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pdfU.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
R
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U.S.
D
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EP
U.S. CENSUS BUREAU
Acting as a collecting agent for
U.S. Department of Labor
Bureau of Labor Statistics
Your Daily Expenses
Help us learn about the buying habits of people in the United States
When you write down how you spend your money in this diary, you will help us understand
more about the products and services that are bought by the people in the United States.
By law (title 13, U.S. Code), we must keep your information confidential; we use it for statistical purposes only.
If you have comments regarding this survey, please send them to the Division of Consumer Expenditure Surveys,
2 Massachusetts Avenue N.E., Room 3985, Washington, DC 20212.
Please record your expenses and purchases
for the following period
Day
Date
1
2
3
4
5
6
7
I will return on: _______________________________________
If you have any questions, please call:
Field representative’s name:
Telephone:
Field representative supervisor’s name:
Telephone:
USCENSUSBUREAU
Black Ink (40% and 100%)
FORM CE-801 (7-1-2005)
OMB No. 1220-0050
Frequently
requently Asked
sked Questions
uestions
(continued on other side)
1. How detailed should my descriptions be?
Refer to pages 4–7 for examples of the level of
detail needed in each part. Do not use brand
names.
2. How should I record multiple quantities?
If the items are identical, you can combine them
on the same line and enter the total cost of all
the items. See examples on pages 5 and 6.
3. How should I record pre-payments such
as a subway fare card?
Record the expense when you pay for it, not
when you use it.
4. How should I record credit card
purchases?
Record the individual expense on the day that
you use your credit card to pay for something,
not on the day you pay your entire credit card
bill.
5. Should I record automatic deductions
taken from my paycheck or bank
account?
Yes, record automatic deductions (such as
health insurance premiums taken out of your
account or paycheck) only if they are deducted
that week. Write them in the section called All
Other Products, Services, and Expenses (Part 4).
6. Should I record typical monthly bills?
Yes, record typical monthly bills only if you pay
them during the week that you have the diary.
Write them in the section called All Other
Products, Services, and Expenses (Part 4).
7. What should I do when I use coupons,
discount cards, or loyalty cards?
Subtract the discount from the original price and
write the amount that you paid.
8. Can I just give you receipts instead of
writing the information down?
No, we need you to actually write the
information in the diary. We encourage you to
save your receipts to review them with your
field representative at the end of the week. You
can use the pocket on the inside of the back
cover to store your receipts until you’re ready to
record your purchases.
9. How should I record items if I don’t
know whether it includes tax?
Write down the amount paid.
(continued on other side)
FORM CE-801 (7-1-2005)
Black Ink (40% and 100%)
CE-801, Panton Blue 313 (20% and 100%)
Frequently
requently Asked
sked Questions
uestions
(continued on other side)
10. What if I make a contribution or
charitable donation?
Record money contributions or donations in the
section called All Other Products, Services, and
Expenses (Part 4).
11. What about gift certificates or gift
cards?
If you buy a gift certificate to give to someone,
write down the cost of it under the appropriate
section (e.g. a certificate to a clothing store
would go under Clothing, Shoes, Jewelry, and
Accessories (Part 3) and a certificate to a
department store would go under All Other
Products, Services, and Expenses (Part 4)). If
you buy something using a gift card, write
down the full amount for your purchase
ignoring the gift card.
12. What do I do about returns & exchanges?
If an item is bought and returned during the
diary week, it can be erased or crossed out. If it
was bought outside the week and returned
during the week, do not make an entry. If an
item is exchanged during the week, change the
entry. If the new cost is different, cross out the
old cost and write in the new cost (see
examples on page 7).
13. Should I record subsidized/reimbursed
expenses?
Yes, but if someone not on your list pays for or
helps pay for an expense or if you will be
reimbursed for an expense, only record any
extra amount that you or someone on your list
has to pay.
14. What should I do about shipping &
handling costs?
Record the items bought under the appropriate
section and then record the shipping and
handling cost separately under the section
called All Other Products, Services, and
Expenses (Part 4).
15. What’s the difference between a
concession stand and a mobile vendor?
A concession stand has to stay in a permanent
location and a mobile vendor does not. Some
mobile vendors may seem permanent because
they are usually in the same location, but they
are still considered mobile vendors because
they have the option to change locations.
