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pdfItems Booklet for
Specification:
Section: Assets and Liabilities TM
AL06A
Mark One Only
Now I want to talk about assets held in retirement accounts,
such as IRA or KEOGH accounts.
I recorded earlier that [fill TEMPNAME] owned an
IRA or KEOGH account.
As of [fill LDORP], did [fill HESHE] have any Individual
Retirement Accounts - any IRAs?
[r]H[n]
[if MS eq <1> or MS eq <2>]
[fill TEMP1]
[fill TEMP2]
[endif]
(1)
(2)
Yes
No
@
AL06B
Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME]
contributed to [fill HISHER] IRA accounts?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@ Years
Enter Number
AL06C
As of [fill LDORP], what was the total balance or
market value (including interest earned) of the
IRA accounts in [fill HISHER] own name?
ENTER (N) FOR NONE
$@
Mark One Only
AL06D
Was the total (1)
(2)
(3)
(4)
Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?
@
Monday, April 05, 2010
Page 1 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
AL06E
Multiple Entry
As of [fill LDORP], which kinds of
assets did [fill TEMPNAME] hold in [fill HISHER] IRA accounts?
Was [fill HISHER] IRA account invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1
Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
@2
@3
@4
AL06F
Multiple Entry
Please specify the Other Assets.
(1)
(2)
@1
@2
AL06G
Mark One Only
As of [fill LDORP], did [fill TEMPNAME] have a KEOGH account
in [fill HISHER] OWN name?
[r]H[n]
(1)
(2)
Yes
No
@
AL06H
Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] contributed
to [fill HISHER] KEOGH account?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@ Years
Enter Number
AL06I
As of [fill LDORP], what was the total balance or market value of
assets in [fill PTEMPNAME] KEOGH account(s)?
ENTER (N) FOR NONE
$@
Mark One Only
AL06J
Was the total (1)
(2)
(3)
(4)
Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?
@
Page 2 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
AL06K
Multiple Entry
As of [fill LDORP], which kinds of
assets did [fill TEMPNAME] hold in [fill HISHER] KEOGH
account(s)?
Was [fill HISHER] KEOGH account invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1
Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings bonds
Stocks or mutual fund shares
Other assets
@2
@3
@4
AL06L
Multiple Entry
Please specify the other assets held.
(1)
(2)
@1
@2
AL07A
Mark One Only
Now I want to talk about assets held in retirement accounts,
such as 401k, 403b or thrift plans.
I recorded earlier that [fill TEMPNAME] participated in a
401k, 403b, or thrift plan.
Did [fill HESHE] have that account as of [fill LDORP]?
[r]H[n]
(1)
(2)
Yes
No
@
AL07B
Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] contributed
to [fill HISHER] 401k, 403b, or thrift plans?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@
Enter Number
AL07C
As of [fill LDORP], what was the total balance or market
value (including interest earned) of any 401k, 403b, or
thrift plans held in [fill PTEMPNAME] own name?
ENTER (N) FOR NONE
$@
Monday, April 05, 2010
Page 3 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
Mark One Only
AL07D
Was the total (1)
(2)
(3)
(4)
Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?
@
Multiple Entry
AL07E
As of [fill LDORP], which kinds of assets did [fill TEMPNAME]
hold in [fill HISHER] 401k, 403b, or thrift plans?
Was [fill HISHER] 401k/403b/thrift plan invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1
Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
@2
@3
@4
Multiple Entry
AL07F
Please specify the Other Assets.
(1)
(2)
@1
@2
Mark One Only
AL01A
As of [fill LDORP], did anyone outside of this
household owe money to [fill TEMPNAME] as the
result of the sale of a business or property?
(Exclude mortgages owed to [fill TEMPNAME] which
have already been reported.)
(1)
(2)
Yes
No
@
Enter Number
AL01B
How much was owed to [fill TEMPNAME]?
If shared, count only [fill PTEMPNAME] share.
$@
Page 4 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
AL02A
Mark One Only
I recorded earlier that [fill TEMPNAME] owned Series E or EE
U.S. Savings Bonds.
Did [fill HESHE] own them as of [fill LDORP]?
[r]H[n]
(1)
(2)
Yes
No
@
AL02B
Enter Number
What was the FACE VALUE of the U.S. Savings Bonds that
[fill TEMPNAME] owned?
If ownership was shared, count only [fill PTEMPNAME] share.
[r]H[n]
$@
AL02D
Mark One Only
As of [fill LDORP], did [fill TEMPNAME] own jointly with
[fill HISHER] [fill SPOUSE] any checking accounts which did
not earn interest?
[if MS eq <1> and JTCI1_ARR(<1>,<1>) eq <1> and AST2A eq <1>]
(Do not include any jointly owned interest-earning checking
accounts reported earlier.)
[endif]
(1)
(2)
Yes
No
@
AL02E
Enter Number
What is your best estimate of the amount of money
[fill TEMPNAME] and [fill HISHER] [fill SPOUSE] had in those
checking accounts as of [fill LDORP]?
ENTER (N) FOR NONE
$@
AL02F
Multiple Entry
As of [fill LDORP], did [fill TEMPNAME] and
[fill HISHER] [fill SPOUSE] together owe any money for (1)
(2)
Yes
No
Store bills or credit card bills?
@B
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
@L
Any other debt we have not yet mentioned, including
medical bills not covered by insurance, money owed
to private individuals, educational loans, or any
other debt not covered and excluding mortgages,
home equity loans, and car loans?
@O
Monday, April 05, 2010
Page 5 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
AL03A
Multiple Entry
How much was owed as of [fill LDORP] for [if AL02F@B eq <1>]
Store bills or credit card bills?
[endif]
[if AL02F@L eq <1>]
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
[endif]
$@B
$@L
[if AL02F@O eq <1>]
Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any other
debt not covered and excluding mortgages,
home equity loans, and car loans?
$@O
[endif]
Mark One Only
AL04A
[if MS eq <1> and AL02D eq <1>]
Beside any checking accounts owned jointly with [fill HISHER]
[fill SPOUSE], as of [fill LDORP], did [fill TEMPNAME] own any
[fill TEMP1] checking accounts in [fill HISHER] OWN name which did
NOT earn interest?
[fill TEMP5]
[fill TEMP6]
[else]
As of [fill LDORP], did [fill TEMPNAME] own any [fill TEMP1]
checking accounts in [fill HISHER] OWN name which did NOT earn
interest?
[fill TEMP5]
[fill TEMP6]
[endif]
(1)
(2)
Yes
No
@
Enter Number
AL04B
What is your best estimate of the amount of money
[fill TEMPNAME] had in those checking accounts as of
[fill LDORP]?
ENTER (N) FOR NONE
$@
Mark One Only
AL04C
Did [fill TEMPNAME] have any debts in [fill HISHER] own name,
such as credit card bills, loans from a financial institution,
or educational loans?
(1)
(2)
Yes
No
@
Page 6 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
AL04D
Multiple Entry
As of [fill LDORP], did [fill TEMPNAME] owe any money in
[fill HISHER] own name for (1)
(2)
Yes
No
Store bills or credit card bills?
@B
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
@L
Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any
other debt not covered and excluding mortgages, home
equity loans, and car loans?
@O
AL05A
Multiple Entry
How much was owed as of [fill LDORP] for [if AL04D@B eq <1>]
Store bills or credit card bills?
[endif]
[if AL04D@L eq <1>]
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
[endif]
[if AL04D@O eq <1>]
Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any
other debt not covered and excluding mortgages,
home equity loans, and car loans?
[endif]
$@B
$@L
$@O
AL07G
Mark One Only
As of [fill LDORP], did [fill TEMPNAME] have any life insurance?
INCLUDE GROUP POLICES PROVIDED BY EMPLOYERS
[r]H[n]
(1)
(2)
Yes
No
@
AL07H
Enter Number
What is the CURRENT CASH VALUE of ALL life insurance
policies that [fill TEMPNAME] [fill HAVHAS]?
[r]H[n]
$@
Monday, April 05, 2010
Page 7 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
AL07I
Mark One Only
What types of life insurance [fill DODOES] [fill TEMPNAME] have is it "term insurance", "whole life", or [fill DODOES]
[fill HESHE] have both of these types?
[r]H[n]
(1) Term only
(2) Whole life only
(3) Both types
@
AL08A
Mark One Only
Are any of [fill PTEMPNAME] life insurance policies provided
through [fill HISHER] current employer(s)?
(1)
(2)
Yes
No
@
AL08B
Enter Number
What is the CASH VALUE of the life insurance policies
provided through [fill HISHER] employer(s)?
[r]H[n]
$@
Enter Number
IAJ07
Earlier I recorded that [fill TEMPNAME]
owned the following assets jointly with
[fill HISHER] spouse [fill OTHERSFIL]:
[if FLAGCK(<1>) eq <1>]
an interest earning checking account
[endif]
[if FLAGCK(<2>) eq <1>]
a savings account
[endif]
[if FLAGCK(<3>) eq <1>]
a money market deposit account
[endif]
[if FLAGCK(<4>) eq <1>]
a certificate of deposit (CD)
[endif]
As of [fill LDORP], what
[fill SHAREOFFIL] the total amount of
money held in these joint
account(s) [fill BELONGFIL]?
ENTER (N) FOR NONE
$@
Page 8 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
Mark One Only
IAJ08
Was it (1)
(2)
(3)
(4)
Less than $500
$500 to $1,000
$1,001 to $5,000
More than $5,000
@
Enter Number
IAI03
[fill OTHFIL]
Earlier I recorded that [fill TEMPNAME]
owned the following asset(s):
[if FLAGCK2(<1>) eq <1>]
an interest earning checking account
[endif]
[if FLAGCK2(<2>) eq <1>]
a savings account
[endif]
[if FLAGCK2(<3>) eq <1>]
a money market deposit acount
[endif]
[if FLAGCK2(<4>) eq <1>]
a certificate of deposit (CD)
[endif]
As of [fill LDORP], what was
[fill SHAREOFFIL] the total amount of
money held in these account(s)?
ENTER (N) FOR NONE
$@
Mark One Only
IAI04
Was it (1)
(2)
(3)
(4)
Less than $500
$500 to $1,000
$1,001 to $5,000
More than $5,000?
@
Monday, April 05, 2010
Page 9 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
Enter Number
IMJ05
Earlier I recorded that [fill TEMPNAME]
owned the following assets jointly with
[fill HISHER] spouse [fill OTHERSFIL]:
[if FLAGCK(<5>) eq <1>]
Municipal or Corporate Bonds
[endif]
[if FLAGCK(<6>) eq <1>]
U.S. Government Securities
[endif]
As of
[fill
money
[fill
[fill LDORP], what
SHAREOFFIL] the total amount of
held in these joint account(s)
BELONGFIL]?
ENTER (N) FOR NONE
$@
Mark One Only
IMJ06
Was it (1)
(2)
(3)
(4)
Less than
$1,000 to
$5,001 to
More than
$1,000
$5,000
$10,000
$10,000?
@
Enter Number
IMI03
[fill OTHFIL]
Earlier I recorded that [fill TEMPNAME]
owned the following asset(s):
[if FLAGCK2(<5>) eq <1>]
Municipal or Corporate Bonds
[endif]
[if FLAGCK2(<6>) eq <1>]
U.S. Government Securities
[endif]
As of [fill LDORP], what was
[fill SHAREOFFIL] the total amount of
money held in these account(s)?
ENTER (N) FOR NONE
$@
Mark One Only
IMI04
Was it (1)
(2)
(3)
(4)
Less than
$1,000 to
$5,001 TO
More than
$1,000
$5,000
$10,000
$10,000?
@
Page 10 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
Mark One Only
SMJ02
I recorded earlier that [fill TEMPNAME] owned mutual
funds.
Did [fill TEMPNAME] own any of these funds jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(1)
(2)
Yes
No
@
Mark One Only
SMJ03
I recorded earlier that [fill TEMPNAME] owned stocks.
Did [fill TEMPNAME] own any of these stocks jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(1)
(2)
Yes
No
@
Enter Number
SMJ04
Earlier I recorded that [fill TEMPNAME]
held [fill STOCMUTFIL] jointly with
[fill HISHER] spouse [fill OTHERSFIL].
As of [fill LDORP], what was
[fill SHAREFIL] market value of the
[fill STOCMUTFIL] held [fill SPOUSEFIL]?
EXCLUDE STOCK IN OWN CORPORATION IF THE
VALUE OF THAT CORPORATION WAS ALREADY
OBTAINED
ENTER (N) FOR NONE
$@
Mark One Only
SMJ05
Was it (1)
(2)
(3)
(4)
Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More then $25,000?
@
Mark One Only
SMJ06
Was any debt or margin account held against
these jointly held [if SMJ02 eq <1>][fill TEMP1] [endif]
[if SMJ02 eq <1> and SMJ03 eq <1>][fill TEMP2] [endif]
[if SMJ03 eq <1>][fill TEMP3] [endif]
as of [fill LDORP]?
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 11 of 107
Survey:
Section: Assets and Liabilities TM
Enter Number
Items Booklet
SMJ07
As of [fill LDORP], what was the
amount of the debt or margin account?
ENTER (N) FOR NONE
$@
Mark One Only
SMI02
[if SMJ02 eq <1> or SMJ03 eq <1>]
Besides the stocks or mutual fund shares held jointly with
[fill PTEMPNAME] [fill SPOUSE], did [fill TEMPNAME] hold
any other stocks or mutual fund shares in [fill HISHER]
own name as of [fill LDORP]?
[else]
[if MS eq <1> and SMJ02 ne <1> and SMJ03 ne <1>]
Did [fill TEMPNAME] hold any stocks or mutual fund shares in
[fill HISHER] own name as of [fill LDORP]?
