ SKIP to question 29c
No

Yes
No, outside the city/town limits
d. Name of county

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

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

f. ZIP Code

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 31
No

§.9h<¤

ACS-1(X)Seq, Page 12, Base (Black)

ACS-1(X)Seq, Page 12, GREEN Pantone 354 (10, 20, 40, and 50%)

13247135

Person 2 (continued)
30 Has this person been looking for work during

36

the last 4 weeks?
Yes
No ➔ SKIP to question 32

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.

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

Name of company, business, or other employer

Yes ➔ $

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

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
37
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

32 When did this person last work, even for a

What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank)

Yes ➔ $

few days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 35
Over 5 years ago or never worked ➔ SKIP to
question 41

38

WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
Weeks

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

40
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
41
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?
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?

§.9hD¤
ACS-1(X)Seq, Page 13, Base (Black)

Loss

Is this mainly – Mark (X) one box.
Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

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

manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

33 During the PAST 12 MONTHS, how many

.00

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

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

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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)

INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

,
No
TOTAL AMOUNT for past
If net income was a loss, mark the "Loss" box to
12 MONTHS
the right of the dollar amount.
42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
For income received jointly, report the appropriate
41h; subtract any losses. If net income was a loss, enter
share for each person – or, if that’s not possible,
the amount and mark (X) the "Loss" box.
report the whole amount for only one person and
mark the "No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.

None OR $
Loss

Yes ➔
No

$

,

.00

TOTAL AMOUNT for past
12 MONTHS

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

Continue with the questions for Person 3 on the
next page. If only 2 people are listed on pages 2, 3,
and 4, SKIP to page 24 for mailing instructions.

13
ACS-1(X)Seq, Page 13, GREEN Pantone 354 (10, 20, 40, and 50%)

13247143

Information about children helps
your community plan for child care,
education, and recreation.

Person 3
➜

First Name

7

11

Please copy the name of Person 3 from
page 3, then continue answering
questions below.
Last Name

MI

Where was this person born?
In the United States – Print name of state.

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

8

Is this person a CITIZEN of the United States?
Yes, born in the United States ➔ SKIP to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE
box. If currently enrolled, mark the previous grade
or highest degree received.

14

Person is under 1 year old ➔ SKIP to the
questions for Person 4 on page 17.
Yes, this house ➔ SKIP to F
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

No schooling completed
Nursery school to 4th grade
5th grade or 6th grade
7th grade or 8th grade
9th grade
10th grade
11th grade
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, AB, BS)
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)

No, different house in the United States
b. Where did this person live 1 year ago?
Name of city, town, or post office

c. Did this person live inside the limits of the
city or town?
Yes
No, outside the city/town limits

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

Name of county

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

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to
a high school diploma or a college degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)

14

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

13

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

F

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 17.

15

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

Yes
No ➔ SKIP to question 14
b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese 16

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

ZIP Code

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

Yes

No

Because of a physical, mental, or emotional
condition lasting 6 months or more, does
this person have any difficulty in doing any
of the following activities:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

§.9hL¤

ACS-1(X)Seq, Page 14, Base (Black)

ACS-1(X)Seq, Page 14, GREEN Pantone 354 (10, 20, 40, and 50%)

13247150

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 17.

21

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

17 Because of a physical, mental, or emotional

condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?
b. Working at a job or business?

H

Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.

18 Has this person given birth to any children in
the past 12 months?
Yes
No

22

23

Yes
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?
Yes
No ➔ SKIP to question 20

24

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

20 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.

§.9hS¤
ACS-1(X)Seq, Page 15, Base (Black)

WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab

I

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 33
Other method

Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.

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

LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
27 What time did this person usually leave home
pay in a family business or farm for 15 hours or
to go to work LAST WEEK?
more, or was on active duty in the Armed Forces.
Hour
Minute
Yes
a.m.
No ➔ SKIP to question 29
p.m.
At what location did this person work LAST
28 How many minutes did it usually take this
WEEK? If this person worked at more than one
person to get from home to work LAST WEEK?
location, print where he or she worked most last
week.
Minutes
a. Address (Number and street name)

:

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.

Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 23
No, never served in the military ➔ SKIP to
question 23

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

25 How did this person usually get to work LAST

Less than 2 years
2 years or more

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

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

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.

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office

J

Answer questions 29–32 ONLY IF this
person did NOT work last week. Otherwise,
SKIP to question 33.

29 a. LAST WEEK, was this person on layoff from
a job?
c. Is the work location inside the limits of that
city or town?

Yes ➔ SKIP to question 29c
No

Yes
No, outside the city/town limits
d. Name of county

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

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

f. ZIP Code

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 31
No

15
ACS-1(X)Seq, Page 15, GREEN Pantone 354 (10, 20, 40, and 50%)

13247168

Person 3 (continued)
30 Has this person been looking for work during

36

the last 4 weeks?
Yes
No ➔ SKIP to question 32

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.

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

Name of company, business, or other employer

Yes ➔ $

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

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
37
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

32 When did this person last work, even for a

What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank)

Yes ➔ $

few days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 35
Over 5 years ago or never worked ➔ SKIP to
question 41

38

WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
Weeks

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

40
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
41
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?
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?

16

Loss

Is this mainly – Mark (X) one box.
Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

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

manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

33 During the PAST 12 MONTHS, how many

.00

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

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

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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)

INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

,
No
TOTAL AMOUNT for past
If net income was a loss, mark the "Loss" box to
12 MONTHS
the right of the dollar amount.
42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
For income received jointly, report the appropriate
41h; subtract any losses. If net income was a loss, enter
share for each person – or, if that’s not possible,
the amount and mark (X) the "Loss" box .
report the whole amount for only one person and
mark the "No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.

None OR $
Loss

Yes ➔
No

$

,

.00

TOTAL AMOUNT for past
12 MONTHS

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

Continue with the questions for Person 4 on the
next page. If only 3 people are listed on pages 2, 3,
and 4, SKIP to page 24 for mailing instructions.

§.9he¤

ACS-1(X)Seq, Page 16, Base (Black)

ACS-1(X)Seq, Page 16, GREEN Pantone 354 (10, 20, 40, and 50%)

13247176

Knowing about age, race, and sex helps
your community better meet the needs
of everyone.

Person 4
➜

First Name

7

11

Please copy the name of Person 4 from
page 3, then continue answering
questions below.
Last Name

MI

Where was this person born?
In the United States – Print name of state.

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

8

Is this person a CITIZEN of the United States?
Yes, born in the United States ➔ SKIP to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE
box. If currently enrolled, mark the previous grade
or highest degree received.

14

Person is under 1 year old ➔ SKIP to the
questions for Person 5 on page 20.
Yes, this house ➔ SKIP to F
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

No schooling completed
Nursery school to 4th grade
5th grade or 6th grade
7th grade or 8th grade
9th grade
10th grade
11th grade
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, AB, BS)
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)

No, different house in the United States
b. Where did this person live 1 year ago?
Name of city, town, or post office

c. Did this person live inside the limits of the
city or town?
Yes
No, outside the city/town limits

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

Name of county

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

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to
a high school diploma or a college degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)

§.9hm¤
ACS-1(X)Seq, Page 17, Base (Black)

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

13

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

F

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 20.

15

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

Yes
No ➔ SKIP to question 14
b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese 16

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

ZIP Code

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

Yes

No

Because of a physical, mental, or emotional
condition lasting 6 months or more, does
this person have any difficulty in doing any
of the following activities:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

17
ACS-1(X)Seq, Page 17, GREEN Pantone 354 (10, 20, 40, and 50%)

13247184

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 20.

21

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

17 Because of a physical, mental, or emotional

condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?
b. Working at a job or business?

H

Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.

18 Has this person given birth to any children in
the past 12 months?
Yes
No

22

23

Yes
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?
Yes
No ➔ SKIP to question 20

24

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

20 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.

18

WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab

I

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 33
Other method

Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.

