The American Community Survey

Attachment E

Your Guide for

THE

American
Community
Survey

This guide gives helpful information on
completing your survey form. If you need more
help, call 1–800–354–7271. The telephone call is
free. After you have completed your survey
form, please return it in the postage-paid
envelope we have provided.

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

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(2-2013)

Attachment E

Page
Your
Answers are Confidential and
Required by Law

2

How
to Fill Out the Survey Form

3

Examples
of Printed and Marked Entries

3

Instructions
for Completing the Survey Questions

3

What
the Survey is About – Some Questions
and Answers

16

Why
the Census Bureau Asks Certain Questions

16

YOUR ANSWERS ARE CONFIDENTIAL AND REQUIRED
BY LAW
The law, Title 13, Sections 9, 141, 193, and 221 of the U.S. Code,
authorizing the American Community Survey, also provides that
your answers are confidential. No one except Census Bureau
employees may see your completed form and they can be fined
and/or imprisoned for any disclosure of your answers.
The same law that protects the confidentiality of your answers
requires that you provide the information asked in this survey
to the best of your knowledge.

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Attachment E
HOW TO FILL OUT THE AMERICAN COMMUNITY
SURVEY FORM
Use blue or black ink to complete the form. Please mark the category or
categories as they apply to your household. Some questions ask you to
print the information. See Examples below.
Make sure you answer questions for each person in this household. If
anyone in the household, such as a roomer or boarder, does not want to
give you his or her personal information, print at least the person’s name
and answer questions 2 and 3. An interviewer may telephone to get
the information from that person.
There may be a question you cannot answer exactly. For example, you
may not know the age of an older person or the price for which your
house would sell. Ask someone else in your household; if no one knows,
give your best estimate.
Read these instructions and also follow the instructions provided
throughout the questionnaire. These instructions will help you understand
the questions and to answer them correctly. If you need assistance, call
1–800–354–7271. The telephone call is free.

EXAMPLES OF PRINTED AND MARKED ENTRIES
14

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

X

Yes

No ➜ SKIP to question 15a

b. What is this language?