(continued on other side)
FORM CE-801 (7-1-2005)
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
Examples
(continued on other side)
1. Food and Drinks Away from Home
■
■
■
■
Fast Food, Take-out, Delivery, Concession
(you pay BEFORE you eat/drink)
Full Service Places (you pay AFTER you eat/drink)
Vending Machines or Mobile Vendors (include
vending machines, carts, & trucks that move from
place to place)
Employer and School Cafeterias
Includes elementary school pre-payments
2. Food and Drinks for Home Consumption
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Grain Products (cake mixes, cereal, cornmeal, flour,
pasta, rice, spaghetti, etc.)
Bakery Products (cakes, cookies, frozen waffles, pies,
white bread, other bread, etc.)
Beef (briskets, ground beef, round & other roasts,
sirloin, etc.)
Pork (bacon, ham, pork chops, sausage, etc.)
Poultry (chicken parts, duck, whole turkey, etc.)
Other meats (bologna, frankfurters, lamb, liverwurst,
organ meats, salami, etc.)
Fish & Seafood (fish, shellfish, etc.)
Oils, Fats & Dressings (salad dressing, shortening,
vinegar, etc.)
Eggs & Dairy Products (butter, cream, cheese, ice
cream, skim milk, powdered milk, etc.)
Fruits & Fruit Juices (apples, bananas, cranberry
juice, oranges, orange juice, etc.)
Sugar, Sugar Substitutes & Sweets (artificial
sweeteners, candy, gum, jams, jellies, etc.)
Vegetables & Vegetable juices (beans, corn, lettuce,
potatoes, tomatoes, tomato juice, etc.)
Other Food Items (baby food, pet food, frozen foods,
gourmet/specialty items, sauces, seasonings, soups,
etc.)
Non-Alcoholic Beverages (carbonated &
non-carbonated waters, cola & other carbonated
beverages, fruit-flavored beverages, instant & ground
coffee, tea, etc.)
Alcoholic Beverages (beer, champagne, liqueurs,
whiskey, wine, etc.)
Food & Beverages Purchases as Gifts for someone
not on your list (candy, cheese, fruit baskets, wine, etc.)
3. Clothing, Shoes, Jewelry, and Accessories
■
■
■
■
■
■
Casual, Sportswear, Formal (dress, pants, shirt, shorts,
suit, sweater, etc.)
Undergarments & Sleep Clothes (hosiery, lingerie,
pajamas, socks, etc.)
Outdoor, Work, School, Costumes (coat, jacket,
thermals, uniform, windbreaker, etc.)
Shoes (boots, dress, sandals, slippers, sneakers, etc.)
Sports-team Clothes & Sports Shoes (cleats, golf
shoes, ski boots, team uniform, etc.)
Jewelry, Accessories, & Sewing Items (belt, buttons,
hairpiece, hat, ring, thread, umbrella, etc.)
(continued on other side)
FORM CE-801 (7-1-2005)
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
Examples
(continued on other side)
4. All Other Products, Services, and Expenses
■
Clothing Services (alterations, dry cleaning, shoe
repairs, storage, tailoring, etc.)
■
Medicines, Medical Supplies & Services (bandages,
canes & other medical equipment, doctor & dentist
services, prescription eyeglasses, health insurance,
prescription drugs, ointments, vitamins, wheelchairs,
etc.)
■
Tobacco & Smoking Supplies (cigarettes, cigars, pipes,
smoking accessories, tobacco, etc.)
■
Gasoline, Oil, & Additives (brake fluid, coolants,
gasoline, motor oil, etc.)
■
Personal Care Products & Services (cosmetics, dental
products, deodorants, hair care products, hand soap,
men’s & women’s haircuts, perfume, shaving products,
skin care products, etc.)
■
Housekeeping Supplies & Services (bathroom tissue,
brooms, laundry & cleaning detergents, light bulbs,
maid service, mops, paper towels, sponges, etc.)
■
Housewares & Small Household Appliances
(blenders, coffee makers, cooking utensils,
dinnerware, glassware, irons, utensils, pots & pans,
telephones, & toasters, etc.)
■
Home Furnishings, Decorative Items, Linens, & Major
Appliances (art work, clocks, curtains, lamps, picture
frames, pillows, plants, refrigerators, rugs, sheets,
sofas, stoves, table cloths, tables, towels, vases, etc.)