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

LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
27 What time did this person usually leave home
pay in a family business or farm for 15 hours or
to go to work LAST WEEK?
more, or was on active duty in the Armed Forces.
Hour
Minute
Yes
a.m.
No ➔ SKIP to question 29
p.m.
At what location did this person work LAST
28 How many minutes did it usually take this
WEEK? If this person worked at more than one
person to get from home to work LAST WEEK?
location, print where he or she worked most last
week.
Minutes
a. Address (Number and street name)

:

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.

Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 23
No, never served in the military ➔ SKIP to
question 23

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

25 How did this person usually get to work LAST

Less than 2 years
2 years or more

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

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

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.

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office

J

Answer questions 29–32 ONLY IF this
person did NOT work last week. Otherwise,
SKIP to question 33.

29 a. LAST WEEK, was this person on layoff from
a job?
c. Is the work location inside the limits of that
city or town?

Yes ➔ SKIP to question 29c
No

Yes
No, outside the city/town limits
d. Name of county

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

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

f. ZIP Code

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 31
No

§.9hu¤

ACS-1(X)Seq, Page 18, Base (Black)

ACS-1(X)Seq, Page 18, GREEN Pantone 354 (10, 20, 40, and 50%)

13247192

Person 4 (continued)
30 Has this person been looking for work during

36

the last 4 weeks?
Yes
No ➔ SKIP to question 32

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.

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

Name of company, business, or other employer

Yes ➔ $

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

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
37
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

32 When did this person last work, even for a

What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank)

Yes ➔ $

few days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 35
Over 5 years ago or never worked ➔ SKIP to
question 41

38

WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
Weeks

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

40
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
41
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?
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?

§.9h}¤
ACS-1(X)Seq, Page 19, Base (Black)

Loss

Is this mainly – Mark (X) one box.
Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

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

manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

33 During the PAST 12 MONTHS, how many

.00

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

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

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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)

INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

,
No
TOTAL AMOUNT for past
If net income was a loss, mark the "Loss" box to
12 MONTHS
the right of the dollar amount.
42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
For income received jointly, report the appropriate
41h; subtract any losses. If net income was a loss, enter
share for each person – or, if that’s not possible,
the amount and mark (X) the "Loss" box.
report the whole amount for only one person and
mark the "No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.

None OR $
Loss

Yes ➔
No

$

,

.00

TOTAL AMOUNT for past
12 MONTHS

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

Continue with the questions for Person 5 on the
next page. If only 4 people are listed on pages 2, 3,
and 4, SKIP to page 24 for mailing instructions.

19
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13247200

Your answers help your
community plan for the future.

Person 5
➜

First Name

7

11

Please copy the name of Person 5 from
page 4, then continue answering
questions below.
Last Name

MI

Where was this person born?
In the United States – Print name of state.

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

8

Is this person a CITIZEN of the United States?
Yes, born in the United States ➔ SKIP to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
12

9

What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE
box. If currently enrolled, mark the previous grade
or highest degree received.

14

Person is under 1 year old ➔ SKIP to the
mailing instructions on page 24.
Yes, this house ➔ SKIP to F
No, outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.,
below; then SKIP to F

No schooling completed
Nursery school to 4th grade
5th grade or 6th grade
7th grade or 8th grade
9th grade
10th grade
11th grade
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE – high school
DIPLOMA or the equivalent (for example: GED)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, AB, BS)
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)

No, different house in the United States
b. Where did this person live 1 year ago?
Name of city, town, or post office

c. Did this person live inside the limits of the
city or town?
Yes
No, outside the city/town limits

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

Name of county

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

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to
a high school diploma or a college degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)

20

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

13

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

F

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:

Yes
No ➔ SKIP to question 14
b. What is this language?

For example: Korean, Italian, Spanish, Vietnamese 16

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

ZIP Code

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

Yes

No

Because of a physical, mental, or emotional
condition lasting 6 months or more, does
this person have any difficulty in doing any
of the following activities:
Yes
No
a. Learning, remembering, or
concentrating?
b. Dressing, bathing, or getting around
inside the home?