Korean
For example: Korean, Italian, Spanish, Vietnamese

23 In what year did this person last get married?
Year

1998
INSTRUCTIONS FOR COMPLETING THE SURVEY QUESTIONS
List the name of each person who lives at this address. If you are not sure if
you should list a person, see the guidelines on the front page of the form.
If you are still not sure, call 1–800–354–7271 for help.
In the space labeled Person 1, print the name of the household member
living or staying here in whose name the house or apartment is owned,
being bought, or rented.
If there is no such person, any adult household member can be Person 1.
If there are more than 5 people in your household, please provide the
name of each additional person on page 4. For each additional person
listed on page 4, you should also provide this person’s sex and age.
Complete this form for the first five people listed on pages 2, 3, and 4, and
mail it back in the enclosed envelope as soon as possible. An interviewer
may telephone to obtain information for the additional persons.
If no one is living or staying at this address for more than 2 months,
complete questions 1, 2, 4, 6, 7, and 8 on page 5. If the home is for rent or
rented, but not yet occupied, also complete question 18 on page 7. If the
home is for sale only or sold, but not yet occupied, also complete question
19 on page 7.
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Attachment E
ANSWER PERSON QUESTIONS 1 THROUGH 6 FOR THE FIRST FIVE
PEOPLE LISTED ON PAGES 2, 3, AND 4 OF THE QUESTIONNAIRE.
1. Print the person’s Last Name, First Name, and Middle Initial (MI) in
the spaces provided.
2. If the person is related to Person 1 by birth, marriage, or adoption,
but is not the Husband or wife, Biological son or daughter,
Adopted son or daughter, Stepson or stepdaughter, Brother or
sister, Father or mother, Grandchild, Parent-in-law, Son-in-law
or daughter-in-law, of Person 1, mark the "Other relative" box.
Therefore, a niece or nephew of Person 1 would be categorized as
"Other relative."
If a person is not related to Person 1, mark the applicable box. A
"Roomer or boarder" is someone who occupies room(s) and makes
cash or non-cash payment(s). A "Housemate or roommate" is
someone sharing the house/apartment (but who is not romantically
involved) with Person 1. A "Housemate or roommate" is also 15
years old or over and who shares living quarters primarily to share
expenses. An "Unmarried partner," also known as a domestic
partner, is a person who shares a close personal relationship with
Person 1. A "Foster child" is someone under the age of 21 who is
involved in the formal foster care system. For all other people who are
not related to person 1, mark the "Other nonrelative" box.
3. Mark one box to indicate this person’s biological sex.
4. For each person, print this person’s age and month, day, and year of
birth. Print the age at the last birthday. Do not round the age up if
this person is close to having a birthday. If the exact age is not known,
provide an estimate. Print "0" for babies less than 1 year old.
Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not
races.
5. A person is of Hispanic, Latino, or Spanish origin if the person’s origin
(ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban,
Argentinean, Colombian, Costa Rican, Dominican, Ecuadorian,
Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other
Spanish-speaking countries of Central or South America or from Spain.
The term Mexican Am. refers to persons of Mexican-American origin or
ancestry.
If you mark the "Yes, another Hispanic, Latino, or Spanish origin"
box, print the name of the specific origin.
If a person is not of Hispanic, Latino, or Spanish origin, answer this
question by marking the "No, not of Hispanic, Latino, or Spanish
origin" box.
This question should be answered for ALL persons.
6. Mark all boxes for the appropriate races.
The concept of race, as used by the Census Bureau, reflects
self-identification by individuals according to the race or races with
which they identify.
The instruction before question 5, "For this survey, Hispanic origins are
not races" reflects the federal government’s treatment of Hispanic origin
and race as separate and distinct concepts. People who identify their
origin as Hispanic, Latino, or Spanish may be of any race.
People may choose to provide two or more races either by marking two
or more race response boxes, by providing multiple write-in responses, or
by some combination of marking boxes and writing in responses.
If you mark the "American Indian or Alaska Native" box, also print
the name of the tribe(s) in which the person is enrolled. If the person
is not enrolled in a tribe, print the name of the principal tribe.

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If you mark the "Other Asian" box, print the name of the specific
race(s) or group(s) in the space provided. The category "Other
Asian" includes persons who identify themselves as Burmese,
Hmong, Indonesian, Laotian, Thai, Pakistani, Cambodian, Sri
Lankan, and so on.
If you mark the "Other Pacific Islander" box, print the name of
the specific race(s) or group(s) in the space provided. The category
"Other Pacific Islander" includes persons who identify themselves as Fijian, Tongan, Polynesian, Tahitian, and so on.
If you mark the "Some other race" box, print the race(s) or
group(s) in the space provided.
This question should be answered for ALL persons.
ANSWER HOUSING QUESTIONS 1 THROUGH 24 FOR THE HOUSE,
APARTMENT, OR MOBILE HOME AT THE ADDRESS ON THE MAILING
LABEL.
1.

Mark only one category.
Count both occupied and vacant apartments in the house or
building. Do not count stores or office space.
Detached means there is open space on all sides, or the house is
joined only to a shed or garage. Attached means that the house is
joined to another house or building by at least one wall that goes
from ground to roof. An example of A one-family house attached
to one or more houses is a house in a row of houses attached to
one another, sometimes referred to as a townhouse.
A mobile home that has had one or more rooms added or built
onto it should be considered as A one-family house detached
from any other house. If only a porch or shed has been added to
a mobile home, it should be considered as a mobile home.
Towable RVs, such as travel trailers or fifth-wheel trailers, should be
considered as A mobile home. Self-propelling RVs or motorhomes
should be considered as a Boat, RV, van, etc.

2.