[else]
[if MS gt <1> and (AST3A eq <1> or AST3B eq <1>)]
I recorded earlier that [fill TEMPNAME] owned
[fill TEMP1]. Did [fill TEMPNAME] hold any stocks or mutual fund
shares in [fill HISHER] own name as of [fill LDORP]?
[endif] [endif] [endif]
(1)
(2)
Yes
No
@
Enter Number
SMI03
Earlier I recorded that [fill TEMPNAME]
held [fill STOCMUTFIL].
As of [fill LDORP], what was
[fill SHAREFIL] the market value of the
[fill STOCMUTFIL]?
EXCLUDE STOCK IN OWN CORPORATION IF
VALUE OF THAT CORPORATION WAS ALREADY
OBTAINED
ENTER (N) FOR NONE
$@
Mark One Only
SMI04
Was it (1)
(2)
(3)
(4)
Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More than $25,000
@
Page 12 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
SMI05
Mark One Only
Did [fill TEMPNAME] have a debt or margin account held
against these stocks or mutual funds as of [fill LDORP]?
(1)
(2)
Yes
No
@
SMI06
Enter Number
As of [fill LDORP], what was the amount of the debt or margin account?
ENTER (N) FOR NONE
$@
VB03
Enter Number
As of [fill LDORP], what percent of
[fill ALLBUS] did [fill TEMPNAME] own?
(Value Between 1% and 100%)
@
VB04
Mark One Only
DO NOT READ TO RESPONDENT
Has information below about the total value and total debt
for [fill ALLBUS] already been obtained from another
household member?
(1) Yes
(2) No
@
VB05
Enter Number
As of [fill LDORP], what was the
total value of [fill ALLBUS] before figuring in any
debts that might be owed against it?
[r]H[n]
ENTER (N) FOR NONE
$@
Mark One Only
VB07
Was the value:
(1)
(2)
(3)
(4)
(5)
Less than $1
Between $1 and $1,000
Between $1,001 to $10,000
Between $10,001 to $100,000
More than $100,000?
@
Monday, April 05, 2010
Page 13 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
VB08
Enter Number
As of [fill LDORP], what was the
total debt owed against [fill ALLBUS]?
[r]H[n]
ENTER (N) FOR NONE
$@
VB10
Mark One Only
Was the debt:
(1)
(2)
(3)
(4)
(5)
Less than $1
Between $1 to $1,000
Between $1,001 to $10,000
Between $ 10,001 to $100,000
More than $100,000?
@
RJ01
Mark One Only
[if JTCI9_ARR(<1>) eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with [fill HISHER] [fill SPOUSE],
Did [fill HESHE] and
property as of [fill
[else]
Did [fill HESHE] and
property as of [fill
[endif]
(1)
(2)
[fill HISHER] [fill SPOUSE] own rental
LDORP]?
[fill HISHER] [fill SPOUSE] own rental
LDORP]?
Yes
No
@
RJ02
Enter Number
Earlier I recorded that [fill TEMPNAME] owned rental property
joint with [fill HISHER] [fill SPOUSE].
How many properties did [fill TEMPNAME] own jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(01 to 99)
@
RJ03
Multiple Entry
What type of [if RJ02 eq <1>][fill TEMP1][else][fill TEMP2][endif]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Page 14 of 107
Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2
@3
@4
@5
@6
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
Enter Text
RJ04
Please specify the type of property.
@
Mark One Only
RJ05
[if RJ02 eq <1>][fill TEMP1] [else][fill TEMP2] [endif]
attached to or located on the same land as [fill HISHER]
own residence?
(1)
(2)
Yes
No
@
Mark One Only
RJ06
ASK OR VERIFY:
Were all of these properties attached to or located
on the same land as [fill HISHER] own residence?
(1)
(2)
Yes
No
@
Enter Number
RJ07
[if RJ06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[else]
[if RJ05 eq <2>]
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[endif] [endif]
$@
Mark One Only
Was it
RJ08
-
(1)
(2)
(3)
(4)
Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000
@
Monday, April 05, 2010
Page 15 of 107
Survey:
Section: Assets and Liabilities TM
Items Booklet
Mark One Only
RJ09
[if RJ06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP1] as of [fill LDORP]?
[else]
[if RJ05 eq <2>]
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP1] as of [fill LDORP]?
[endif] [endif]
(1)
(2)
Yes
No
@
Enter Number
RJ10
[if RJ02 eq <1>]
As of [fill LDORP], how much principal was owed on the
property?
[else]
As of [fill LDORP], how much principal was owed on the
properties?
[endif]
(N) None
$@
Mark One Only
Was it
RJ11
-
(1)
(2)
(3)
(4)
Less than $25,000
$25,000 to $50,000
$50,001 to $100,000
More than $100,000
@
Mark One Only
RI01
[if OWNRNT eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
in [fill HISHER] own name.
Did [fill HESHE] own
own name as of [fill
[else]
Did [fill HESHE] own
own name as of [fill
[endif]
(1)
(2)
any rental property in [fill HISHER]
LDORP]?
any rental property in [fill HISHER]
LDORP]?
Yes
No
@
Page 16 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
RI02
Enter Number
Earlier I recorded that [fill TEMPNAME] owned rental property in
[fill HISHER] own name.
How many properties did [fill TEMPNAME] own in
[fill HISHER] OWN name as of [fill LDORP]?
@
RI03
Multiple Entry
What type of [if RI02 eq <1>][fill TEMP1][else][fill TEMP2][endif]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2
@3
@4
@5
@6
Enter Text
RI04
Please specify the type of property.
@
Mark One Only
RI05
[if RI02 eq <1>][fill TEMP1] [else][fill TEMP2] [endif]
attached to or located on the same
land as [fill HISHER] own residence?
(1)
(2)
Yes
No
@
Mark One Only
RI06
ASK OR VERIFY:
Were all of these properties attached to or located on
the same land as [fill HISHER] own residence?
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 17 of 107
Survey:
Section: Assets and Liabilities TM
Enter Number
Items Booklet
RI07
[if RI06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[else]
[if RI05 eq <2>]
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[endif] [endif]
$@
Mark One Only
Was it
RI08
-
(1)
(2)
(3)
(4)
Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000
@
Mark One Only
RI09
[if RI06 eq <2>]
Excluding properties attached to or located on
[fill PTEMPNAME] own residence,
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP2] as of [fill LDORP]?
[else]
[if RI05 eq <2>]
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP2] as of [fill LDORP]?
[endif] [endif]
(1)
(2)
Yes
No
@
Enter Number
RI10
As of [fill LDORP], how much principal was owed on the
[if RI02 eq <1>][fill TEMP4] [else][fill TEMP5] [endif]?
ENTER (N) FOR NONE
$@
Mark One Only
Was it
RI11
-
(1)
(2)
(3)
(4)
Less than $25,000
$25,000 to $50,000
$50,001 to $100,000
More than $100,000
@
Page 18 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
RNT01
Mark One Only
[if JTCI9_ARR(<2>) eq <1> and RJ01 eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with other people besides [fill HISHER] [fill SPOUSE].
Did [fill HESHE] jointly own any rental property jointly with
other people besides [fill HISHER] [fill SPOUSE] as of
[fill LDORP]?
[else]
[if JTCI9_ARR(<2>) eq <1> and (RJ01 eq <2> or MS gt <1>)]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with other people.
Did [fill HESHE] jointly
other people as of [fill
[else]
Did [fill HESHE] jointly
other people as of [fill
[endif] [endif]
(1)
(2)
own any rental property jointly with
LDORP]?
own any rental property jointly with
LDORP]?
Yes
No
@
RNT02
Enter Number
Earlier I recorded that [fill TEMPNAME] owned rental property
jointly with other people [fill BESIDESPOUFIL].
How many properties did [fill TEMPNAME] own jointly with other
people as of [fill LDORP]?
@
RNT03
Multiple Entry
What type of [fill TEMP1]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2
@3
@4
@5
@6
Enter Text
RNT04
Please specify the type of property.
@
Enter Number
RNT07
What was the total market value of the rental
[fill TEMP5] as of [fill LDORP]?
$@
Monday, April 05, 2010
Page 19 of 107
Survey:
Section: Assets and Liabilities TM
Mark One Only
Items Booklet
RNT08
Was there a mortgage, deed of trust, or other debt
on the [fill TEMP5] as of [fill LDORP]?
(1)
(2)
Yes
No
@
Enter Number
RNT09
As of [fill LDORP], how much principal was owed on the
[fill TEMP5]?
ENTER (N) FOR NONE
$@
Enter Number
RNT10
What was the total value of [fill HISHER] share of equity,
(or loss) in the rental [fill TEMP5] owned jointly with
others as of [fill LDORP]?
"EQUITY" IS THE TOTAL MARKET VALUE OF THE PROPERTY, LESS
ANY DEBTS HELD AGAINST IT.
ENTER (N) FOR NONE
$@
Mark One Only
Was it
RNT11
-
(1)
(2)
(3)
(4)
Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000
@
Enter Number
MO2A
Earlier I recorded that [fill TEMPNAME]
held mortgages jointly with [fill HISHER]
spouse [fill OTHERSFIL].
As of [fill LDORP], what was
[fill SHAREFIL] of the principal owed on
this mortgage or these mortgages?
INCLUDE PRINCIPAL FOR ALL MORTGAGES
JOINTLY HELD
ENTER (N) FOR NONE
$@
Page 20 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Assets and Liabilities TM
Mark One Only
MO2B
Was it (1)
(2)
(3)
(4)
Less than $10,000
$10,000 to $25,000
$25,001 to $50,000
Over $50,000
@
Enter Number
M04
Earlier I recorded that [fill TEMPNAME]
held a mortgage from which [fill HESHE]
received payments.
As of [fill LDORP], what was
[fill SHAREFIL] the principal owed on
this mortgage or these mortgages?
ENTER (N) FOR NONE
$@
Mark One Only
MO5
Was it (1)
(2)
(3)
(4)
Less than $10,000
$10,000 to $25,000
$25,001 to $50,000
Over $50,000
@
Enter Number
OA02
Earlier [fill TEMPNAME] reported owning other financial
investments:
[fill OTHFIN]
As of [fill LDORP], what was
[fill HISHER] equity in these investments?
(Equity is the total market value of the property, less any debts
held against it. If the investment is jointly owned, count
only [fill HISHER] share of equity.)
ENTER (N) FOR NONE
$@
Mark One Only
OA03
Was it (1)
(2)
(3)
(4)
Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More than $25,000?
@
Monday, April 05, 2010
Page 21 of 107
Survey:
Section: Real Estate TM
Page 22 of 107
Items Booklet
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
Mark One Only
RE02
ASK IF NOT APPARENT:
Is this residence a mobile home?
(1)
(2)
Yes
No
@
Multiple Entry
RE03
Which persons in this household are the
owners of this home?
ENTER LINE NUMBER OF PERSON(S) IN
HOUSEHOLD WHO OWN HOME.
ENTER (N) FOR NONE/NO MORE
@1
@2
@3
Multiple Entry
RE04
When was this home purchased?
MONTH:
YEAR:
@MO
@YR
Mark One Only
RE05
Is there a mortgage, home equity loan, or other debt on this
home?
INCLUDE RENTAL PROPERTIES ATTACHED TO OR LOCATED IN THE RESIDENCE
(1)
(2)
Yes
No
@
Enter Number
RE06
Altogether, how many mortgages, home equity loans, or other
debts are there on this home?
@
Number
Mark One Only
RE062BIG
THE NUMBER OF MORTGAGES/LOANS/ETC. ENTERED -- [FILL RE06] -IS VERY LARGE.
IS IT CORRECT?
DOES THE RESPONDENT UNDERSTAND THAT WE ARE ASKING ABOUT THE *NUMBER
OF DIFFERENT LOANS* (*NOT* THE TERM OF THE MORTGAGE -- THE NUMBER
OF YEARS OVER WHICH IT IS TO BE PAID OFF)?
(1) BACK UP AND CORRECT
(P) PROCEED
@
Monday, April 05, 2010
Page 23 of 107
Survey:
Section: Real Estate TM
Items Booklet
Enter Number
RE07
FIRST MORTGAGE
How much principal is currently owed on the first mortgage
or loan?
If possible, please check any records you may have from the
lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number
RE08
FIRST MORTGAGE
In what year was the first mortgage or loan obtained?
If the mortgage was assumed, report the original date of
the mortgage.
YEAR:
@
Enter Number
RE09
FIRST MORTGAGE
And in which month was the first mortgage or loan obtained?
Month:
@
Enter Number
RE10
FIRST MORTGAGE
What was the amount of the mortgage or loan when it was
obtained or last refinanced?
If the mortgage was assumed, give the original amount of
the mortgage.
$@
Enter Number
RE11
FIRST MORTGAGE
What is the total number of years over which payments are to
be made?
ENTER (N) FOR NOT FIXED
@
Page 24 of 107
Number of Years
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
RE12
Enter Number
FIRST MORTGAGE
Field Rep Note: Respondent's usually report mortgage interest rates as
whole numbers followed by fractions. For example, "5 and 3/8ths %".
Here is a "Fraction to Decimal Conversion Chart" to help convert the
second part, the fraction, of the respondent's answer:
1/8 = .125
1/4 = .25
3/8 = .375
1/2 = .5
5/8 = .625
3/4 = .75
7/8 = .875
Examples of complete mortgage interest rates, that is whole numbers
followed by a fraction, converted to decimal form are listed below.