■
Home Maintenance, Hardware, Lawn Supplies &
Services (hand tools, improvement & repair
equipment, lawn/garden equipment, nails, power
tools, screws, supplies, services, etc.)
■
Housing Expenses (cable service, electricity, garbage
removal, heating/cooling, insurance, maintenance
fees, mortgage payments, property taxes, rent,
telephone, etc.)
■
Entertainment/Amusements & Sports/Recreation
(admissions to movies, clubs, sporting & cultural
events, camping, CDs, concert tickets, hunting, sports
& exercise equipment, tapes, toys, TVs, video/stereo
equipment, video purchase/rental, etc.)
■
Transportation Expenses (airline fares, buses, car
rental, commuter fares, new & used cars,
maintenance and repair, parking fees, taxis, tolls, train
fares, etc.)
■
School Expenses (daycare, high school & college
tuition, room & board, school supplies, textbooks, etc.)
■
All Other Expenses (alteration & repair of household
furnishings, ATM service fees, babysitting, books,
club dues, diaper services, donations, legal &
accounting fees, magazines, newspapers, pet supplies
& veterinary services, photographic supplies, postage,
sewing goods, shipping & handling, stationery, etc.)
(continued on other side)
FORM CE-801 (7-1-2005)
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
Record Your Daily Expenses
The people on your list:
Record the purchases and expenses made by ALL of these people.
Notes
FORM CE-801 (7-1-2005)
Black Ink (40% and 100%)
Thank you for agreeing to fill out this diary.
We understand that this task takes time; however, your information is
very important to us and will be used for many purposes that affect all
Americans. Among the most important, it is used to help calculate the
Consumer Price Index, or CPI, which is a basic measure of the rate of
inflation.
Here are some of the uses of the Consumer Price Index:
♦ Provide cost-of-living wage adjustments for millions of American workers
♦ Adjust Social Security payments
♦ Determine the cost of school lunches
♦ Adjust Federal income-tax brackets
For more information about the survey, visit: http://www.bls.gov/cex and http://www.census.gov
Office Use: Place the barcode label here
Questions?
Some Frequently Asked Questions are answered on the flap attached to the back cover.
If you still have questions after reviewing these, please call your field representative.
1
FORM CE-801 (7-1-2005)
§)""¤
080101
Black Ink (40% and 100%)
General Instructions
■
Fill out this diary for an entire week, writing down EVERYTHING you and the
people on your list spend money on each day – the products you buy, the
services you use, the household expenses you have during the week – no matter
how large or small they are.
■
We recommend that you record your expenses each day.
Think about where you went and what you’ve done.
■
Talk to the people on your list every day to find out how they spent their money.
■
Include payments by:
Cash
Check
Food Stamps
■
Credit/Debit Card
Money Order
WIC Voucher
Automatic Withdrawal/Payroll Deduction
Store Charge Card
Grocery Certificate
Keep receipts and other records so that you will remember to record what you
bought or paid for. Use the pocket at the back of the diary to store them.
Some record types include:
Receipts
Utility Bills
Pay Stubs
Bank Statements
Telephone Bills
Catalog/Internet Order Invoices
Credit Card Statements
Include items that you bought for people who are not on your list, such as gifts.
Refer to the flap
attached to the
front cover for
Examples of Expenses.
Refer to the flap
attached to the
back cover for answers to
Frequently Asked Questions.
Do NOT record:
♦ Expenses of people on your list while they were away from home overnight.
♦ Business or farm operating expenses
♦ Sales tax for:
Part 2. Food and Drinks for Home Consumption
Part 3. Clothing, Shoes, Jewelry, and Accessories
Part 4. All Other Products, Services, and Expenses
2
FORM CE-801 (7-1-2005)
§)"#¤
FORM CE-801 (1-1-2005)
1
080102
Black Ink
CE-801, Page 2, Pantone Blue 313 (20%, 40%, and 100%)
How to Fill Out Your Diary
The diary is divided into 7 days and each day is divided into 4 parts.
Enter each item in the appropriate part for each day.
These are the 4 parts within each day of the diary:
1. Food and Drinks Away from Home
■ Mark one of the four choices that best describes the type of meal and describe briefly.
■ Mark one of the four choices that best describes where you made the purchase.