Mark the box that corresponds to the year in which the original
construction was completed, not the time of any later remodeling,
additions, or conversions.
If the building was first built in 2000 or later, enter the exact year
it was built.
If you live on a boat or in a mobile home, enter the year
corresponding to the model year in which it was manufactured.
If you do not know the year the building was first built, enter your
best estimate.

3.

Enter the month and year that Person 1 listed on page 2 last
moved into this house, apartment, or mobile home.

4.

Complete this question if you live in a one-family house or in a
mobile home; include only land that you own or rent.
The number of acres is the acreage on which the house or mobile
home is located; include adjoining land you rent for your use.

6.

Complete this question if you live in a one-family house or
mobile home. A business, such as a grocery store or barber shop,
is easily recognized from the outside and usually has a separate
entrance. A medical office is a doctor’s or dentist’s office
regularly visited by patients.

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Attachment E
7b. Include all rooms intended to be used as bedrooms in this house,
apartment, or mobile home, even if they are currently being used for other
purposes.
Print "0" for an efficiency or studio apartment that does not have a
separate bedroom. Your response to this question (7b) should be smaller
than the number of rooms reported in question 7a.
8a. Mark "Yes" to "hot and cold running water" even if the unit has hot
water only part of the time.
8d. Mark "Yes" to "sink with a faucet" if the sink is inside the house,
apartment or mobile home and the water can be turned on and off with a
faucet.
8e. Mark "Yes" to "a stove or range" if the stove or range is inside the
house, apartment or mobile home. Portable cooking equipment is not
considered a stove or range.
8g. Mark "Yes" to "telephone service ..." if (1) there is a telephone in
working order, and someone receives service at this house, apartment, or
mobile home; or (2) if someone has a cell phone from which you can both
make and receive calls. If service has been discontinued because of
nonpayment or any other reason, mark the "No" box.
9.

Mark the "Yes" or "No" box for each part of question 9.
DO NOT include devices such as portable book readers, Internet movie
players, portable gaming devices, and other devices with limited computing
capabilities.
"Desktop, laptop, netbook, or notebook computer" are types of
computers that operate primarily with a keyboard.
"Handheld computer, smart mobile phone, or other handheld
wireless computer" are types of computers that can be used by holding in
one hand. Some handheld computers, such as smartphones, are able to
make phone calls while others cannot.
"Some other type of computer" are devices with advanced capabilities,
such as tablet computers. These devices often feature “touch screen”
operations and have applications that allow them to function like a desktop
or a laptop computer.

10.

Mark only one box.
Access to the Internet with a subscription to an Internet service
includes any service that any member of the household obtains directly
through a contract agreement with an Internet service provider, or through
payments to a landlord, the government, or someone else. Access to the
Internet without a subscription to an Internet service includes services
that do not require an account or contract agreement.

11.

Mark the "Yes" or "No" box for each part of question 11.
"Dial-up service" is a type of Internet service that uses a regular telephone
line to connect to the Internet. "DSL service" is a broadband Internet
service that uses a regular telephone line and, unlike dial-up, allows users to
be online and use the phone at the same time. "Cable modem service" is
a broadband Internet service that uses a cable TV line. "Fiber-optic
service" is a broadband Internet service that uses a fiber-optic line.
"Mobile broadband plan for a computer or a cell phone" include
wireless broadband Internet service that can be accessed through a portable
modem in a computer or cell phone. "Satellite Internet service" is a
broadband Internet service that uses a satellite dish.

12.

Include company cars, vans or SUVs (including police cars and taxicabs) and
company trucks of one-ton (2,000 pounds) capacity or less that are regularly
kept at home and used by household members for nonbusiness purposes.
DO NOT count (1) cars or trucks permanently out of working order, or (2)
motorcycles or other recreational vehicles.

13.

Mark ONE category for the fuel used MOST to heat this house, apartment,
or mobile home. In buildings containing more than one apartment, you may
obtain this information from the owner, manager, or janitor.
Solar energy is provided by a system that collects, stores, and distributes
heat from the sun. Other fuel includes any fuel not listed separately, such
as purchased steam, fuel briquettes, and waste material.