REMEMBER, RESPONDENT MAY GIVE ANY WHOLE NUMBER OR A WHOLE NUMBER AND
A FRACTION RESPONSE, NOT JUST THE BELOW EXAMPLES:
If rate is 3 and 1/8 th %, then enter 3.125 %
If rate is 4 and 1/4 %, then enter 4.25 %
If rate is 5 and 3/8 ths %, then enter 5.375 %
If rate is 6 and 1/2 %, then enter 6.5 %
If rate is 7 and 5/8 ths %, then enter 7.625 %
If rate is 8 and 3/4 %, then enter 8.75 %
If rate is 7 and 7/8 ths %, then enter 7.875 %
If rate is 7 %, then enter 7.0 %
If rate is 11%, then enter 11.0 %
What is the current annual interest rate on this mortgage or loan?
ENTER BOTH A WHOLE NUMBER AND A DECIMAL ANSWER FROM 00.001% TO 30.000%
@ %
Mark One Only
RE13
FIRST MORTGAGE
Is the interest rate variable or fixed?
VARIABLE INTEREST RATES CAN CHANGE OVER THE TERM OF THE MORTGAGE
OR LOAN
(1)
(2)
Variable interest rate
Fixed interest rate
@
Monday, April 05, 2010
Page 25 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE14
FIRST MORTGAGE
Was this mortgage obtained through an FHA or VA mortgage
program?
(1) Yes - FHA LOAN
(2) Yes - VA LOAN
(3) No
@
Enter Number
RE15
SECOND MORTGAGE
How much principal is currently owed on the second mortgage
or loan?
If possible, please check any records you may have from the
lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number
RE16
SECOND MORTGAGE
In what year was the second mortgage or loan obtained?
If the mortgage was assumed, report the original date of
the mortgage.
ENTER 4 DIGIT YEAR: @
Enter Number
RE17
SECOND MORTGAGE
And in which month was the second mortgage or loan obtained?
Month: @
Enter Number
RE18
SECOND MORTGAGE
What was the amount of the mortgage or loan when it was
obtained or last refinanced?
If the mortgage was assumed, give the original amount of
the mortgage.
$@
Page 26 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
RE19
Enter Number
SECOND MORTGAGE
What is the total number of years over which payments are to
be made?
ENTER (N) FOR NOT FIXED
@ Number of years
RE20
Enter Number
SECOND MORTGAGE
Field Rep Note: Respondent's usually report mortgage interest rates as
whole numbers followed by fractions. For example, "5 and 3/8ths %".
Here is a "Fraction to Decimal Conversion Chart" to help convert the
second part, the fraction, of the respondent's answer:
1/8 = .125
1/4 = .25
3/8 = .375
1/2 = .5
5/8 = .625
3/4 = .75
7/8 = .875
Examples of complete mortgage interest rates, that is whole numbers
followed by a fraction, converted to decimal form are listed below.
REMEMBER, RESPONDENT MAY GIVE ANY WHOLE NUMBER OR A WHOLE NUMBER AND
A FRACTION RESPONSE, NOT JUST THE BELOW EXAMPLES:
If rate is 3 and 1/8 th %, then enter 3.125 %
If rate is 4 and 1/4 %, then enter 4.25 %
If rate is 5 and 3/8 ths %, then enter 5.375 %
If rate is 6 and 1/2 %, then enter 6.5 %
If rate is 7 and 5/8 ths %, then enter 7.625 %
If rate is 8 and 3/4 %, then enter 8.75 %
If rate is 7 and 7/8 ths %, then enter 7.875 %
If rate is 7 %, then enter 7.0 %
If rate is 11%, then enter 11.0 %
What is the current annual interest rate on the second mortgage or loan?
ENTER BOTH A WHOLE NUMBER AND A DECIMAL ANSWER FROM 00.001% TO 30.000%
@ %
Mark One Only
RE21
SECOND MORTGAGE
Is the interest rate variable or fixed?
VARIABLE INTEREST RATES CAN CHANGE OVER THE TERM OF THE MORTGAGE
OR LOAN
(1)
(2)
Variable interest rate
Fixed interest rate
@
Monday, April 05, 2010
Page 27 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE22
SECOND MORTGAGE
Was this mortgage obtained through an FHA or VA mortgage
program?
(1) Yes - FHA LOAN
(2) Yes - VA LOAN
(3) No
@
Enter Number
RE23
THIRD+ MORTGAGE
How much principal is currently owed on all the remaining
mortgages or loans not reported previously?
If possible, please check any records you may have from any
other lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number
RE24
What is the current value of this property; that is, how
much do you think it would sell for on today's market if it
were for sale? Include rental properties attached to or
located on this residence.
$@
Mark One Only
RE25
MOBILE HOME
Is there a mortgage, installment loan, contract to purchase,
or other debt on this mobile home or site?
(1) Yes
(2) No
@
Mark One Only
RE26
MOBILE HOME
Is this mortgage, contract, or other debt for just the site,
or does it also apply to this mobile home?
(1) Mobile home only
(2) Site only
(3) Site and home
@
Page 28 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
RE27
Enter Number
MOBILE HOME
How much principal is currently owed on all mortgages?
$@
RE28
Enter Number
MOBILE HOME
How much do you think this mobile home [fill TEMP1] would sell
for today if it were for sale?
$@
RE29
Enter Number
How much was this household's[if TENURE eq <2>] [fill TEMP1]
[else] [fill TEMP2] [endif]last month[fill CONDOFIL]
[fill FEEFIL]
IF RESPONDENT REPORTS "0" ENTER (N) FOR NONE
$@
RE30
Enter Number
How much did this household pay for electricity, gas, basic
telephone service, and other utilities last month?
[r]H[n]
IF RESPONDENT REPORTS "0", NOTHING,
OR INCLUDED IN RENT ENTER (N) FOR NONE
$@
Mark One Only
RE31
Did more than one of the persons living
here pay the [fill TEMP1] last month?
(1) Yes
(2) No
@
Enter Number
RE32
Which person paid?
ENTER LINE NUMBER OF PERSON WHO PAID
@
Monday, April 05, 2010
Page 29 of 107
Survey:
Section: Real Estate TM
Items Booklet
Multiple Entry
RE33
Which persons paid and how much did each
pay?
IF 4 OR MORE PEOPLE ARE PAYING, LIST
ONLY THE AMOUNT THE FIRST 3 RESPONDENTS PAY
ENTER LINE NUMBERS OF PERSONS WHO PAID
ENTER (N) FOR NO MORE
Person 1:
Person 2:
Person 3:
Line number
@LN1
@LN2
@LN3
Amount paid last month
$@AMT1
$@AMT2
$@AMT3
Mark One Only
RE34
Last month, did anyone here pay for the care of a child or a
disabled person so that a household member could work,
attend training, or look for a job?
(1) Yes
(2) No
@
Enter Number
RE35
What was the total cost of these care arrangements last month?
$@
Mark One Only
RE36
OTHER REAL ESTATE
[if PCNT eq <1>]
Do you own any other real estate such as a vacation home or
undeveloped lot? Exclude rental property previously reported or
rental property attached to or located on the same land as your
own residence.
[else]
Does anyone in this household own any other real estate such as a
vacation home or undeveloped lot? Exclude rental property
previously reported or rental property attached to or located on
the same land as your own residence. [endif]
(1) Yes
(2) No
@
Multiple Entry
RE37
OTHER REAL ESTATE
Which household members own this property?
ENTER LINE NUMBERS OF HOUSEHOLD MEMBERS
WHO OWN PROPERTY.
ENTER (N) FOR NONE/NO MORE.
@1
Page 30 of 107
@2
@3
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
RE38
Enter Number
OTHER REAL ESTATE
What is the total value of the equity in this real estate?
[r]H[n]
$@
Mark One Only
RE39
Does anyone in this household own a car, van, or truck,
excluding recreational vehicles (RV's) and motorcycles?
DO NOT INCLUDE LEASED VEHICLES OR COMPANY CARS AS BEING
OWNED BY THE RESPONDENT.
(1)
(2)
Yes
No
@
Enter Number
RE40
[if PCNT eq <1>]
How many cars, trucks, or vans do you own?
[else]
How many cars, trucks, or vans do members of this household own?
[endif]
DO NOT INCLUDE LEASED VEHICLES OR COMPANY CARS AS BEING
OWNED BY THE RESPONDENT.
@ Number of motor vehicles
Multiple Entry
RE41
[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 1: NEWEST VEHICLE
Who owns [fill TEMP1]?
ENTER LINE NUMBER OF PERSON(S) WHO OWN
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1
@LN2
Enter Number
RE42
VEHICLE 1: NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@
Monday, April 05, 2010
Page 31 of 107
Survey:
Section: Real Estate TM
Items Booklet
RE43
Mark One Only
Vehicle 1:
Newest vehicle
What is the make of this vehicle?
WHEN THERE IS A TRUCK LISTED FOR A VEHICLE
AND MINIVANS ARE CLASSIFIED AS TRUCKS. (E.G.,
DODGE CARAVAN.) OTHERWISE CARS, TRUCKS, SUVS,
ARE LISTED TOGETHER. (E.G., ENTER CODE 42 FOR
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
(57)
(58)
Page 32 of 107
MAKE,SUVS, VANS
ENTER CODE 21 FOR
VANS AND MINIVANS
LINCOLN NAVIGATOR.)
ACURA
ACURA TRUCK
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BMW TRUCK
BUICK
BUICK TRUCK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HONDA TRUCK
HUMMER
HYUNDAI
HYUNDAI TRUCK
INFINITI
INFINITI TRUCK
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(72)
(73)
(74)
(99)
PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
SMART
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE
@
Enter Text
Vehicle 1:
RE44
Newest vehicle
What is the make of this vehicle?
@
Monday, April 05, 2010
Page 33 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE45
VEHICLE 1: NEWEST VEHICLE
What is the model of this vehicle?