■ Enter the total cost with tax and tip.
■ If alcohol was part of the purchase, check whether it was wine, beer, and/or other
alcohol and enter the total cost of the alcohol.
2. Food and Drinks for Home Consumption
■ Describe the item.
■ Mark whether the item was fresh, frozen, bottled/canned, or other.
■ Enter the cost without tax and deduct any discounts or coupons.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).
3. Clothing, Shoes, Jewelry, and Accessories
■ Describe the item and enter the cost without tax.
■ Mark the appropriate sex and age range of the person for whom the item was bought.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).
4. All Other Products, Services, and Expenses
■ Describe the item and enter the total cost without tax.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).
There is an "Additional Pages" section on pages 36–44 in case you
run out of lines on any particular day.
Look on the next 4 pages for examples and tips
on how to record your purchases.
*Please Note: If you are unsure about whether to include an item or
where to record an item, write it down wherever it seems best or
make a note and ask your field representative.
3
FORM CE-801 (7-1-2005)
§)"$¤
3
080103
Black Ink
CE-801, Page 3, Pantone Blue 313 (20%, 40%, and 100%)
EXAMPLE1
Day
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
101
1
2
3
4
1
2
3
4
X
102
1
X
2
3
If alcoholic
Mark (X) one that best describes
Include tax & tip beverages
where you made this purchase for part 1 only.
included,
☛
bagel, juice
1
pizza
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
1
2
1
X
105
106
X
107
108
X
1
2
X
1
sandwich, soda
4
with tax & tip
X
1
2 79
4
3
5 57
2
3
4
2
3
4
2
3
1 35
5 15
4
X
elem.school lunch - month
1
2
1
X soda
3
2
1
2
3
X
3
70
4
X
X
4
65
4
E
L
P
M
A
EX
1
23
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
X
4
2
3
4
1
2
3
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
4
1
2
3
4
3
4
1
2
3
4
1
2
3
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
1
2
3
4
1
2
3
1
2
3
4
1
2
3
1
2
3
4
1
2
3
X
2
62
3
3
110
1
00
2
4
X drinks from cash bar
2
45
1
3
109
1
mark (X) all
that apply
X
caterer - Family Reunion
111
112
113
114
X
15 00
350 00
Enter the
total cost of
the alcohol
other
Total Cost
X
X chips
buffet
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
X
4
1
104
Full
Service
Places
☛ Level of detail needed:
briefly describe the meal.
X coffee
103
Fast Food
Take-out
Delivery
Concession
beer
(See examples above
and on the flap)
wine
Description
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
X X
12
00
15
00
95
00
3
X X X
☛
If alcohol was included
in the purchase, mark
whether it was wine, beer,
and/or other and enter the
1 the
2 alcohol.
3
total cost of
115
116
117
118
119
120
☛
Use the pocket on the inside of the back
cover to store your receipts until you’re ready
to record your purchases.
121
1
2
3
4
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
4
FR USE:
None
TR
VC
FORM CE-801 (7-1-2005)
§)"%¤
080104
Black Ink (10%, 50%, & 100%)
CE-801, Page 4, Pantone Blue 313 (20%, 40%, & 100%)
CE-801, Page 4, Pantone Yellow 101 (70%)
SUN
MON
TUE
WED
THU
FRI
EXAMPLE1
Day
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
☛
Do not
include
tax for
fish
parts 2, 3, & 4.
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
1
chicken wings
apples
beer
skim milk
orange juice
candy
vegetable oil
frozen
other
2
3
4
2
3
4
1
2
3
4
BEEF – Specify the cut and describe, such as
round roast, ground beef, etc.
1
2
3
4
PORK – Specify the cut and describe, such as
whole ham, bacon, spareribs, etc.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
1
2
3
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
wheat bread
eggs
fresh
Total Cost
bottled/
canned
☛ Level of detail needed:
1
BREAD – Specify if white, wheat, rye, etc.
CHICKEN – Specify if whole or parts, such as
chicken legs, chicken wings, etc.
SOFT DRINKS – Specify if soda or other
type: if not cola, specify if carbonated or non.
X
X
X
X
X
X
X
COFFEE – Specify if ground or instant.