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Attachment E
14a–14d.
If your house, apartment, or mobile home is rented, enter the costs
for utilities and fuels only if you pay for them in addition to the
monthly rent.
If you live in a condominium, enter the costs for utilities and fuels
only if you pay for them in addition to your condominium fee.
If your fuel and utility costs are included in your rent or condominium
fee, mark the "Included in rent or condominium fee" box.
DO NOT enter any dollar amounts.
For items 14a and 14b, report LAST MONTH’S COSTS. For items 14c
and 14d, report total costs for the PAST 12 MONTHS.
Estimate as closely as possible if you do not know exact costs. If you
have lived in this house, apartment, or mobile home less than one
year, estimate the costs for the PAST 12 MONTHS in 14c and 14d.
Report amounts even if your bills are unpaid or paid by someone
else. If the bills include utilities or fuel used also by another
apartment or a business establishment, estimate the amounts for
your house or apartment only. If gas and electricity are billed
together, enter the combined amount in 14a and mark the
"Included in electricity payment entered above" box in
item 14b.
15.

On October 1, 2008, the federal Food Stamp Program was renamed
SNAP (Supplemental Nutrition Assistance Program). Some states may
have their own specific name for this program. If you or any member
of this household received benefits from the government to buy
food for your family using a benefit card, mark the "Yes" box.

16.

A condominium is housing in which the apartments, houses, or
mobile homes in a building or development are individually owned,
but the common areas, such as lobbies and halls, are jointly owned.
Occupants of a cooperative should mark the "No" box.
A condominium fee is normally assessed by the condominium
owners’ association for the purpose of improving and maintaining
the common areas. Enter a monthly amount even if it is unpaid or
paid by someone else. If the amount is paid on some other periodic
basis, see the instruction for question 18a on how to change it to a
monthly amount.

17.

Housing is owned if the owner or co-owner lives in it.
If the house, apartment, or mobile home is mortgaged or there is a
contract to purchase, mark the "Owned by you or someone in this
household with a mortgage or loan? Include home equity
loans." box. If there is no mortgage or other debt, mark the
"Owned by you or someone in this household free and clear
(without a mortgage or loan)?" box. If the house, apartment, or
mobile home is owned but the land is rented, mark one of the
"owned" categories. If the mobile home is owned without an
installment loan, but there is a mortgage on the land, mark the
"Owned by you or someone in this household with a mortgage
or loan? Include home equity loans." box.
If any money rent is paid, even if the rent is paid by people who are
not members of your household, or paid by a federal, state, or local
government agency, mark the "Rented?" box.
If the unit is not owned or being bought by a member of this
household and if money rent is not paid or contracted, mark the
"Occupied without payment of rent?" box. The unit may be
owned by friends or relatives who live elsewhere and who allow
you to occupy this house, apartment, or mobile home without
charge. A house or apartment may be provided as part of wages or
salary. Examples are: caretaker’s or janitor’s house or apartment;
parsonages; tenant farmer or sharecropper houses for which the
occupants do not pay rent; or military housing.

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Attachment E
18a. Report the rent agreed to or contracted for, even if the rent for your
house, apartment, or mobile home is unpaid or paid by someone else.
If rent is paid:

Multiply
rent by:

By the day . . . . . . . . 30
By the week . . . . . . . 4
Every other week . . . 2

If rent is paid:

Divide
rent by:

4 times a year . . . . . . . 3
2 times a year . . . . . . 6
Once a year . . . . . . . . 12

18b. If meals are included in the monthly rent payment, or you must
contract for meals or a meal plan in order to live in this house,
apartment, or mobile home, mark the "Yes" box.
ANSWER HOUSING QUESTIONS 19 THROUGH 23 IF YOU OR ANY
MEMBER OF THIS HOUSEHOLD OWNS OR IS BUYING THIS HOUSE,
APARTMENT, OR MOBILE HOME.
19.