[if RE43 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
CL
INTEGRA
LEGEND
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER
[else] [if RE43 eq <02>]
(01) MDX
(02) RDX
(99) OTHER
[else] [if RE43 eq <03>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)
164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER
[else] [if RE43 eq <04>]
(01)
(02)
(03)
(99)
ALLIANCE
AMC
EAGLE
OTHER
[else] [if RE43 eq <05>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE43 eq <06>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
Page 34 of 107
80 SERIES
90 SERIES
100
200
A3
A4
A5
A6
A8
ALL ROAD
CABRIOLET
Q7
QUATTRO
RS4
RS6
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(16)
(17)
(18)
(19)
(20)
(21)
(99)
S4
S5
S6
S8
TT
V8 SEDAN
OTHER
[else] [if RE43 eq <07>]
(01)
(02)
(03)
(99)
ARNAGE
AZURE
CONTINENTAL
OTHER
[else] [if RE43 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
325
328
330
525
528
530
540
735
740
750
840
850
1-SERIES
3-SERIES
5-SERIES
6-SERIES
7-SERIES
8-SERIES
L6
L7
M3
M5
M6
Z SERIES
Z3
Z4-SERIES
Z8-SERIES
OTHER
[else] [if RE43 eq <09>]
(01) X3-SERIES
(02) X5-SERIES
(03) X6
(99) OTHER
[else] [if RE43 eq <10>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
CENTURY
ELECTRA
ESTATE WAGON
LACROSSE
LESABRE
LUCERNE
PARK AVENUE
RAINIER
REATTA
REGAL
RENDEZVOUS
RIVIERA
ROADMASTER
SKYLARK
OTHER
Monday, April 05, 2010
Page 35 of 107
Survey:
Section: Real Estate TM
Items Booklet
[else] [if RE43 eq <11>]
(01) ENCLAVE
(02) TERRAZA
(99) OTHER
[else] [if RE43 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
DTS
ELDORADO
FLEETWOOD
SEVILLE
SIXTY SPECIAL
STS
XLR
OTHER
[else] [if RE43 eq <13>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE43 eq <14>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(99)
AVEO
BERETTA
CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CELEBRITY
COBALT
CORSICA
CORVETTE
CORVETTE-ZR1
HHR
IMPALA
LUMINA
MALIBU
METRO
MONTE CARLO
PRIZM
OTHER
[else] [if RE43 eq <15>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 36 of 107
APV/LUMINA
ASTRO
AVALANCHE
BLAZER
C1500 PICKUP
C2500 PICKUP
C3500/R3500 PICKUP
C/K 3500
COLORADO
EQUINOX
EXPRESS
G10 VAN
G1500
G1500 VAN
G20 VAN
G2500 VAN
G30 VAN
G3500
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(99)
G3500 VAN
K1500 BLAZER
LUMINA MINIVAN
S 10
SILVERADO
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
TRAVERSE
UPLANDER
V1500 BLAZER
VENTURE
OTHER
[else] [if RE43 eq <16>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
300 V6
300M
CIRRUS
CONCORDE
CROSSFIRE
FIFTH AVENUE
IMPERIAL
LEBARON
LHS
NEON
NEW YORKER
PROWLER
PT CRUISER
SEBRING
OTHER
[else] [if RE43 eq <17>]
(01)
(02)
(03)
(04)
(99)
ASPEN
PACIFICA
TOWN & COUNTRY
VOYAGER
OTHER
[else] [if RE43 eq <18>]
(01)
(02)
(03)
(99)
LANOS
LEGANZA
NUBIRA
OTHER
[else] [if RE43 eq <19>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE43 eq <20>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
AVENGER
CALIBER
CHALLENGER V9
CHARGER
COLT
DAYTONA
DYNASTY
INTREPID
MAGNUM
MONACO
NEON
OMNI
Monday, April 05, 2010
Page 37 of 107
Survey:
Section: Real Estate TM
(13)
(14)
(15)
(16)
(17)
(99)
Items Booklet
SHADOW
SPIRIT
STEALTH
STRATUS
VIPER
OTHER
[else] [if RE43 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
B 150, 250, OR 350 VAN
CARAVAN
D 150,250, 0R 350 PICKUP
DAKOTA PICKUP
DURANGO
GRAND CARAVAN
JOURNEY
NITRO
RAM BR CHASSIS CAB
RAMCHARGER
RAM PICKUP
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
OTHER
[else] [if RE43 eq <22>]
(01)
(02)
(03)
(04)
(99)
PREMIER
SUMMIT
TALON
VISION
OTHER
[else] [if RE43 eq <23>]
(01)
(02)
(03)
(04)
(99)
360
456M
575M MARANELLO
ENZO
OTHER
[else] [if RE43 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)
ASPIRE
CONTOUR
CROWN VICTORIA
ESCORT
FESTIVA
FIVE HUNDRED
FOCUS
FUSION
LTD CROWN VICTORIA
MUSTANG
MUSTANG-V6
MUSTANG-V8
PROBE
TAURUS
TEMPO
THUNDERBIRD
ZX2
OTHER
[else] [if RE43 eq <25>]
(01)
(02)
(03)
(04)
(05)
Page 38 of 107
AEROSTAR
BRONCO
BRONCO II
CLUB WAGON
E150 VAN
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
E250 VAN
E350 VAN
ECONOLINE
EDGE
ESCAPE
EXCURSION
EXPEDITION
EXPLORER
F150 PICKUP
F150 SUPERCREW PICKUP
F250 PICKUP
F350 PICKUP
F450
F550
F650
F750
FLEX
FREESTAR
FREESTYLE
RANGER
TAURUS X
WINDSTAR
OTHER
[else] [if RE43 eq <26>]
(01)
(02)
(03)
(04)
(05)
(99)
METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER
[else] [if RE43 eq <27>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
ACADIA
C1500, C2500, C3500, OR R3500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA
S15 PICKUP
SAFARI
SAVANNA
SIERRA
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER
[else] [if RE43 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CRX
DEL SOL
FIT
INSIGHT
Monday, April 05, 2010
Page 39 of 107
Survey:
Section: Real Estate TM
Items Booklet
(09) PRELUDE
(10) S2000
(99) OTHER
[else] [if RE43 eq <29>]
(01) CR-V
(02) ELEMENT
(03) ODYSSEY
(04) PASSPORT
(05) PILOT
(99) OTHER
[else] [if RE43 eq <30>]
(01)
(02)
(03)
(99)
H1
H2
H3
OTHER
[else] [if RE43 eq <31>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
ACCENT
AZERA
ELANTRA
EXCEL
GENESIS
SANTA FE
SCOUPE
SONATA
TIBURON
XG300
XG350
OTHER
[else] [if RE43 eq <32>]
(01)
(02)
(03)
(99)
ENTOURAGE
TUSCON
VERACRUZ
OTHER
[else] [if RE43 eq <33>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
G37
I30
I35
J30
M30
M35
M45
Q45
OTHER
[else] [if RE43 eq <34>]
(01)
(02)
(03)
(04)
(99)
EX45
FX
QX4
QX 56
OTHER
[else] [if RE43 eq <35>]
Page 40 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUPS
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER
[else] [if RE43 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)
S-TYPE
X-TYPE
XF
XJ6
XJ8
XJS
XK8
OTHER
[else] [if RE43 eq <37>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
CHEROKEE
COMANCHE
COMMANDER
COMPASS
GRAND CHEROKEE
GRAND WAGONEER
LIBERTY
PATRIOT
WRANGLER
OTHER
[else] [if RE43 eq <38>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
AMANTI
BORREGO
NEW SPECTRA
OPTIMA
RIO
RONDO
SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER
[else] [if RE43 eq <39>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE43 eq <40>]
(01)
(02)
(03)
(04)
(05)
(99)
DISCOVERY
FREELANDER
L2
L3
RANGE ROVER
OTHER
[else] [if RE43 eq <41>]
Monday, April 05, 2010
Page 41 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
Items Booklet
ES SERIES
GS SERIES
GX SERIES
IS SERIES
LS SERIES
LX SERIES
RX SERIES
SC SERIES
OTHER
[else] [if RE43 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AVIATOR
BLACKWOOD
CONTINENTAL
LS
MARK VII
MARK VIII
MARK LT PICKUP
MKS
MKX
MKZ
NAVIGATOR
TOWN CAR
ZEPHYR
OTHER
[else] [if RE43 eq <43>]
(01) ESPRIT
(99) OTHER
[else] [if RE43 eq <44>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE43 eq <45>]
(01) 57
(02) 62
(99) OTHER
[else] [if RE43 eq <46>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
323
626
929
MAZDA3
MAZDA5
MAZDA6
MAZDASPEED6
MILLENIA
MX3
MX5
MX5 MIATA
MX6
PROTEGE
RX7
RX8
OTHER
[else] [if RE43 eq <47>]
(01) B SERIES PICKUPS (B2300, B3500, B4000 ETC.)
(02) CX-7
(03) CX-9
Page 42 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(04)
(05)
(06)
(99)
MPV
NAVAJO
TRIBUTE
OTHER
[else] [if RE43 eq <48>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)
190
260E
300
350
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
CLS CLASS
E CLASS
G CLASS
GL CLASS
M CLASS
ML320
R CLASS
S CLASS
SL CLASS
SLK CLASS
OTHER
[else] [if RE43 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
CAPRI
COUGAR
GRAND MARQUIS
MARAUDER
MARINER
MONTEREY
MOUNTAINEER
MYSTIQUE
SABLE
TOPAZ
TRACER
VILLAGER
OTHER
[else] [if RE43 eq <50>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE43 eq <51>]
(01) COOPER
(99) OTHER
[else] [if RE43 eq <52>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
Monday, April 05, 2010
Page 43 of 107
Survey:
Section: Real Estate TM
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
Items Booklet
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PICKUPS
PRECIS
RAIDER
SIGMA
STARION
TREDIA
VAN/WAGON
OTHER
[else] [if RE43 eq <53>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER
[else] [if RE43 eq <54>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
ARMANDA
FRONTIER
MURANO
PATHFINDER
PATHFINDER ARMADA
PICKUPS
QUEST
ROUGE
TITAN
XTERRA
OTHER
[else] [if RE43 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
ACHIEVA
ALERO
AURORA
BRAVADA
CIERA
CUSTOM CRUISER
CUTLASS
EIGHTY-EIGHT
INTRIGUE-V6
LSS-V6
NINETY-EIGHT
REGENCY
SILHOUETTE
TORONADO
OTHER
[else] [if RE43 eq <56>]
(01) 405
(02) 505
(99) OTHER
Page 44 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
[else] [if RE43 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
ACCLAIM
BREEZE
COLT
HORIZON
LASER
NEON
PROWLER
SUNDANCE
OTHER
[else] [if RE43 eq <58>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE43 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
6000
BONNEVILLE-V6
FIREBIRD
G5
G6
G8
GRAND AM
GRAND AM SE-V6
GRAND PRIX
GTO
LEMANS
SOLSTICE
SUNBIRD
SUNFIRE
VIBE
OTHER
[else] [if RE43 eq <60>]
(01)
(02)
(03)
(04)
(99)
AZTEK
MONTANA
TORRENT
TRANS SPORT
OTHER
[else] [if RE43 eq <61>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
911
928
944
968
996
BOXSTER
CAYENNE
CAYMAN
OTHER
[else] [if RE43 eq <62>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE43 eq <63>]
(01) PHANTOM
(99) OTHER
[else] [if RE43 eq <64>]
Monday, April 05, 2010
Page 45 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(99)
Items Booklet
9-2X
9-3
9-5
9-7X
900
9000
OTHER
[else] [if RE43 eq <65>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
ASTRA
AURA
ION
L SERIES
OUTLOOK
RELAY
S SERIES
SKY
VUE
OTHER
[else] [if RE43 eq <66>]
(01)
(02)
(03)
(04)
(99)
tC
xA
xB
xD
OTHER
[else] [if RE43 eq <67>]
(01) FORTWO
(99) OTHER
[else] [if RE43 eq <68>]
(01) 827
(99) OTHER
[else] [if RE43 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
SVX
TRIBECA
XT
OTHER
[else] [if RE43 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
Page 46 of 107
AERIO
ESTEEM
FORENZA
GRAND VITARIA
RENO
SAMURAI
SIDEKICK
SWIFT
VERONA
VITARA
SX4
X-90
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(13) XL-7
(99) OTHER
[else] [if RE43 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
MATRIX
MR2(SPIDER)
PASEO
PRIUS
SUPRA
TERCEL
YARIS
OTHER
[else] [if RE43 eq <72>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
4RUNNER
FJ CRUISER
HIGHLANDER
LAND CRUISER
PICKUPS
PREVIA
RAV4
SEQUOIA
SIENNA
T100 PICKUP
TACOMA
TUNDRA
OTHER
[else] [if RE43 eq <73>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(99)
BEETLE
CABRIO
CABRIOLET
CORRADO
EOS
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW CABRIO
NEW GOLF
NEW JETTA
NEW PASSAT
PASSAT
PHAETON
QUANTUM
R32
ROUTAN
SCIRROCCO
TIGUAN
TOUAREG
VANAGON
OTHER
[else] [if RE43 eq <74>]
(01) 240
Monday, April 05, 2010
Page 47 of 107
Survey:
Section: Real Estate TM
Items Booklet
(02) 740
(03) 760
(04) 780
(05) 850
(06) 940
(07) 960
(08) C30
(09) C40
(10) C70
(11) S40
(12) S60
(13) S70
(14) S80
(15) S90
(16) V40
(17) V50
(18) V70
(19) V90
(20) XC90
(99) OTHER
[endif all]
@
Mark One Only
RE47
VEHICLE 1: NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number
RE48
VEHICLE 1: NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only
RE49
VEHICLE 1: NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@
Page 48 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
Multiple Entry
RE50
[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 2: SECOND NEWEST VEHICLE
Who owns [fill TEMP1]?
ENTER LINE NUMBER OF PERSON(S) WHO OWN
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1
@LN2
Enter Number
RE51
VEHICLE 2: SECOND NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@
Monday, April 05, 2010
Page 49 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE52
VEHICLE 2: SECOND NEWEST VEHICLE
What is the make of this vehicle?
WHEN THERE IS A TRUCK LISTED FOR A VEHICLE MAKE, SUVS, VANS AND
MINIVANS ARE CLASSIFIED AS TRUCKS. (E.G., ENTER CODE 21 FOR DODGE
CARAVAN.) OTHERWISE CARS, TRUCKS, SUVS, VANS AND MINIVANS ARE LISTED
TOGETHER. (E.G., ENTER CODE 42 FOR LINCOLN NAVIGATOR.)
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
(57)
(58)
Page 50 of 107
ACURA
ACURA TRUCK
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BMW TRUCK
BUICK
BUICK TRUCK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HONDA TRUCK
HUMMER
HYUNDAI
HYUNDAI TRUCK
INFINITI
INFINITI TRUCK
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Monday, April 05, 2010
Items Booklet
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(72)
(73)
(74)
(99)
Survey:
Section: Real Estate TM
PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
SMART
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE
@
Monday, April 05, 2010
Page 51 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE54
VEHICLE 2: SECOND NEWEST VEHICLE
What is the model of this vehicle?