E
L
P
M
A
EX
OTHER FOOD – Give a complete description,
such as scalloped potatoes.
baby food (5 jars)
potato chips
frozen meals (3 boxes)
ketchup
soup (4 cans)
soda (2 bottles)
pork chops
shrimp
X
X
X
X
X
X
X
X
ground beef
ground coffee
bagels
wine
dog food
X
4
4
X
apple pie
☛
List food & drinks from
specialty food stores in this part
(i.e. bakery, liquor store, farmers’
market, convenience store, etc.)
X
X
X
1
49
1
50
6
78
2
80
4
29
2
99
3
99
2
50
2
99
4
95
2
79
8
97
1
59
4
96
1
98
6
36
11
20
3
50
X
4
99
X
2
cookies
carbonated water
X
without tax
Mark (X) If
purchased for
someone not
on your list
X
X
4
89
X
X
5
87
2
79
5
25
42
00
5
85
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
5
FORM CE-801 (7-1-2005)
§)"&¤
080105
Black Ink (10%, 50%, & 100%)
CE-801, Page 5, Pantone Blue 313 (20%, 40%, & 100%)
CE-801, Page 5, Pantone Yellow 101 (70%)
EXAMPLE1
Day
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
shirt
sweater
shorts
Examples:
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
Was the
item for:
without tax
male female
3 dress-shirts ($25 each)
301
1 dress-shirt
302
non-prescription sunglasses
304
305
306
Level of detail needed:
SHOES – If sports shoes, specify
sport, such as football cleats, etc.
baseball cap
JEWELRY – Specify type of jewelry,
such as watches, etc.
bib
ACCESSORIES – If eyewear, specify
prescription or non-prescription.
2
Under
16 &
2–15
2
Over
1
2
3
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
3
1
X
1
CLOTHING – Specify type of clothing
and give a description of the item.
running shoes
303
☛
75 00
30 00
child’s costume (returned for refund)
wallet
308
necklace
309
14 99
X
50
trouser socks
312
313
314
315
316
X
1
2
2
1
2
3
1
2
1
2
3
1
2
1
2
3
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
X
1
29 00
X
X
99
99
X
X
X
E
L
P
M
A
EX
4
X
2
15 00
3
X
X
1
311
X
250 00
scarf
310
X
X
1
307
X
X
59 00
Mark (X) If
purchased for
someone not
on your list
X
X
69 00
3
Age
X
X
X
X
X
317
318
319
320
321
322
☛
323
If you run out of space in any
section, continue listing the items
under that section on the Additional
Pages in the back (p. 36–44)
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
6
§)"’¤
080106
Black Ink (10%, 50%, & 100%)
CE-801, Page 6, Pantone Blue 313 (20%, 40%, & 100%)
CE-801, Page 6, Pantone Yellow 101 (70%)
SUN
MON
TUE
WED
THU
FRI
EXAMPLE1
Day
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
401
cold medicine (non-prescription)
402
gasoline
403
highway tolls
404
music CD
405
cigarettes
☛ Level of detail needed:
DOCTOR BILLS – Specify type of doctor visited, such
as an internist, orthodontist, etc.
MEDICINE – Specify if prescription or non-prescription.
6
95
12
86
2
00
10
99
8
99
15
50
1
00
1
50
Mark (X) If
purchased for
someone not
on your list
X
X
TOOLS – Specify if power or hand tool.
406
dry cleaning (clothing)
407
lottery tickets
408
bus fare
409
piano lessons
410
electric drill
411
postage stamps
412
video rental
413
car speakers
414
car oil change
415
board game
DRY-CLEANING – Specify whether household item
(such as drapes) or apparel.
E
L
P
M
A
EX
416
area rug (exchanged for a different area rug)
417
concert tickets
150 00
65
00
6
80
4
00
140 00
48
50
8
97
20
99
39
99
X
100 00
3
99
418
dog leash dog toy (exchange)
6
99
419
ATM service fee
2
00
420
Health insurance
250
00 last column of
421
Mortgage payment
875
a purchase
00 ifwas
made for
422
Telephone bill
120
not
00 someone
on your list.