Enter your best estimate of the value of the property; that is, how
much you think the property would sell for if it were on the market.
If this is a house, include the value of the house, the land it is on,
and any other structures on the same property. If the house is
owned but the land is rented, estimate the combined value of the
house and the land. If this is a condominium unit, estimate the value
for the condominium, including your share of the common
elements. If this is a mobile home, include the value of the mobile
home and the value of the land only if you own the land.

20.

Report taxes for all taxing jurisdictions (city or town, county,
state, school district, etc.) even if they are included in your
mortgage payment, not yet paid or paid by someone else, or are
delinquent. DO NOT include taxes past due from previous years.

21.

When premiums are paid other than on a yearly basis, convert to
a yearly basis. Enter the yearly amount even if no payment was
made during the past year.

22a. The word mortgage indicates all types of loans secured by real estate.
22b. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see the
instructions for 18a to change it to a monthly amount.
Include payments on first mortgages and contracts to purchase only.
Report payments for second or junior mortgages and home equity
loans in 23b.
If this is a mobile home, report payments on installment loans but
DO NOT include personal property taxes, site rent, registration fees, and
license fees on the mobile home and site. Report these fees in item 24.
23a. A second mortgage or home equity loan is also secured by real estate.
You must have a first mortgage in order to have a second mortgage.
You may have a home equity loan and other mortgages on the
property or the home equity loan may be the only mortgage.
23b. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see
instructions for 18a to change it to a monthly amount. Include
payments on all second or junior mortgages or home equity loans.
ANSWER HOUSING QUESTION 24 IF THIS IS A MOBILE HOME THAT
YOU OWN OR ARE BUYING.
24.

Report an amount even if your bills are unpaid or are paid
by someone else.
Include payments for personal property taxes, land or site rent,
registration fees and license fees. DO NOT include real estate taxes
already reported in 20. Report the total annual amount even if you
make payments in two or more installments. Estimate as closely as
possible when you don’t know exact costs.