[if RE52 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
CL
INTEGRA
LEGEND
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER
[else] [if RE52 eq <02>]
(01) MDX
(02) RDX
(99) OTHER
[else] [if RE52 eq <03>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)
164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER
[else] [if RE52 eq <04>]
(01)
(02)
(03)
(99)
ALLIANCE
AMC
EAGLE
OTHER
[else] [if RE52 eq <05>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE52 eq <06>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
Page 52 of 107
80 SERIES
90 SERIES
100
200
A3
A4
A5
A6
A8
ALL ROAD
CABRIOLET
Q7
QUATTRO
RS4
RS6
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(16)
(17)
(18)
(19)
(20)
(21)
(99)
S4
S5
S6
S8
TT
V8 SEDAN
OTHER
[else] [if RE52 eq <07>]
(01)
(02)
(03)
(99)
ARNAGE
AZURE
CONTINENTAL
OTHER
[else] [if RE52 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
325
328
330
525
528
530
540
735
740
750
840
850
1-SERIES
3-SERIES
5-SERIES
6-SERIES
7-SERIES
8-SERIES
L6
L7
M3
M5
M6
Z SERIES
Z3
Z4-SERIES
Z8-SERIES
OTHER
[else] [if RE52 eq <09>]
(01) X3-SERIES
(02) X5-SERIES
(03) X6
(99) OTHER
[else] [if RE52 eq <10>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
CENTURY
ELECTRA
ESTATE WAGON
LACROSSE
LESABRE
LUCERNE
PARK AVENUE
RAINIER
REATTA
REGAL
RENDEZVOUS
RIVIERA
ROADMASTER
SKYLARK
OTHER
Monday, April 05, 2010
Page 53 of 107
Survey:
Section: Real Estate TM
Items Booklet
[else] [if RE52 eq <11>]
(01) ENCLAVE
(02) TERRAZA
(99) OTHER
[else] [if RE52 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
DTS
ELDORADO
FLEETWOOD
SEVILLE
SIXTY SPECIAL
STS
XLR
OTHER
[else] [if RE52 eq <13>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE52 eq <14>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(99)
AVEO
BERETTA
CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CELEBRITY
COBALT
CORSICA
CORVETTE
CORVETTE-ZR1
HHR
IMPALA
LUMINA
MALIBU
METRO
MONTE CARLO
PRIZM
OTHER
[else] [if RE52 eq <15>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 54 of 107
APV/LUMINA
ASTRO
AVALANCHE
BLAZER
C1500 PICKUP
C2500 PICKUP
C3500/R3500 PICKUP
C/K 3500
COLORADO
EQUINOX
EXPRESS
G10 VAN
G1500
G1500 VAN
G20 VAN
G2500 VAN
G30 VAN
G3500
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(99)
G3500 VAN
K1500 BLAZER
LUMINA MINIVAN
S 10
SILVERADO
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
TRAVERSE
UPLANDER
V1500 BLAZER
VENTURE
OTHER
[else] [if RE52 eq <16>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
300 V6
300M
CIRRUS
CONCORDE
CROSSFIRE
FIFTH AVENUE
IMPERIAL
LEBARON
LHS
NEON
NEW YORKER
PROWLER
PT CRUISER
SEBRING
OTHER
[else] [if RE52 eq <17>]
(01)
(02)
(03)
(04)
(99)
ASPEN
PACIFICA
TOWN & COUNTRY
VOYAGER
OTHER
[else] [if RE52 eq <18>]
(01)
(02)
(03)
(99)
LANOS
LEGANZA
NUBIRA
OTHER
[else] [if RE52 eq <19>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE52 eq <20>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
AVENGER
CALIBER
CHALLENGER V9
CHARGER
COLT
DAYTONA
DYNASTY
INTREPID
MAGNUM
MONACO
NEON
OMNI
Monday, April 05, 2010
Page 55 of 107
Survey:
Section: Real Estate TM
(13)
(14)
(15)
(16)
(17)
(99)
Items Booklet
SHADOW
SPIRIT
STEALTH
STRATUS
VIPER
OTHER
[else] [if RE52 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
B 150, 250, OR 350 VAN
CARAVAN
D 150,250, 0R 350 PICKUP
DAKOTA PICKUP
DURANGO
GRAND CARAVAN
JOURNEY
NITRO
RAM BR CHASSIS CAB
RAMCHARGER
RAM PICKUP
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
OTHER
[else] [if RE52 eq <22>]
(01)
(02)
(03)
(04)
(99)
PREMIER
SUMMIT
TALON
VISION
OTHER
[else] [if RE52 eq <23>]
(01)
(02)
(03)
(04)
(99)
360
456M
575M MARANELLO
ENZO
OTHER
[else] [if RE52 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)
ASPIRE
CONTOUR
CROWN VICTORIA
ESCORT
FESTIVA
FIVE HUNDRED
FOCUS
FUSION
LTD CROWN VICTORIA
MUSTANG
MUSTANG-V6
MUSTANG-V8
PROBE
TAURUS
TEMPO
THUNDERBIRD
ZX2
OTHER
[else] [if RE52 eq <25>]
(01)
(02)
(03)
(04)
(05)
Page 56 of 107
AEROSTAR
BRONCO
BRONCO II
CLUB WAGON
E150 VAN
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
E250 VAN
E350 VAN
ECONOLINE
EDGE
ESCAPE
EXCURSION
EXPEDITION
EXPLORER
F150 PICKUP
F150 SUPERCREW PICKUP
F250 PICKUP
F350 PICKUP
F450
F550
F650
F750
FLEX
FREESTAR
FREESTYLE
RANGER
TAURUS X
WINDSTAR
OTHER
[else] [if RE52 eq <26>]
(01)
(02)
(03)
(04)
(05)
(99)
METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER
[else] [if RE52 eq <27>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
ACADIA
C1500, C2500, C3500, OR R3500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA
S15 PICKUP
SAFARI
SAVANNA
SIERRA
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER
[else] [if RE52 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CRX
DEL SOL
FIT
INSIGHT
Monday, April 05, 2010
Page 57 of 107
Survey:
Section: Real Estate TM
Items Booklet
(09) PRELUDE
(10) S2000
(99) OTHER
[else] [if RE52 eq <29>]
(01)
(02)
(03)
(04)
(05)
(99)
CR-V
ELEMENT
ODYSSEY
PASSPORT
PILOT
OTHER
[else] [if RE52 eq <30>]
(01)
(02)
(03)
(99)
H1
H2
H3
OTHER
[else] [if RE52 eq <31>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
ACCENT
AZERA
ELANTRA
EXCEL
GENESIS
SANTA FE
SCOUPE
SONATA
TIBURON
XG300
XG350
OTHER
[else] [if RE52 eq <32>]
(01)
(02)
(03)
(99)
ENTOURAGE
TUSCON
VERACRUZ
OTHER
[else] [if RE52 eq <33>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
G37
I30
I35
J30
M30
M35
M45
Q45
OTHER
[else] [if RE52 eq <34>]
(01)
(02)
(03)
(04)
(99)
EX45
FX
QX4
QX 56
OTHER
[else] [if RE52 eq <35>]
Page 58 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUPS
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER
[else] [if RE52 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)
S-TYPE
X-TYPE
XF
XJ6
XJ8
XJS
XK8
OTHER
[else] [if RE52 eq <37>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
CHEROKEE
COMANCHE
COMMANDER
COMPASS
GRAND CHEROKEE
GRAND WAGONEER
LIBERTY
PATRIOT
WRANGLER
OTHER
[else] [if RE52 eq <38>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
AMANTI
BORREGO
NEW SPECTRA
OPTIMA
RIO
RONDO
SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER
[else] [if RE52 eq <39>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE52 eq <40>]
(01)
(02)
(03)
(04)
(05)
(99)
DISCOVERY
FREELANDER
L2
L3
RANGE ROVER
OTHER
[else] [if RE52 eq <41>]
Monday, April 05, 2010
Page 59 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
Items Booklet
ES SERIES
GS SERIES
GX SERIES
IS SERIES
LS SERIES
LX SERIES
RX SERIES
SC SERIES
OTHER
[else] [if RE52 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AVIATOR
BLACKWOOD
CONTINENTAL
LS
MARK VII
MARK VIII
MARK LT PICKUP
MKS
MKX
MKZ
NAVIGATOR
TOWN CAR
ZEPHYR
OTHER
[else] [if RE52 eq <43>]
(01) ESPRIT
(99) OTHER
[else] [if RE52 eq <44>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE52 eq <45>]
(01) 57
(02) 62
(99) OTHER
[else] [if RE52 eq <46>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
323
626
929
MAZDA3
MAZDA5
MAZDA6
MAZDASPEED6
MILLENIA
MX3
MX5
MX5 MIATA
MX6
PROTEGE
RX7
RX8
OTHER
[else] [if RE52 eq <47>]
(01) B SERIES PICKUPS (B2300, B3500, B4000 ETC.)
(02) CX-7
(03) CX-9
Page 60 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(04)
(05)
(06)
(99)
MPV
NAVAJO
TRIBUTE
OTHER
[else] [if RE52 eq <48>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)
190
260E
300
350
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
CLS CLASS
E CLASS
G CLASS
GL CLASS
M CLASS
ML320
R CLASS
S CLASS
SL CLASS
SLK CLASS
OTHER
[else] [if RE52 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
CAPRI
COUGAR
GRAND MARQUIS
MARAUDER
MARINER
MONTEREY
MOUNTAINEER
MYSTIQUE
SABLE
TOPAZ
TRACER
VILLAGER
OTHER
[else] [if RE52 eq <50>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE52 eq <51>]
(01) COOPER
(99) OTHER
[else] [if RE52 eq <52>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
Monday, April 05, 2010
Page 61 of 107
Survey:
Section: Real Estate TM
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
Items Booklet
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PICKUPS
PRECIS
RAIDER
SIGMA
STARION
TREDIA
VAN/WAGON
OTHER
[else] [if RE52 eq <53>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER
[else] [if RE52 eq <54>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
ARMANDA
FRONTIER
MURANO
PATHFINDER
PATHFINDER ARMADA
PICKUPS
QUEST
ROUGE
TITAN
XTERRA
OTHER
[else] [if RE52 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
ACHIEVA
ALERO
AURORA
BRAVADA
CIERA
CUSTOM CRUISER
CUTLASS
EIGHTY-EIGHT
INTRIGUE-V6
LSS-V6
NINETY-EIGHT
REGENCY
SILHOUETTE
TORONADO
OTHER
[else] [if RE52 eq <56>]
(01) 405
(02) 505
(99) OTHER
Page 62 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
[else] [if RE52 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
ACCLAIM
BREEZE
COLT
HORIZON
LASER
NEON
PROWLER
SUNDANCE
OTHER
[else] [if RE52 eq <58>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE52 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
6000
BONNEVILLE-V6
FIREBIRD
G5
G6
G8
GRAND AM
GRAND AM SE-V6
GRAND PRIX
GTO
LEMANS
SOLSTICE
SUNBIRD
SUNFIRE
VIBE
OTHER
[else] [if RE52 eq <60>]
(01)
(02)
(03)
(04)
(99)
AZTEK
MONTANA
TORRENT
TRANS SPORT
OTHER
[else] [if RE52 eq <61>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
911
928
944
968
996
BOXSTER
CAYENNE
CAYMAN
OTHER
[else] [if RE52 eq <62>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE52 eq <63>]
(01) PHANTOM
(99) OTHER
[else] [if RE52 eq <64>]
Monday, April 05, 2010
Page 63 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(99)
Items Booklet
9-2X
9-3
9-5
9-7X
900
9000
OTHER
[else] [if RE52 eq <65>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
ASTRA
AURA
ION
L SERIES
OUTLOOK
RELAY
S SERIES
SKY
VUE
OTHER
[else] [if RE52 eq <66>]
(01)
(02)
(03)
(04)
(99)
tC
xA
xB
xD
OTHER
[else] [if RE52 eq <67>]
(01) FORTWO
(99) OTHER
[else] [if RE52 eq <68>]
(01) 827
(99) OTHER
[else] [if RE52 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
SVX
TRIBECA
XT
OTHER
[else] [if RE52 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
Page 64 of 107
AERIO
ESTEEM
FORENZA
GRAND VITARIA
RENO
SAMURAI
SIDEKICK
SWIFT
VERONA
VITARA
SX4
X-90
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(13) XL-7
(99) OTHER
[else] [if RE52 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
MATRIX
MR2(SPIDER)
PASEO
PRIUS
SUPRA
TERCEL
YARIS
OTHER
[else] [if RE52 eq <72>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
4RUNNER
FJ CRUISER
HIGHLANDER
LAND CRUISER
PICKUPS
PREVIA
RAV4
SEQUOIA
SIENNA
T100 PICKUP
TACOMA
TUNDRA
OTHER
[else] [if RE52 eq <73>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(99)
BEETLE
CABRIO
CABRIOLET
CORRADO
EOS
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW CABRIO
NEW GOLF
NEW JETTA
NEW PASSAT
PASSAT
PHAETON
QUANTUM
R32
ROUTAN
SCIRROCCO
TIGUAN
TOUAREG
VANAGON
OTHER
[else] [if RE52 eq <74>]
(01) 240
Monday, April 05, 2010
Page 65 of 107
Survey:
Section: Real Estate TM
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
[endif all]
Items Booklet
740
760
780
850
940
960
C30
C40
C70
S40
S60
S70
S80
S90
V40
V50
V70
V90
XC90
OTHER
@
Mark One Only
RE56
VEHICLE 2: SECOND NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number
RE57
VEHICLE 2: SECOND NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only
RE58
VEHICLE 2: SECOND NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@
Page 66 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
Multiple Entry
RE59
[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 3: THIRD NEWEST VEHICLE
Who owns the third newest motor vehicle?
ENTER LINE NUMBER OF PERSON(S) WHO OWNS
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1
@LN2
Enter Number
RE60
VEHICLE 3: THIRD NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@
Monday, April 05, 2010
Page 67 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE61
VEHICLE 3: THIRD NEWEST VEHICLE
What is the make of this vehicle?
WHEN THERE IS A TRUCK LISTED FOR A VEHICLE MAKE, SUVS, VANS AND
MINIVANS ARE CLASSIFIED AS TRUCKS. (E.G., ENTER CODE 21 FOR
DODGE CARAVAN.) OTHERWISE CARS, TRUCKS, SUVS, VANS AND MINIVANS
ARE LISTED TOGETHER. (E.G., ENTER CODE 42 FOR LINCOLN NAVIGATOR.)
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
(57)
(58)
Page 68 of 107
ACURA
ACURA TRUCK
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BMW TRUCK
BUICK
BUICK TRUCK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HONDA TRUCK
HUMMER
HYUNDAI
HYUNDAI TRUCK
INFINITI
INFINITI TRUCK
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Monday, April 05, 2010
Items Booklet
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(72)
(73)
(74)
(99)
Survey:
Section: Real Estate TM
PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
SMART
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE
@
Monday, April 05, 2010
Page 69 of 107
Survey:
Section: Real Estate TM
Items Booklet
Mark One Only
RE63
VEHICLE 3: THIRD NEWEST VEHICLE
What is the model of this vehicle?