423
veterinarian fees
424
Shipping and Handling for internet purchase
425
Donation
☛ Mark the
parts 2, 3, & 4
85
00
6
95
50
00
X
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
7
FORM CE-801 (7-1-2005)
§)"(¤
080107
Black Ink (10%, 50%, & 100%)
CE-801, Page 7, Pantone Blue 313 (20%, 40%, & 100%)
CE-801, Page 7, Pantone Yellow 101 (70%)
Day 1
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
8
FR USE:
None
TR
VC
§)")¤
080108
Black Ink (50% & 100%)
CE-801, Page 8, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 1
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
9
FORM CE-801 (7-1-2005)
§)"*¤
080109
Black Ink (50% & 100%)
CE-801, Page 9, Pantone Blue 313 (20%, 40%, & 100%)
Day 1
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
without tax
Was the
item for:
Age
Under
16 &
2–15 Over
male female
2
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
10
§)"+¤
080110
Black Ink (50%, & 100%)
CE-801, Page 10, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 1
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
11
FORM CE-801 (7-1-2005)
§)",¤
080111
Black Ink (50%, & 100%)
CE-801, Page 11, Pantone Blue 313 (20%, 40%, & 100%)
Day 2
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
12
FR USE:
None
TR
VC
§)"-¤
080112
Black Ink (50%, & 100%)
CE-801, Page 12, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 2
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
13
FORM CE-801 (7-1-2005)
§)".¤
080113
Black Ink (50%, & 100%)
CE-801, Page 13, Pantone Blue 313 (20%, 40%, & 100%)
Day 2
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Was the
item for:
Total Cost
Age
Under
16 &
2–15 Over
male female
2
without tax
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
14
§)"/¤
080114
Black Ink (50%, & 100%)
CE-801, Page 14, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 2
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
15
FORM CE-801 (7-1-2005)
§)"0¤
080115
Black Ink (50%, & 100%)
CE-801, Page 15, Pantone Blue 313 (20%, 40%, & 100%)
Day 3
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
16
FR USE:
None
TR
VC
§)"1¤
080116
Black Ink (50%, & 100%)
CE-801, Page 16, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 3
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
17
FORM CE-801 (7-1-2005)
§)"2¤
080117
Black Ink (50%, & 100%)
CE-801, Page 17, Pantone Blue 313 (20%, 40%, & 100%)
Day 3
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
without tax
Was the
item for:
Age
Under
16 &
2–15 Over
male female
2
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
18
§)"3¤
080118
Black Ink (50%, & 100%)
CE-801, Page 18, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 3
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
19
FORM CE-801 (7-1-2005)
§)"4¤
080119
Black Ink (50% & 100%)
CE-801, Page 19, Pantone Blue 313 (20%, 40%, & 100%)
Day 4
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
20
FR USE:
None
TR
VC
§)"5¤
080120
Black Ink (50% & 100%)
CE-801, Page 20, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 4
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
21
FORM CE-801 (7-1-2005)
§)"6¤
080121
Black Ink (50% & 100%)
CE-801, Page 21, Pantone Blue 313 (20%, 40%, & 100%)
Day 4
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
without tax
Was the
item for:
Age
Under
16 &
2–15 Over
male female
2
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
22
§)"7¤
080122
Black Ink (50% & 100%)
CE-801, Page 22, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 4
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
23
FORM CE-801 (7-1-2005)
§)"8¤
080123
Black Ink (50% & 100%)
CE-801, Page 23, Pantone Blue 313 (20%, 40%, & 100%)
Day 5
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
24
FR USE:
None
TR
VC
§)"9¤
080124
Black Ink (50% & 100%)
CE-801, Page 24, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 5
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
25
FORM CE-801 (7-1-2005)
§)":¤
080125
Black Ink (50% & 100%)
CE-801, Page 25, Pantone Blue 313 (20%, 40%, & 100%)
Day 5
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
without tax
Was the
item for:
Age
Under
16 &
2–15 Over
male female
2
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
26
§)";¤
080126
Black Ink (50% & 100%)
CE-801, Page 26, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 5
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
27
FORM CE-801 (7-1-2005)
§)"<¤
080127
Black Ink (50% & 100%)
CE-801, Page 27, Pantone Blue 313 (20%, 40%, & 100%)
Day 6
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
28
FR USE:
None
TR
VC
§)"=¤
080128
Black Ink (50% & 100%)
CE-801, Page 28, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 6
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
29
FORM CE-801 (7-1-2005)
§)">¤
080129
Black Ink (50% & 100%)
CE-801, Page 29, Pantone Blue 313 (20%, 40%, & 100%)
Day 6
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Was the
item for:
Total Cost
Age
Under
16 &
2–15 Over
male female
2
without tax
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
30
§)"?¤
080130
Black Ink (50% & 100%)
CE-801, Page 30, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 6
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
31
FORM CE-801 (7-1-2005)
§)"@¤
080131
Black Ink (50% & 100%)
CE-801, Page 31, Pantone Blue 313 (20%, 40%, & 100%)
Day 7
SUN
MON
TUE
WED
THU
FRI
SAT