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Attachment E
ANSWER PERSON QUESTIONS 7 THROUGH 17 FOR ALL PERSONS
ON PAGES 2, 3, AND 4.
Questions 7 – 48 are a continuation of the questions for each person.
(Questions 1 – 6 appear on pages 2, 3, and 4 of the questionnaire.)
7. For people born in the United States:
Mark the "In the United States" box and then print the name of
the state in which the person was born. If the person was born in
Washington, D.C., print "District of Columbia."
For people born outside the United States:
Mark the "Outside the United States" box, and then print the
name of the foreign country or Puerto Rico, Guam, etc. where the
person was born. Use current boundaries, not boundaries at the time
of the person’s birth. For example, specify Czech Republic or Slovakia,
not Czechoslovakia; North or South Korea, not Korea. Specify the
particular country, not region. For example, specify Jamaica, not West
Indies; Kenya, not East Africa.
8. If the person was born in the United States (50 states and the District of
Columbia), mark the "Yes, born in the United States" box. If the
person was born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas, mark the "Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas" box. Although not listed,
if the person was born in American Samoa, mark "Yes, born in Puerto
Rico, Guam, the U.S. Virgin Islands, or Northern Marianas" box. If
the person was born outside the United States (50 states and the District
of Columbia) or at sea and had at least one parent who was a U.S.
citizen at the time of the person’s birth, mark the "Yes, born abroad
of U.S. citizen parent or parents" box. Mark the "Yes, U.S. citizen
by naturalization" box only if this person was born outside the United
States (50 states and the District of Columbia) and has completed the
naturalization process and is now a United States citizen. In the boxes
below "Print year of naturalization," print the four-digit year this
person completed the formal naturalization process. If this person is not
a U.S. citizen, mark the "No, not a U.S. citizen" box. Legal Permanent
Residents (LPRs) or "green card" holders, or other non-naturalized
immigrants or visitors to the U.S. are not citizens of the United States
and therefore should mark the "No, not a U.S. citizen" box.
9. If the person came to live in the United States (that is, the 50 states
and the District of Columbia) more than once, enter the latest year
he or she came to live in the United States.
10a. A public school is any school or college that is supported and
controlled primarily by a local, county, state, or federal government.
Schools are private if supported and controlled primarily by religious
organizations or other private groups. Home school applies to parental
guided education outside of a public or private school for grades 1–12.
10b. Only record grades that the person attended in the LAST 3 months. If
this is currently a summer month, do not record grades the person will
attend in the future.
11. Mark only one box to indicate the highest grade or level of schooling the
person has COMPLETED or the highest degree the person received.
Report schooling completed in foreign or ungraded schools as the
equivalent level of schooling in the regular American school system.
Mark the "GED or alternative credential" box for persons who did not
receive a regular high school diploma but completed high school by
receiving a GED or other formal recognition of high school completion
from a school or governmental authority.
If the person has not completed any college courses for credit, mark
the highest level completed below the college level. If the person has
not completed enough credit to be counted as a sophomore, mark the
"Some college credit, but less than 1 year of college credit" box.
For the "Professional degree beyond a bachelor’s degree"
category, DO NOT include certificates or diplomas for training in specific
trades or occupations such as computer and electronics technology,
medical assistant, or cosmetology. DO NOT include post-bachelor’s
certificates that are related to occupational training in such fields as
teaching, accounting, or engineering.
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12. Answer this question only if the person has a bachelor’s degree or
higher and print the specific major of this person’s bachelor’s
degree. If this person has more than one bachelor’s degree or more
than one major, print the names of the specific majors for all of this
person’s bachelor’s degree(s).
13. Print the ancestry group(s). Ancestry refers to the person’s ethnic
origin or descent, "roots," or heritage. Ancestry may also refer to the
country of birth of the person or the person’s parents or ancestors
before their arrival in the United States. Answer this question for ALL
persons, regardless of citizenship status.
Do not report a religious group as a person’s ancestry.
A person may report two ancestry groups (for example: German, Irish).
14a. Mark the"Yes" box if the person sometimes or always speaks a
language other than English at home.
Mark the "No" box if the person speaks only English, or if a non-English
language is spoken only at school or is limited to a few expressions
or slang.
14b. If this person speaks more than one non-English language and cannot
determine which is spoken more often, report the one the person first
learned to speak.
15a. If the person did not live in the United States or Puerto Rico one year
ago, mark the "No, outside the United States and Puerto Rico"
box and print the name of the foreign country, or U.S. Virgin Islands,
Guam, etc., where the person lived. Be specific when printing the name
of the foreign country, for example, specify Czech Republic or Slovakia,
not Czechoslovakia; North or South Korea, not Korea. Specify the
particular country, not region. For example, specify Jamaica, not West
Indies; Kenya, not East Africa. Then SKIP to question 16.
If the person lived somewhere else in the United States or Puerto Rico
one year ago, mark the "No, different house in the United States
or Puerto Rico" box.
15b. Include the house or structure number; street name; street type (for
example, St., Road, Ave.); and the street direction (if a direction such
as "North" is part of the address). For example, print 1239 N. Main St.
or 1239 Main St., N.W., not just 1239 Main. If the person lived in
Puerto Rico, the address should also include the name of the
development or condominium.
If the only known address is a post office box, give a description of the
residence location. For example, print the name of the building where
the person lived, the nearest intersection, the name of a military base
or installation, or the nearest street where the residence was located,
etc. DO NOT GIVE A POST OFFICE BOX NUMBER.
Print the name of the U.S. county or the name of the municipio in
Puerto Rico. If the person lived in Louisiana, print the parish name in
the "Name of U.S. county or municipio in Puerto Rico" space. If
the person lived in Alaska, print the borough or census area name, if
known. If the person lived in New York City and the county name is
not known, print the borough name. If the person lived in an
independent city (not in any county) or in Washington, D.C., leave the
"Name of U.S. county or municipio in Puerto Rico" space blank.
16. Mark the "Yes" or "No" box for each part of question 16.
If the person reports any other type of coverage plan in 16h, specify the type
of coverage or name of the plan in the write-in box. DO NOT include plans
that cover only one type of health care (such as dental plans) or plans that only
cover a person in case of an accident or disability.

