Form AHS-30 American Housing Survey Worksheet

FORM AHS-30(WS) (xx-xx-xxxx) U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration

U.S. CENSUS BUREAU

AMERICAN HOUSING

SURVEY WORKSHEETUTILITY COSTS FOR MOST RECENT MONTHSUtility January April August December Electricity $ $ $ $ Are you billed separately for electricity? Yes No Are your costs for electricity the same every month? Yes NoUtility January April August December Gas $ $ $ $ Are you billed separately for gas? Yes NoAre your costs for gas the same every month? Yes NoOTHER HOUSING COSTSTotal cost of fuel oil for the past year? $ Total garbage and trash collection costs for the past year? $ Total water and sewer costs for the past year? $ OTHER COSTS FOR HOME OWNERSTotal real estate tax for the past year? $ Total amount of the down payment for this house? (Dollars or percent)$%1^st Mortgage/ Home Loan2^nd Mortgage/ Home Loan3^rd Mortgage/ Home LoanWhen did you get this loan? (month/year)///How much was borrowed?$$…the amount you still owe?$$$…the current payment?$$$…the current interest rate?%%%This worksheet is not a questionnaire but an aid to help you when our field representative contacts you. Do not mail this back to the U.S. Census Bureau.

Completing the survey will be easier if you will look up these costs in your checkbook or other records before the interview.

Record the amounts for the past year in the spaces provided, skipping any costs that do not apply to you.

Please keep this worksheet and copies of your utility bills, regular mortgage statement, and year end mortgage statement (IRS Form 1098), so you can refer to them when our field representative contacts you.

Thank you again for your time and effort in completing this important survey!

We expect it will take about 15 minutes for you to provide this information, but it may be somewhat shorter or longer, depending on your circumstances. If you have any comments on this survey or have recommendations for reducing its length, please send them to the Director, Housing and Demographic Analysis Division, Office of Policy Development and Research, Office of Economic Affairs, Department of Housing and Urban Development, Washington, DC 20410. The Office of Management and Budget (OMB) control number for this survey is 2528-0017. This number confirms that we have approval from OMB to conduct this survey. Approval for this survey expires on XXXX.