1. Food and Drinks Away from Home
Examples:
breakfast buffet
carry-out lunch
dinner & cocktails at restaurant
pizza delivery
Chinese takeout
child’s school lunch
beer at happy hour
pretzels at ballgame
wine at tavern
croissant from café
ice cream from truck
wedding reception caterer
soda from vending machine
hot dog from convenience store
popcorn and soda at movies
Please unfold the LEFT FLAP to see Additional Examples
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples above
and on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
FORM CE-801 (7-1-2005)
32
FR USE:
None
TR
VC
§)"A¤
080132
Black Ink (50% & 100%)
CE-801, Page 32, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 7
SAT
2. Food and Drinks for Home Consumption
Examples:
eggs
whole milk
sugar
cereal
white bread
cooking oil
tea
cola
ground coffee
beer
liquor
oranges
apple juice
tomato juice
carbonated water
ground beef
bacon
lettuce
chicken parts
whole chicken
baby food
fish
shellfish
pet food
Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples above and on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) If
purchased for
someone not
on your list
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
33
FORM CE-801 (7-1-2005)
§)"B¤
080133
Black Ink (50% & 100%)
CE-801, Page 33, Pantone Blue 313 (20%, 40%, & 100%)
Day 7
SUN
MON
TUE
WED
THU
FRI
SAT
3. Clothing, Shoes, Jewelry, and Accessories
Examples:
shirt
sweater
shorts
suit
dress
pants
sandals
sneakers
shoe repairs
soccer cleats
team uniform
ski boots
gloves
slippers
dance costume
watch
necklace
belt
coat
jacket
windbreaker
pajamas
lingerie
socks
Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)
Was the
item for:
Total Cost
Age
Under
16 &
2–15 Over
male female
2
without tax
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
FORM CE-801 (7-1-2005)
34
§)"C¤
080134
Black Ink (50% & 100%)
CE-801, Page 34, Pantone Blue 313 (20%, 40%, & 100%)
SUN
MON
TUE
WED
THU
FRI
Day 7
SAT
4. All Other Products, Services, and Expenses
Examples:
cigarettes
gasoline
utility gas bill
prescription drugs
cordless telephone
dry clean (curtains)
movie tickets
DVD rental
bus fare
phone bill
car insurance
brake work
hand soap
dish soap
power tools
paper towels
bath towel
rent
textbooks
cook book
airline fares
computer cables
cable TV bill
color television
Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?
Total Cost
(see examples above and on the flap)
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
35
FORM CE-801 (7-1-2005)
§)"D¤
080135
Black Ink (50% & 100%)
CE-801, Page 35, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
1. Food and Drinks Away from Home
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
beer
(see examples on the flap)
Fast-Food
Take-out
Delivery
Concession
Enter the
total cost of
the alcohol
other
Description
If alcoholic
beverages
included,
mark (X) all
that apply
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
FORM CE-801 (7-1-2005)
36
§)"E¤
080136
Black Ink (100%)
CE-801, Page 36, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
1. Food and Drinks Away from Home
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
other
Fast-Food
Take-out
Delivery
Concession
If alcoholic
beverages
included,
mark (X) all
that apply
beer
Description
(see examples on the flap)
Mark (X) one that best describes
where you made this purchase
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
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2
3
4
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2
3
4
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2
3
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2
3
4
1
2
3
4
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2
3
1
2
3
4
1
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3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
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2
3
4
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2
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2
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4
1
2
3
4
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2
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2
3
4
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2
3
4
1
2
3
Enter the
total cost of
the alcohol
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FORM CE-801 (7-1-2005)
§)"F¤
080137
Black Ink (100%)
CE-801, Page 37, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
(see examples on the flap)
fresh
frozen
without tax
Mark (X) if
purchased for
someone not
on your list
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FORM CE-801 (7-1-2005)
38
§)"G¤
080138
Black Ink (100%)
CE-801, Page 38, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) if
purchased for
someone not
on your list
228
229
230
231
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234
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242
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39
FORM CE-801 (7-1-2005)
§)"H¤
080139
Black Ink (100%)
CE-801, Page 39, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples on the flap)
Total Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) if
purchased for
someone not
on your list
255
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257
258
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FORM CE-801 (7-1-2005)