[if RE61 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
CL
INTEGRA
LEGEND
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER
[else] [if RE61 eq <02>]
(01) MDX
(02) RDX
(99) OTHER
[else] [if RE61 eq <03>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)
164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER
[else] [if RE61 eq <04>]
(01)
(02)
(03)
(99)
ALLIANCE
AMC
EAGLE
OTHER
[else] [if RE61 eq <05>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE61 eq <06>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
Page 70 of 107
80 SERIES
90 SERIES
100
200
A3
A4
A5
A6
A8
ALL ROAD
CABRIOLET
Q7
QUATTRO
RS4
RS6
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(16)
(17)
(18)
(19)
(20)
(21)
(99)
S4
S5
S6
S8
TT
V8 SEDAN
OTHER
[else] [if RE61 eq <07>]
(01)
(02)
(03)
(99)
ARNAGE
AZURE
CONTINENTAL
OTHER
[else] [if RE61 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
325
328
330
525
528
530
540
735
740
750
840
850
1-SERIES
3-SERIES
5-SERIES
6-SERIES
7-SERIES
8-SERIES
L6
L7
M3
M5
M6
Z SERIES
Z3
Z4-SERIES
Z8-SERIES
OTHER
[else] [if RE61 eq <09>]
(01) X3-SERIES
(02) X5-SERIES
(03) X6
(99) OTHER
[else] [if RE61 eq <10>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
CENTURY
ELECTRA
ESTATE WAGON
LACROSSE
LESABRE
LUCERNE
PARK AVENUE
RAINIER
REATTA
REGAL
RENDEZVOUS
RIVIERA
ROADMASTER
SKYLARK
OTHER
Monday, April 05, 2010
Page 71 of 107
Survey:
Section: Real Estate TM
Items Booklet
[else] [if RE61 eq <11>]
(01) ENCLAVE
(02) TERRAZA
(99) OTHER
[else] [if RE61 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
DTS
ELDORADO
FLEETWOOD
SEVILLE
SIXTY SPECIAL
STS
XLR
OTHER
[else] [if RE61 eq <13>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE61 eq <14>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(99)
AVEO
BERETTA
CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CELEBRITY
COBALT
CORSICA
CORVETTE
CORVETTE-ZR1
HHR
IMPALA
LUMINA
MALIBU
METRO
MONTE CARLO
PRIZM
OTHER
[else] [if RE61 eq <15>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 72 of 107
APV/LUMINA
ASTRO
AVALANCHE
BLAZER
C1500 PICKUP
C2500 PICKUP
C3500/R3500 PICKUP
C/K 3500
COLORADO
EQUINOX
EXPRESS
G10 VAN
G1500
G1500 VAN
G20 VAN
G2500 VAN
G30 VAN
G3500
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(99)
G3500 VAN
K1500 BLAZER
LUMINA MINIVAN
S 10
SILVERADO
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
TRAVERSE
UPLANDER
V1500 BLAZER
VENTURE
OTHER
[else] [if RE61 eq <16>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
300 V6
300M
CIRRUS
CONCORDE
CROSSFIRE
FIFTH AVENUE
IMPERIAL
LEBARON
LHS
NEON
NEW YORKER
PROWLER
PT CRUISER
SEBRING
OTHER
[else] [if RE61 eq <17>]
(01)
(02)
(03)
(04)
(99)
ASPEN
PACIFICA
TOWN & COUNTRY
VOYAGER
OTHER
[else] [if RE61 eq <18>]
(01)
(02)
(03)
(99)
LANOS
LEGANZA
NUBIRA
OTHER
[else] [if RE61 eq <19>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE61 eq <20>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
AVENGER
CALIBER
CHALLENGER V9
CHARGER
COLT
DAYTONA
DYNASTY
INTREPID
MAGNUM
MONACO
NEON
OMNI
Monday, April 05, 2010
Page 73 of 107
Survey:
Section: Real Estate TM
(13)
(14)
(15)
(16)
(17)
(99)
Items Booklet
SHADOW
SPIRIT
STEALTH
STRATUS
VIPER
OTHER
[else] [if RE61 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
B 150, 250, OR 350 VAN
CARAVAN
D 150,250, 0R 350 PICKUP
DAKOTA PICKUP
DURANGO
GRAND CARAVAN
JOURNEY
NITRO
RAM BR CHASSIS CAB
RAMCHARGER
RAM PICKUP
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
OTHER
[else] [if RE61 eq <22>]
(01)
(02)
(03)
(04)
(99)
PREMIER
SUMMIT
TALON
VISION
OTHER
[else] [if RE61 eq <23>]
(01)
(02)
(03)
(04)
(99)
360
456M
575M MARANELLO
ENZO
OTHER
[else] [if RE61 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)
ASPIRE
CONTOUR
CROWN VICTORIA
ESCORT
FESTIVA
FIVE HUNDRED
FOCUS
FUSION
LTD CROWN VICTORIA
MUSTANG
MUSTANG-V6
MUSTANG-V8
PROBE
TAURUS
TEMPO
THUNDERBIRD
ZX2
OTHER
[else] [if RE61 eq <25>]
(01)
(02)
(03)
(04)
(05)
Page 74 of 107
AEROSTAR
BRONCO
BRONCO II
CLUB WAGON
E150 VAN
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(99)
E250 VAN
E350 VAN
ECONOLINE
EDGE
ESCAPE
EXCURSION
EXPEDITION
EXPLORER
F150 PICKUP
F150 SUPERCREW PICKUP
F250 PICKUP
F350 PICKUP
F450
F550
F650
F750
FLEX
FREESTAR
FREESTYLE
RANGER
TAURUS X
WINDSTAR
OTHER
[else] [if RE61 eq <26>]
(01)
(02)
(03)
(04)
(05)
(99)
METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER
[else] [if RE61 eq <27>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
ACADIA
C1500, C2500, C3500, OR R3500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA
S15 PICKUP
SAFARI
SAVANNA
SIERRA
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER
[else] [if RE61 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CRX
DEL SOL
FIT
INSIGHT
Monday, April 05, 2010
Page 75 of 107
Survey:
Section: Real Estate TM
Items Booklet
(09) PRELUDE
(10) S2000
(99) OTHER
[else] [if RE61 eq <29>]
(01)
(02)
(03)
(04)
(05)
(99)
CR-V
ELEMENT
ODYSSEY
PASSPORT
PILOT
OTHER
[else] [if RE61 eq <30>]
(01)
(02)
(03)
(99)
H1
H2
H3
OTHER
[else] [if RE61 eq <31>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
ACCENT
AZERA
ELANTRA
EXCEL
GENESIS
SANTA FE
SCOUPE
SONATA
TIBURON
XG300
XG350
OTHER
[else] [if RE61 eq <32>]
(01)
(02)
(03)
(99)
ENTOURAGE
TUSCON
VERACRUZ
OTHER
[else] [if RE61 eq <33>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
G37
I30
I35
J30
M30
M35
M45
Q45
OTHER
[else] [if RE61 eq <34>]
(01)
(02)
(03)
(04)
(99)
EX45
FX
QX4
QX 56
OTHER
[else] [if RE61 eq <35>]
Page 76 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUPS
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER
[else] [if RE61 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)
S-TYPE
X-TYPE
XF
XJ6
XJ8
XJS
XK8
OTHER
[else] [if RE61 eq <37>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
CHEROKEE
COMANCHE
COMMANDER
COMPASS
GRAND CHEROKEE
GRAND WAGONEER
LIBERTY
PATRIOT
WRANGLER
OTHER
[else] [if RE61 eq <38>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)
AMANTI
BORREGO
NEW SPECTRA
OPTIMA
RIO
RONDO
SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER
[else] [if RE61 eq <39>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE61 eq <40>]
(01)
(02)
(03)
(04)
(05)
(99)
DISCOVERY
FREELANDER
L2
L3
RANGE ROVER
OTHER
[else] [if RE61 eq <41>]
Monday, April 05, 2010
Page 77 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
Items Booklet
ES SERIES
GS SERIES
GX SERIES
IS SERIES
LS SERIES
LX SERIES
RX SERIES
SC SERIES
OTHER
[else] [if RE61 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)
AVIATOR
BLACKWOOD
CONTINENTAL
LS
MARK VII
MARK VIII
MARK LT PICKUP
MKS
MKX
MKZ
NAVIGATOR
TOWN CAR
ZEPHYR
OTHER
[else] [if RE61 eq <43>]
(01) ESPRIT
(99) OTHER
[else] [if RE61 eq <44>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE61 eq <45>]
(01) 57
(02) 62
(99) OTHER
[else] [if RE61 eq <46>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
323
626
929
MAZDA3
MAZDA5
MAZDA6
MAZDASPEED6
MILLENIA
MX3
MX5
MX5 MIATA
MX6
PROTEGE
RX7
RX8
OTHER
[else] [if RE61 eq <47>]
(01) B SERIES PICKUPS (B2300, B3500, B4000 ETC.)
(02) CX-7
(03) CX-9
Page 78 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(04)
(05)
(06)
(99)
MPV
NAVAJO
TRIBUTE
OTHER
[else] [if RE61 eq <48>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)
190
260E
300
350
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
CLS CLASS
E CLASS
G CLASS
GL CLASS
M CLASS
ML320
R CLASS
S CLASS
SL CLASS
SLK CLASS
OTHER
[else] [if RE61 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
CAPRI
COUGAR
GRAND MARQUIS
MARAUDER
MARINER
MONTEREY
MOUNTAINEER
MYSTIQUE
SABLE
TOPAZ
TRACER
VILLAGER
OTHER
[else] [if RE61 eq <50>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE61 eq <51>]
(01) COOPER
(99) OTHER
[else] [if RE61 eq <52>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
Monday, April 05, 2010
Page 79 of 107
Survey:
Section: Real Estate TM
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
Items Booklet
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PICKUPS
PRECIS
RAIDER
SIGMA
STARION
TREDIA
VAN/WAGON
OTHER
[else] [if RE61 eq <53>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER
[else] [if RE61 eq <54>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)
ARMANDA
FRONTIER
MURANO
PATHFINDER
PATHFINDER ARMADA
PICKUPS
QUEST
ROUGE
TITAN
XTERRA
OTHER
[else] [if RE61 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
ACHIEVA
ALERO
AURORA
BRAVADA
CIERA
CUSTOM CRUISER
CUTLASS
EIGHTY-EIGHT
INTRIGUE-V6
LSS-V6
NINETY-EIGHT
REGENCY
SILHOUETTE
TORONADO
OTHER
[else] [if RE61 eq <56>]
(01) 405
(02) 505
(99) OTHER
Page 80 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
[else] [if RE61 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
ACCLAIM
BREEZE
COLT
HORIZON
LASER
NEON
PROWLER
SUNDANCE
OTHER
[else] [if RE61 eq <58>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE61 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
6000
BONNEVILLE-V6
FIREBIRD
G5
G6
G8
GRAND AM
GRAND AM SE-V6
GRAND PRIX
GTO
LEMANS
SOLSTICE
SUNBIRD
SUNFIRE
VIBE
OTHER
[else] [if RE61 eq <60>]
(01)
(02)
(03)
(04)
(99)
AZTEK
MONTANA
TORRENT
TRANS SPORT
OTHER
[else] [if RE61 eq <61>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)
911
928
944
968
996
BOXSTER
CAYENNE
CAYMAN
OTHER
[else] [if RE61 eq <62>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE61 eq <63>]
(01) PHANTOM
(99) OTHER
[else] [if RE61 eq <64>]
Monday, April 05, 2010
Page 81 of 107
Survey:
Section: Real Estate TM
(01)
(02)
(03)
(04)
(05)
(06)
(99)
Items Booklet
9-2X
9-3
9-5
9-7X
900
9000
OTHER
[else] [if RE61 eq <65>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)
ASTRA
AURA
ION
L SERIES
OUTLOOK
RELAY
S SERIES
SKY
VUE
OTHER
[else] [if RE61 eq <66>]
(01)
(02)
(03)
(04)
(99)
tC
xA
xB
xD
OTHER
[else] [if RE61 eq <67>]
(01) FORTWO
(99) OTHER
[else] [if RE61 eq <68>]
(01) 827
(99) OTHER
[else] [if RE61 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
SVX
TRIBECA
XT
OTHER
[else] [if RE61 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
Page 82 of 107
AERIO
ESTEEM
FORENZA
GRAND VITARIA
RENO
SAMURAI
SIDEKICK
SWIFT
VERONA
VITARA
SX4
X-90
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
(13) XL-7
(99) OTHER
[else] [if RE61 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
MATRIX
MR2(SPIDER)
PASEO
PRIUS
SUPRA
TERCEL
YARIS
OTHER
[else] [if RE61 eq <72>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)
4RUNNER
FJ CRUISER
HIGHLANDER
LAND CRUISER
PICKUPS
PREVIA
RAV4
SEQUOIA
SIENNA
T100 PICKUP
TACOMA
TUNDRA
OTHER
[else] [if RE61 eq <73>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(99)
BEETLE
CABRIO
CABRIOLET
CORRADO
EOS
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW CABRIO
NEW GOLF
NEW JETTA
NEW PASSAT
PASSAT
PHAETON
QUANTUM
R32
ROUTAN
SCIRROCCO
TIGUAN
TOUAREG
VANAGON
OTHER
[else] [if RE61 eq <74>]
(01) 240
Monday, April 05, 2010
Page 83 of 107
Survey:
Section: Real Estate TM
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)
[endif all]
Items Booklet
740
760
780
850
940
960
C30
C40
C70
S40
S60
S70
S80
S90
V40
V50
V70
V90
XC90
OTHER
@
Mark One Only
RE65
VEHICLE 3: THIRD NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number
RE66
VEHICLE 3: THIRD NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only
RE67
VEHICLE 3: THIRD NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@
Mark One Only
RE68
Does anyone in this household own any other type of vehicle,
not used for business, such as a motorcycle, boat, or
recreational vehicle (RV)?
(1) Yes
(2) No
@
Page 84 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Real Estate TM
RE69
Multiple Entry
Does anyone own:
(1)
(1)
(2)
(3)
(4)
Yes
(2)
No
A motorcycle:
A boat:
A recreational vehicle (RV):
Another type of vehicle:
@MTRCYCL
@BOAT
@RV
@OTHERV
IF RESPONDENT OWNS MORE THAN ONE MOTORCYCLE, BOAT, OR RV, REPORT
THE 2ND MOTORCYCLE, BOAT, OR RV UNDER (4) ANOTHER TYPE OF VEHICLE.
(INCLUDE THE VALUE/AMOUNT OWED IN THE "OTHER VEHICLE 2" SCREENS.)