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Attachment E
17a. If the person has multiple plans, consider the primary one that covers the most
services.
17b. Subsidized health coverage is insurance with a reduced premium. Low and
middle income families are eligible to receive tax credits that allow them to
pay lower premiums for insurance bought through healthcare exchanges or
marketplaces.
ANSWER PERSON QUESTIONS 19a THROUGH 19c IF THIS PERSON
IS 5 YEARS OLD OR OVER.
19a–19c.
Mark the "Yes" or "No" box to indicate if the person has serious
difficulty with any of the activities listed in parts a, b, and c because of a
physical, mental, or emotional condition.
ANSWER PERSON QUESTIONS 20 THROUGH 48 IF THIS PERSON IS 15
YEARS OLD OR OVER.
21. Mark the "Now married" box for a married person regardless of whether
his or her spouse is living in the household unless they are separated. If the
person’s only marriage was annulled, mark the "Never married" box.
Mark the “Divorced” box only if the person has received a divorce decree.
22c. Mark the "Yes" box only if the person has received a divorce decree in the
past 12 months.
23. Write the four-digit year when the person last got married, even if the
person is now widowed, divorced, or separated.
ANSWER QUESTION 24 IF THIS PERSON IS FEMALE AND IS 15–50
YEARS OLD.
24. Mark the "Yes" box if the person has given birth to at least one child born
alive in the past 12 months, even if the child died or no longer lives with the
mother. Do not consider miscarriages, or stillborn children, or any adopted,
foster, or stepchildren.
26. Active duty means full-time service, other than active duty for training, as a
member of the Army, Navy, Air Force, Marine Corps, Coast Guard, or as a
commissioned officer of the Public Health Service or the National Oceanic
and Atmospheric Administration, or its predecessors, the Coast and Geodetic
Survey or Environmental Science Service Administration. Active duty also
applies to a person who is a cadet attending one of the five United States
Military Service Academies. For a person with service in the military Reserves
or National Guard, mark the “Only on active duty for training in the
Reserves or National Guard" box if the person has never been called up
for active duty, mobilized, or deployed. For a person whose only service was
as a civilian employee or civilian volunteer for the Red Cross, USO, Public
Health Service, or War or Defense Department, mark the "Never served in
the military" box. For Merchant Marine service, count only the service
during World War II as active duty and no other period of service.
27. Mark as many responses as apply.
28a. Mark the "Yes" box if the person has a Department of Veterans Affairs
(VA) service-connected disability rating.
28b. Mark the "0 percent" box if the person has received a service-connected
disability rating of zero. DO NOT mark the box showing "0 percent" to
indicate no rating.
29a–29b.
Count as work – Mark the "Yes" box if this person performed:
• Work for someone else for wages, salary, piece rate, commission,
tips, or payments "in kind" (for example, food or lodging received as
payment for work performed).
• Work in own business, professional practice, or farm.
• Any work in a family business or farm, paid or not.
• Any part-time work including babysitting, paper routes, etc.
• Active duty in the Armed Forces.
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Attachment E
Do not count as work – Mark the "No" box if this person’s
activities were limited to the following:
•
•
•
•

Housework or yard work at home.
Unpaid volunteer work.
School work done as a student.
Work done as a resident or inmate of an institution.