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13247218

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.

21

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

17 Because of a physical, mental, or emotional

condition lasting 6 months or more, does this
person have any difficulty in doing any of the
following activities:
Yes
No
a. Going outside the home alone to
shop or visit a doctor’s office?
b. Working at a job or business?

H

Answer question 18 ONLY IF this person is
female and 15–50 years old. Otherwise, SKIP
to question 19a.

18 Has this person given birth to any children in
the past 12 months?
Yes
No

22

23

Yes
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?
Yes
No ➔ SKIP to question 20

24

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

20 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.

§.9i3¤
ACS-1(X)Seq, Page 21, Base (Black)

WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab

I

Motorcycle
Bicycle
Walked
Worked at home ➔
SKIP to question 33
Other method

Answer question 26 ONLY IF you marked
"Car, truck, or van" in question 25.
Otherwise, SKIP to question 27.

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

LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
the person worked only 1 hour, or helped without
27 What time did this person usually leave home
pay in a family business or farm for 15 hours or
to go to work LAST WEEK?
more, or was on active duty in the Armed Forces.
Hour
Minute
Yes
a.m.
No ➔ SKIP to question 29
p.m.
At what location did this person work LAST
28 How many minutes did it usually take this
WEEK? If this person worked at more than one
person to get from home to work LAST WEEK?
location, print where he or she worked most last
week.
Minutes
a. Address (Number and street name)

:

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.

Yes, now on active duty
Yes, on active duty during
the last 12 months, but not now
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 23
No, never served in the military ➔ SKIP to
question 23

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

25 How did this person usually get to work LAST

Less than 2 years
2 years or more

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

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

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.

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office

J

Answer questions 29–32 ONLY IF this
person did NOT work last week. Otherwise,
SKIP to question 33.

29 a. LAST WEEK, was this person on layoff from
a job?
c. Is the work location inside the limits of that
city or town?

Yes ➔ SKIP to question 29c
No

Yes
No, outside the city/town limits
d. Name of county

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

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

f. ZIP Code

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 31
No

21
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13247226

Person 5 (continued)
30 Has this person been looking for work during

36

the last 4 weeks?
Yes
No ➔ SKIP to question 32

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.

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

Name of company, business, or other employer

Yes ➔ $

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

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
37
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

32 When did this person last work, even for a

What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank)

Yes ➔ $

few days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to question 35
Over 5 years ago or never worked ➔ SKIP to
question 41

38

WEEKS did this person work? Count paid
vacation, paid sick leave, and military service.
Weeks

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

40
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
41
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?
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?

22

Loss

Is this mainly – Mark (X) one box.
Yes ➔ $

.00

Yes ➔ $

.00

Yes ➔ $

.00

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

manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

33 During the PAST 12 MONTHS, how many

.00

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

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

,
No
TOTAL AMOUNT for past
12 MONTHS
f. Any public assistance or welfare payments
from the state or local welfare office.
,
No
TOTAL AMOUNT for past
12 MONTHS
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

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)

INCOME IN THE PAST 12 MONTHS.
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

.00

Yes ➔ $

.00

,
No
TOTAL AMOUNT for past
12 MONTHS
h. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

,
No
TOTAL AMOUNT for past
If net income was a loss, mark the "Loss" box to
12 MONTHS
the right of the dollar amount.
42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
For income received jointly, report the appropriate
41h; subtract any losses. If net income was a loss, enter
share for each person – or, if that’s not possible,
the amount and mark (X) the "Loss" box .
report the whole amount for only one person and
mark the "No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions
for taxes, bonds, dues, or other items.

None OR $
Loss

Yes ➔
No

$

,

.00

➜

,
,
TOTAL AMOUNT for past
12 MONTHS

.00

Now continue with the mailing
instructions on page 24.

TOTAL AMOUNT for past
12 MONTHS

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13247234

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left blank

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13247242

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 0607-0936, 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
0607-0936" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(X)Seq (12-19-2006)

24

§.9iK¤

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