Multiple Entry
RE70
OTHER VEHICLE 1
Which household members own [fill TEMP1]?
ENTER LINE NUMBER FOR HOUSEHOLD MEMBER(S).
ENTER (N) FOR NO MORE.
@1
@2
Enter Number
RE71
OTHER VEHICLE 1
If this [fill TEMP1] were sold, what would it sell for in its
present condition?
$@
Mark One Only
RE72
OTHER VEHICLE 1
Is this [fill TEMP1] owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number
RE73
OTHER VEHICLE 1
How much is currently owed for this [fill TEMP1]?
$@
Multiple Entry
RE74
OTHER VEHICLE 2
Which household members own [fill TEMP1]?
ENTER LINE NUMBER FOR HOUSEHOLD MEMBER(S).
ENTER (N) FOR NO MORE.
@1
@2
Monday, April 05, 2010
Page 85 of 107
Survey:
Section: Real Estate TM
Items Booklet
Enter Number
RE75
OTHER VEHICLE 2
If this [fill TEMP1] were sold, what would it sell for in its
present condition?
$@
Mark One Only
RE76
OTHER VEHICLE 2
Is this [fill TEMP1] owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number
RE77
OTHER VEHICLE 2
How much is currently owed for this [fill TEMP1]?
$@
Page 86 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
FIN1
Mark One Only
Now I am going to ask questions about the sharing of major
expenses with the household.
[fill C_DODOES] [fill TEMPNAME] pay for all [fill HISHER]
housing expenses with [fill HISHER] own money?
(1)
(2)
Yes
No
@
FIN2
Mark One Only
[fill C_DODOES] [fill HESHE] pay for all [fill HISHER]
food expenses with [fill HISHER] own money?
(1)
(2)
Yes
No
@
FIN3
Mark One Only
[fill C_DODOES] [fill HESHE] pay for all [fill HISHER]
other living expenses such as clothing, transportation,
etc., with [fill HISHER] own money?
(1)
(2)
Yes
No
@
FIN4
Mark One Only
Does all or part of the money to pay for these
expenses come from someone in this household?
(1)
(2)
Yes
No
@
FIN5
Multiple Entry
Who are these persons?
ENTER (A) FOR ALL
ENTER LINE NUMBER OF EACH PERSON
ENTER (N) FOR NO MORE
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
Monday, April 05, 2010
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Page 87 of 107
Survey:
Section: Medical Expenses Utilization TM
Mark One Only
Items Booklet
DISAB1
The next few questions help us learn about people who have
physical, mental, or emotional conditions that cause serious
difficulty with their daily activities.
[fill C_AREIS] [fill TEMPNAME] deaf or [fill DODOES] [fill HESHE] have
serious difficulty hearing?
(1) Yes
(2) No
@
Mark One Only
DISAB2
[fill C_AREIS] [fill HESHE] blind or [fill DODOES] [fill HESHE] have
serious difficulty seeing even when wearing glasses?
(1) Yes
(2) No
@
Mark One Only
DISAB3
Because of a physical, mental, or emotional problem, [fill DODOES]
[fill HESHE] have serious difficulty concentrating, remembering,
or making decisions?
(1) Yes
(2) No
@
Mark One Only
DISAB4
[fill C_DODOES] [fill HESHE] have serious difficulty walking or
climbing stairs ?
(1) Yes
(2) No
@
Mark One Only
DISAB5
[fill C_DODOES] [fill HESHE] have difficulty dressing or bathing ?
(1) Yes
(2) No
@
Mark One Only
DISAB6
Because of a physical, mental, or emotional problem, [fill DODOES]
[fill HESHE] have difficulty doing errands alone such as visiting
a doctor's office or shopping ?
(1) Yes
(2) No
@
Page 88 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
ME01
Mark One Only
These next few questions are about [fill PTEMPNAME]
health. Would you say [fill HISHER] health in
general is excellent, very good, good, fair, or poor?
(1)
(2)
(3)
(4)
(5)
Excellent
Very good
Good
Fair
Poor
@
ME02
Mark One Only
During the past 12 months- that is, since [fill MONTH5] 1st
of last year- [fill WASWERE] [fill HESHE] a patient in a
hospital overnight or longer?
(1)
(2)
Yes
No
@
ME03
Enter Number
How many nights in all did [fill HESHE] spend in a
hospital of any type during the past 12 months?
ENTER (N) FOR NONE OR NO TIMES
@
nights
ME04
Multiple Entry
Which of the following best describes why
[fill HESHE] entered the hospital most recently...
READ ALL ANSWER CATEGORIES
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
RE-ENTER PRECODE TO DELETE
[if
[if
[if
[if
@1
@2
@3
@4
eq
eq
eq
eq
<1>]X
<2>]X
<3>]X
<4>]X
[else]
[else]
[else]
[else]
[endif](1) ...for diagnostic tests to determine what was wrong?
[endif][fill TEMP]
[endif](3) ...to have an operation or surgery?
[endif](4) ...for some other treatment or therapy not including
surgery
[if @5 eq <5>]X [else]
[endif](5)
...or for any other reason
@KEY
Mark One Only
ME05
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), did [fill HESHE] take any prescription
medications?
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 89 of 107
Survey:
Section: Medical Expenses Utilization TM
Items Booklet
ME06
Mark One Only
[fill C_DODOES] [fill HESHE] take prescription medicines on
a daily basis?
(1)
(2)
Yes
No
@
ME08
Enter Number
SHOW FLASHCARD X
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), how many visits did [fill HESHE] make to
a dentist or other dental professional?
[r]H[n]
ENTER (N) FOR NONE OR NO TIMES
@
times
ME09
Mark One Only
[fill C_HAVHAS] [fill HESHE] lost any of [FILL HISHER]
permanent adult teeth?
(1)
(2)
Yes
No
@
ME10
Mark One Only
[fill C_HAVHAS] [fill HESHE] lost ALL of [fill HISHER]
permanent adult teeth?
(1)
(2)
Yes
No
@
ME11
Enter Number
SHOW FLASHCARD Y
[fill TEMP2]
past 12 months (that is, since [fill MONTH5] 1st of last year)
how many times did [fill HESHE] see or talk to a doctor, or
nurse, or any other type of medical provider about
[fill HISHER] health?
ENTER (N) FOR NONE OR NO TIMES
[r]H[n]
@ times
Mark One Only
ME12
Did that visit or call include contact with a physician?
(1)
(2)
Yes
No
@
Page 90 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
ME13
Enter Number
About how many of those [fill ME11] visits or
calls included contact with a physician?
ENTER (A) FOR ALL TIMES
ENTER (N) FOR NONE OR NO TIMES
@
times
ME14
Mark One Only
SHOW FLASHCARD Z
In the last 12 months (that is, since [fill MONTH5] 1st
of last year), did [fill HESHE] purchase any
other medical supplies or services?
[r]H[n]
(1)
(2)
Yes
No
@
Enter Number
ME15
[fill TEMP2] past 12 months,
about how many days did illness or injury keep
[fill HIMHER] in bed more than half of the day?
ENTER (N) FOR NONE OR NO TIMES
@
days
Enter Number
ME16
[if PCNT le <1>]
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much did [fill TEMPNAME] pay
for health insurance premiums?
[else]
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much did [fill TEMPNAME] pay
for health insurance premiums for [fill SELF] or others
in the household?
[endif]
MARK N (NONE) IF THIS PERSON PAID NO COSTS FOR ANYONE'S
HEALTH INSURANCE.
IF SOMEONE ELSE PAYS FOR THIS PERSON'S INSURANCE, DO *NOT*
REPORT THOSE COSTS HERE -- REPORT THOSE COSTS IN THE
INTERVIEW FOR THE PERSON WHO PAYS THEM.
ENTER (N) FOR NO PAYMENTS
@
dollars
Monday, April 05, 2010
Page 91 of 107
Survey:
Section: Medical Expenses Utilization TM
Mark One Only
Items Booklet
ME17
HEALTH INSURANCE PREMIUM COSTS LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
None
$1 to $100
$101 to $250
$251 to $500
$501 to $1000
$1001 to $1500
$1501 to $2000
$2001 to $3000
$3001 to $5000
$5001 or more
@
Enter Number
ME18
During the past 12 months (that is, since [fill MONTH5] 1st of
last year), about how much was paid for [fill PTEMPNAME]
own medical care, including payments for hospital visits,
medical providers, dentists, medicine, or medical supplies?
[if MECNT gt <1>]
Include any amount paid on [fill PTEMPNAME] behalf by
you or anyone else in this household.
[endif]
EXCLUDE ANY COSTS FOR HEALTH INSURANCE PREMIUMS.
ENTER (N) FOR NO PAYMENTS
@
dollars
Mark One Only
ME19
MEDICAL CARE COSTS - LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
None
$1 to $100
$101 to $250
$251 to $500
$501 to $1000
$1001 to $1500
$1501 to $2000
$2001 to $3000
$3001 to $5000
$5001 or more
@
Page 92 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
Mark One Only
ME20
Just to be sure- were these amounts for medical care
and health insurance the total cost to [fill TEMP] or
did [fill HESHE] get reimbursed by some other outside
source?
(1)
(2)
(3)
Total Cost
Got Reimbursed
Expects to get reimbursed but has not yet
@
Multiple Entry
ME21
How much of these expenses were reimbursed?
ENTER (N) FOR NONE
ENTER (A) FOR ALL EXPENSES REIMBURSED
@1
dollars
OR
@2
% ( percent reimbursed if
answer given as a percentage )
Mark One Only
MEWR01
Earlier you said that [fill TEMPNAME] [fill WASWERE] not covered by
any health insurance in [fill TEMP1].
During [fill TEMP2] did [fill HESHE] go to a dentist or other dental
professional?
(1)
(2)
@
Yes
No
Mark One Only
MEWR02
[if MEWR01 ne <>]
During [fill TEMP1]
when [fill HESHE] [fill WASWERE] not insured, did [fill HESHE]
go to a doctor, nurse, or another health care provider?
[else]
Earlier you said that [fill TEMPNAME] [fill WASWERE] not covered
by any health insurance in [fill TEMP1].
During [fill TEMP2], did [fill HESHE] go to a doctor, nurse, or
another health care provider? [endif]
(1)
(2)
@
Yes
No
Mark One Only
MEWR03
Which of the following kinds of care did [FILL HESHE] receive?...
...treatment for an illness or injury?
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 93 of 107
Survey:
Section: Medical Expenses Utilization TM
Items Booklet
MEWR04
Mark One Only
...any routine or preventive care, such as a checkup, [fill TEMP1] or
family planning?
(Did [fill TEMPNAME] receive any of that kind of care while not
insured?)
(1)
(2)
Yes
No
@
MEWR05
Mark One Only
How about ...treatment for a drug or alcohol problem?
(Did [fill TEMPNAME] receive any of that kind of care while not
insured?)
(1)
(2)
Yes
No
@
MEWR06
Enter Text
What kind of treatment did [fill HESHE] receive?
@
MEWR07
Multiple Entry
[if INDEX gt <1>]
Where did [fill HESHE] go to get those health care services?
[else]
Where did [fill HESHE] go to get that health care service?
[endif]
MARK ALL THAT APPLY / ENTER (N) AFTER LAST ENTRY
[fill
[fill
[fill
[fill
[fill
[fill
[fill
MEWR07_1:b]
MEWR07_2:b]
MEWR07_3:b]
MEWR07_4:b]
MEWR07_5:b]
MEWR07_6:b]
MEWR07_7:b]
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Clinic or Public Health Department
Emergency room
Hospital, excluding emergency room
VA hospital
Doctor's office
Dentist's office
Someplace else
@1
[if MEWR07@1 eq <7> and MEWR07@14 eq <>]
Where was that?
@14
[endif]
Enter Text
MEWR07_ERR
"Don't Know and/or Refused" response not permitted with other answers
Enter (B) to backup
@
Page 94 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
Mark One Only
MEWR08
[if INDEX gt <1>]
Were these services free, or did [fill HESHE] have to pay
something for them?
[else]
Was this service free, or did [fill HESHE] have to pay
something for them?
[endif]
"PAY SOMETHING" MEANS MORE THAN JUST BEING BILLED - IT MEANS THAT THE
PERSON ACTUALLY PAID SOME MONEY FOR THE SERVICES
(1)
(2)
(3)
Free
Paid something
Both (some were free,some costs $)
@
Mark One Only
MEWR09
[fill TEMP]
you think [FILL HESHE] paid the full price
[if TEMP2 ne <>][fill TEMP2] [endif]or do you think [FILL HESHE] paid
a reduced price?
(1)
(2)
(3)
Full price
Reduced price
Don't know
@
Mark One Only
MEWR10
Did anyone ask what [fill PTEMPNAME] income was before they set
a price for the services?
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 95 of 107
Survey:
Section: Medical Expenses Utilization TM
Items Booklet
ME22
Mark One Only
[if GRDINC eq <1>][if GRDFLAG eq <1>]
The next few questions are about
[fill CHILDNAME]'s health.
[else]
The next few questions are about the
health of [fill PTEMPNAME]
[fill CHILDN].
[endif]
Let's start with [fill CHILDNAME]. Would
you say [fill HISHERG] health in general is
excellent, very good, good, fair, or poor?
[else]
How about [fill CHILDNAME]...?
(Would you say [fill HISHERG] health in
general is excellent, very good, good,
fair, or poor?)[endif]
(1)
(2)
(3)
(4)
(5)
Excellent
Very good
Good
Fair
Poor
@
ME23
Mark One Only
During the past 12 months, (that is
since [fill MONTH5] 1st of last year)
[fill TEMP1] **READ NAME(S)** a patient
in a hospital overnight or longer?