40
§)"I¤
080140
Black Ink (100%)
CE-801, Page 40, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
(see examples on the flap)
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
Mark (X) if
purchased for
someone not
on your list
Total Cost
without tax
282
283
284
285
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287
288
289
290
291
292
293
294
295
3. Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
(see examples on the flap)
Was the
item for:
Total Cost
without tax
Age:
1
Under
2–15 16 &
female
2
Over
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
male
Mark (X) if
purchased for
someone not
on your list
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305
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309
41
FORM CE-801 (7-1-2005)
§)"J¤
080141
Black Ink (100%)
CE-801, Page 41, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
3. Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
(see examples on the flap)
Was the
item for:
Total Cost
without tax
Age:
1
Under 2–15 16 &
female
Over
2
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
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2
3
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2
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2
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2
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2
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2
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2
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2
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2
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1
2
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2
3
1
2
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2
3
1
2
1
2
3
1
2
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2
3
1
2
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2
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2
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2
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2
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2
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2
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2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
1
2
1
2
3
male
Mark (X) if
purchased for
someone not
on your list
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FORM CE-801 (7-1-2005)
42
§)"K¤
080142
Black Ink (100%)
CE-801, Page 42, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
4. All Other Products, Services, and Expenses
What did you buy or pay for?
Total Cost
(see examples on the flap)
without tax
Mark (X) if
purchased for
someone not
on your list
401
402
403
404
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43
FORM CE-801 (7-1-2005)
§)"L¤
080143
Black Ink (100%)
CE-801, Page 43, Pantone Blue 313 (20%, 40%, & 100%)
Additional Pages
4. All Other Products, Services, and Expenses
What did you buy or pay for?
Total Cost
(see examples on the flap)
without tax
Mark (X) if
purchased for
someone not
on your list
428
429
430
431
432
433
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FORM CE-801 (7-1-2005)
44
§)"M¤
080144
Black Ink (100%)
CE-801, Page 44, Pantone Blue 313 (20%, 40%, & 100%)
Keep your records in this pocket.
(These records are only for your reference; we will not keep them.)
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FORM CE-801 (7-1-2005)
Black Ink (100%)
Receipts
Bank Statements
Credit Card Statements
Pay Stubs
Catalog/Internet Order Invoices
Utility Bills
Telephone bills
Daily Reminder List
Please review the list of expenses below with the people on your list at the end of each day.
If you have forgotten to record any expense, please do so on the appropriate page.
Did you or anyone on your list pay for . . .
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■
■
■
■
■
■
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meals, drinks, or snacks from restaurants, fast food, cafeterias,
vending machines, concession stands, etc.?
catered events or meal plans?
food & drinks from a grocery store or other speciality food store
such as a bakery, candy shop, or liquor store?
clothing, shoes, jewelry, accessories or clothing services such as dry cleaning?
personal care items or services such as cosmetics, soaps, haircuts, etc.?
housekeeping supplies or services for home decoration/maintenance?
toys, books, electronics, hobby supplies, etc.?
cigarettes, tobacco, or other smoking supplies?
commuting costs such as public transportation, parking fees, gasoline, or tolls?
medicine or medical/dental services?
entertainment or recreational activities?
typical bills such as utility bills, cable bills, telephone bills, etc.?
automatic deductions from a paycheck such as insurance premiums?
bank/ATM service fees?
credit card interest or finance charges?
internet or catalog orders?
fees for lessons or instructions?
gifts, contributions, donations?
For more specific examples of expenses, please refer to the flap attached to the front cover.
RO
code
FORM CE-801 (7-1-2005)
Black Ink (100%)
Control Number
PSU code
Segment No. Segment No.
Suffix
Spinoff
Sample
Designation
Serial No.
Serial No.
Suffix
Week
HH No. CU No. Indicator
1
2
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2009-08-10 |
| File Created | 2009-08-10 |