(1)
(2)
Yes
No
@
ME24
Multiple Entry
ASK OR VERIFY:
Which children?
(Which children were in a hospital for
outpatient surgery, or overnight or
longer for any reason during the past 12
months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
Page 96 of 107
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
ME25
Enter Number
[if FIRST_TIME eq <0>]How many nights in all did [fill CHILDNAME] spend in a hospital
of any type during the past 12 months?
[else]How about [fill CHILDNAME]...?
(How many nights in all did [fill HESHEGR] spend in a hospital
of any type during the past 12 months?)[endif]
ENTER (N) FOR NONE OR NO TIMES
@
Nights
ME26
Multiple Entry
Which of the following best describes why [fill CHILDNAME]
entered the hospital most recently...
READ ALL ANSWER CATEGORIES
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
RE-ENTER PRECODE TO DELETE
[if
[if
[if
[if
[if
@1
@2
@3
@4
@5
eq
eq
eq
eq
eq
<1>]X [else]
<2>]X [else]
<3>]X [else]
<4>]X [else]
<5>]X [else]
surgery?
[if @6 eq <6>]X [else]
[endif](1) ...for diagnostic tests to determine what was wrong?
[endif][FILL TEMP]
[endif][FILL TEMP2]
[endif](4) ...to have an operation or surgery?
[endif](5) ...for some other treatment or therapy, not including
[endif](6)
...or for any other reason?
@KEY
ME27
Mark One Only
During the past 12 months (that is,
since [fill MONTH5] 1st of last year)
did, **READ NAME(S)** take any
prescription medications?
(1)
(2)
Yes
No
@
ME28
Multiple Entry
ASK OR VERIFY:
Which children?
(Which children took prescription
medications during the past 12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
Monday, April 05, 2010
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Page 97 of 107
Survey:
Section: Medical Expenses Utilization TM
Items Booklet
ME29
Mark One Only
[if FIRST_TIME eq <0>]Does [fill CHILDNAME] take prescription medicines on a daily basis?
[else]How about [fill CHILDNAME]...?
(Does [fill HESHEGR] take prescription medicines on a daily basis?)[endif]
(1)
(2)
Yes
No
@
ME30
Mark One Only
SHOW FLASHCARD X
During the past 12 months, (that is,
since [fill MONTH5] 1st of last year),
did **READ NAME(S)** visit a dentist, or
other dental professional?
[r]H[n]
(1)
(2)
Yes
No
@
ME31
Multiple Entry
ASK OR VERIFY:
Which children?
(Which children visited a dentist or
other dental professional during the past
12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Enter Number
ME32
SHOW FLASHCARD X
[if FIRST_TIME eq <0>]During the past 12 months, how many visits did [fill CHILDNAME] make
to a dentist or other dental professional?
[else]How about [fill CHILDNAME]...?
(During the past 12 months, how many visits did [fill HESHEGR] make to
a dentist or other dental professional?)[endif]
[r]H[n]
ENTER (N) FOR NONE OR NO TIMES
@
Page 98 of 107
times
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
ME33
Mark One Only
[if MDC1 lt <1>]
Dental sealants are special plastic coatings that are painted on
the tops of the back teeth to prevent tooth decay. They are
different from fillings, caps, crowns, and fluoride treatments.
[endif]
Has [fill CHILDNAME] ever had dental sealants painted on
[fill HISHERG] teeth?
(1)
(2)
Yes
No
@
ME34
Mark One Only
SHOW FLASHCARD X
During the past 12 months (that is,
since [fill MONTH5] 1st of last year)
did [fill TEMPNAME] or anyone else see or
talk to a medical doctor or other medical
provider about **READ NAME(S)** health?
(1)
(2)
Yes
No
@
ME35
Multiple Entry
ASK OR VERIFY:
Which children?
(About which children's health did
[fill TEMPNAME] or anyone else see or
talk to a medical provider during the
past 12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Enter Number
ME36
SHOW FLASHCARD Y
[fill TEMP2] past 12 months,(that is; since [fill MONTH5] 1st of last
year) about how many times did [fill HESHE] or anyone else see
or talk to a medical doctor or other medical provider about
[fill CHILDNAME]'s health?
ENTER (N) FOR NONE OR NO TIMES
@
times
Monday, April 05, 2010
Page 99 of 107
Survey:
Section: Medical Expenses Utilization TM
Items Booklet
ME37
Mark One Only
Did that visit or call include contact with a physician?
(1)
(2)
Yes
No
@
ME38
Enter Number
About how many of those [fill ME36] visits or
calls included contact with a physician?
ENTER (A) FOR ALL VISITS
ENTER (N) FOR NONE
@
times
ME39
Mark One Only
SHOW FLASHCARD Z
In the last 12 months (that is, since
[fill MONTH5] 1st of last year), did
[fill TEMPNAME] [fill ELSEFIL] buy for
**READ NAME(S)** any other medical
supplies or services?
[r]H[n]
(1)
(2)
Yes
No
@
ME40
Multiple Entry
ASK OR VERIFY:
Which children?
(For which children were medical supplies
or services purchased during the past 12
months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24
Page 100 of 107
@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29
@20
@30
Monday, April 05, 2010
Items Booklet
Survey:
Section: Medical Expenses Utilization TM
Enter Number
ME40a
[if FIRST_TIME eq <0>]During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much was paid by anyone in this household
for [fill CHILDNAME]'s medical care, including payments for hospital
visits, medical providers, dentists, medicine, or medical supplies?
[else]How about [fill CHILDNAME]...?
(During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much was paid by anyone in this household
for [fill CHILDNAME]'s medical care, including payments for hospital
visits, medical providers, dentists, medicine, or medical supplies?) [endif]
EXCLUDE ANY COSTS FOR HEALTH INSURANCE PREMIUMS
ENTER (N) FOR NO PAYMENTS
@
dollars
Mark One Only
ME40b
MEDICAL CARE COSTS - LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
None
$1 to $100
$101 to $250
$251 to $500
$501 to $1000
$1001 to $1500
$1501 to $2000
$2001 to $3000
$3001 to $5000
$5001 or more
@
Mark One Only
ME40c
Just to be sure-was this the total actual cost to [fill TEMP]
for [fill CHILDNAME]'s medical care or did some of those costs
get reimbursed by an insurance company, someone outside this
household, or any other outside source?
(1)
(2)
(3)
Total actual Cost
Got Reimbursed
Expects to get reimbursed but has not yet
@
Multiple Entry
ME40d
How much of these expenses for
[fill CHILDNAME] were reimbursed?
ENTER (N) FOR NONE
ENTER (A) FOR ALL EXPENSES REIMBURSED
@1
dollars
OR
@2
Monday, April 05, 2010
% ( percent reimbursed if
answer given as a percentage )
Page 101 of 107
Survey:
Section: Medical Expenses Utilization TM
Mark One Only
Items Booklet
ME41
Earlier I recorded that [fill PTEMPNAME] health or condition
prevents [fill HIMHER] from working.
For how long [fill HAVHAS] [fill HESHE] been prevented
from working? Has it been a year or longer, or has it
been less than a year?
(1)
(2)
A year or longer
Less than a year
@
Mark One Only
ME42
Is it likely that [fill HESHE] will be able to work at
some time in the next 12 months?
(1)
(2)
Yes
No
@
Page 102 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Poverty TM
Multiple Entry
PV01
During the typical week since [fill MONTH1] 1st how did
[fill TEMPNAME] get to work?
Did [fill HESHE] drive [fill HISHER] own vehicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2
@3
@4
@5
Multiple Entry
PV02
During the typical week, since [fill MONTH1] 1st how did
[fill TEMPNAME] get to work?
Did [fill HESHE] drive [fill HISHER] own vechicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2
@3
@4
@5
Multiple Entry
PV03
Now I have a few questions about [fill PTEMPNAME]
work related expenses, including transportation to work.
During the typical week, since [fill MONTH1] 1st how did
[fill TEMPNAME] get to [fill HISHER] work?
Did [fill HESHE] drive [fill HISHER] own vehicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Monday, April 05, 2010
Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2
@3
@4
@5
Page 103 of 107
Survey:
Section: Poverty TM
Items Booklet
Enter Number
PV04
During that same typical week, about how many miles,
in total, did [fill TEMPNAME] drive [fill TEMP1] to get to
and from work?
@
Miles per week
Mark One Only
PV05
(During a typical week,) [fill TEMP] [fill PTEMPNAME]
work-commuting expenses include having to pay for
any parking or tolls?
ENTER (1) FOR "YES" IF ANY PARKING COSTS OR TOLLS ARE OUT-OF-POCKET;
ENTER (2) FOR "NO" IF ALL SUCH COSTS ARE REIMBURSED
(1)
(2)
Yes
No
@
Enter Number
PV06
Typically, how much [fill TEMP] [fill TEMPNAME] spend PER WEEK
for parking or tolls?
INCLUDE ONLY COSTS THAT WERE *NOT* REIMBURSED
@ Costs per week
Enter Number
PV07
[fill TEMP1] a typical week, about how much [fill TEMP3]
[fill HISHER] [fill TEMP2] work commuting expenses?
INCLUDE ONLY [fill OTHERFIL] WORK-COMMUTING COSTS THAT WERE *NOT*
REIMBURSED
@ [fill OTHERFIL2] work-commuting costs per week
Mark One Only
PV08
Not counting expenses [fill HISHER] employer paid,
did [fill HESHE] have any work-related expenses such as
licenses, permits, union dues, special
tools, or uniforms for [fill HISHER] work?
[fill BUSFIL]
(1)
(2)
Yes
No
@
Page 104 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Poverty TM
Enter Number
PV09
Altogether, what [fill TEMP] [fill HISHER] annual expenses
for such items?
(e.g., licenses,permits,union dues, special tools, uniforms)
[fill BUSFIL]
INCLUDE ONLY WORK-RELATED EXPENSES THAT WERE *REQUIRED* FOR EMPLOYMENT
AND THAT WERE *NOT* REIMBURSED
@ Annual expenses
Mark One Only
PVCCARR
I'd like you to think about all of the child care arrangements
used for [fill HISHER] child(ren) during [fill HISHER] work hours
in the last four months. Did [fill TEMPNAME] [fill TEMP] usually
pay for any of these arrangements? [fill TEMP2]
ONLY COUNT CHILD CARE THAT HAPPENED WHILE THE PERSON WORKED OR
COMMUTED TO/FROM WORK.
DO *NOT* INCLUDE ANY TUITION COSTS FOR KINDERGARTEN OR BEYOND
(1)
(2)
Yes
No
@
Multiple Entry
PVCCFP
How much did [fill TEMPNAME] or [fill HISHER] family pay for
child care while [fill HESHE] worked:
ENTER (N) FOR NONE/NO MORE
ENTER (S) FOR SAME AS PREVIOUS AMOUNT
in a typical week in [fill MONTH4]?
@4
in a typical week in [fill MONTH3]?
@3
in a typical week in [fill MONTH2]?
@2
in a typical week in [fill MONTH1]?
@1
Mark One Only
PVCCOTH
Did anyone else pay for all or part of the cost of
[fill HISHER] child care while [fill HESHE] worked?
By this I mean a government agency, an employer, a
relative, or a friend.
(1)
(2)
Yes
No
@
Monday, April 05, 2010
Page 105 of 107
Survey:
Section: Poverty TM
Items Booklet
Multiple Entry
PVCCWHO
Who was that?
(Who or what agency helped pay for [fill HISHER] childcare?)
MARK ALL THAT APPLY
ENTER (N) FOR NONE/NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Government (Federal, state, or local government
agency, or welfare office)
Child's other parent
Employer
Relative or friend
Other
@2
@3
@4
@5
Mark One Only
PV10
[fill C_DODOES] [fill HESHE] have any children
[if TEMP1 ne <>][fill TEMP1] [endif]who lived elsewhere with their other
parent or guardian at anytime during the past 4 months?
(1)
(2)
Yes
No
@
Enter Number
PV11
How many children?
@
Mark One Only
PV12
In the past 4 months- that is, since [fill MONTH1] 1st [fill WASWERE] [fill HESHE] required to pay child support [fill TEMP1]?
INCLUDE ANY PAYMENTS...
...MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
...MADE THROUGH A COURT OR AGENCY; OR
...WITHHELD FROM THIS PERSON'S PAYCHECK
(1)
(2)
Yes
No
@
Page 106 of 107
Monday, April 05, 2010
Items Booklet
Survey:
Section: Poverty TM
PV13
Multiple Entry
How much did you pay in child support in:
COUNT ALL FORMS OF CHILD SUPPORT PAYMENTS INCLUDING...
...PAYMENTS MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
...PAYMENTS MADE THROUGH A COURT OR AGENCY; AND
...PAYMENTS WITHHELD FROM THIS PERSON'S PAYCHECK
ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT.
[fill MONTH4]
@41
@42
@43
@44
@45
[fill MONTH3]
@31
@32
@33
@34
@35
[fill MONTH2]
@21
@22
@23
@24
@25
[fill MONTH1]
@11
@12
@13
@14
@15
PV14
Multiple Entry
What is the total amount of time [fill TEMPNAME] spent with
[fill CHILDFIL] during the past 4 months?
ENTER A RESPONSE IN ONE CATEGORY ONLY
ENTER (N) FOR NONE
Days:@DAYS
Monday, April 05, 2010
Weeks:@WEEKS
Months:@MONTHS
Page 107 of 107
| File Type | application/pdf |
| File Title | N:\SIPP96\Items Booklets\2008 Panel\Wave 7\rptItemsBooklet.snp |
| Author | long0339 |
| File Modified | 2010-04-05 |
| File Created | 2010-04-05 |