30. Include the building or structure number; street name; street type
(for example, St., Road, Ave.); and the street direction (if a direction
such as "North" is part of the address). For example, print 1239 N.
Main St. or 1239 Main St., N.W., not just 1239 Main.
If the only known address is a post office box, give a description of
the work location. For example, print the name of the building or
shopping center where the person works, the nearest intersection,
or the nearest street where the workplace is located, etc. DO NOT
GIVE A POST OFFICE BOX NUMBER.
If the person worked at a military installation or military base that
has no street address, report the name of the military installation or
base, and a description of the work location (such as building
number, building name, nearest street or intersection).
If the person worked at several locations, but reported to the same
location each day to begin work, print the street address of the
location where he or she reported. If the person did not report to
the same location each day to begin work, print the address of the
location where he or she worked most of the time last week.
If the person’s employer operates in more than one location (such as
a grocery store chain or public school system), print the street address
of the location or branch where the person worked. If the street
address of a school is not known, print the name of the school, and a
description of the location (such as nearest street or intersection).
If the person worked on a college or university campus and the street
address of the workplace is not known, print the name of the
building where he or she worked, and a description of the location
(such as nearest street or intersection).
If the person worked in a foreign country or Puerto Rico, Guam, etc.,
print the name of the country on the state or foreign country line.
31. Mark only one box to indicate the method of transportation used to
travel the longest distance to work last week.
• Mark the "Car, truck, or van" box if the person drove a station
wagon, company car, light truck of 1-ton capacity or less, truck cab,
mini bus, or private limousine (NOT for hire).
• Mark the "Streetcar or trolley car" box if the person took light
rail or other vehicle that operates on tracks or rails with overhead
electrical wires.
• Mark the "Subway" box if the person took a subway, or other
vehicle that operates on tracks or rails with complete separation
from other vehicle and pedestrian traffic.
• Mark the "Railroad" box if the person took Amtrak, or any other
commuter train with occasional railroad crossings for vehicle and
pedestrian traffic.
• Mark the "Taxicab" box if the person took a limousine such as an
airport limousine for which a fare is charged.
• Mark the "Motorcycle" box if the person rode a motorbike,
moped, motor scooter, or similar vehicle that is motor driven.
• Mark the "Bicycle" box if the person rode a bicycle or other
vehicle that is pedaled.
• Mark the "Walked" box ONLY if the person walked all the way to
work and used no other means of transportation.
• Mark the "Worked at home" box if the person worked on a farm
where he/she lives, or an office or shop in the person’s own home.
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Attachment E
• Mark the "Other method" box if the person took an airplane,
helicopter, horse, horse and buggy, boat (other than public ferries),
large motor home, dog sled, large truck or truck rig, All-Terrain Vehicle
(ATV), snow machine/snowmobile, Segway® or other self-balancing
electric vehicle, skateboard, inline skates, or motorized chair.
ANSWER PERSON QUESTION 32 IF YOU MARKED "CAR, TRUCK, OR
VAN" IN QUESTION 31.
32.

If the person was driven to work by someone who then drove back
home or to a non-work destination, enter "1" in the box labeled
Person(s).
DO NOT include persons who rode to school or some other non-work
destination in the count of persons who rode in the vehicle.

33.

Give the time of day the person usually left home to go to work.
DO NOT give the time that the person usually began his or her work.
If the person usually left home to go to work sometime between
12:00 o’clock midnight and 12:00 o’clock noon, mark "a.m.".
If the person usually left home to go to work sometime between
12:00 o’clock noon and 12:00 o’clock midnight, mark "p.m.".

34.

Travel time is from door to door. Enter a one-way commute time
for this person’s usual daily commute from home to work last
week. Include time waiting for public transportation or picking up
passengers in a carpool.

ANSWER PERSON QUESTIONS 35a THROUGH 38 IF THE PERSON DID
NOT WORK LAST WEEK.
35a. Persons are on layoff if they are waiting to be recalled to a job
from which they were temporarily separated for business-related
reasons.
35b. If the person works only during certain seasons or on a day-by-day
basis when work is available, mark the "No" box.
35c. If the person was informed by his or her employer, either formally
or informally, that they will be recalled within the next 6 months,
mark the "Yes" box. Also mark the "Yes" box if the person has
been given, formally or informally, a specific date to return to
work, even if that date is more than 6 months away.
36. Mark the "Yes" box if the person tried to get a job or start a
business or professional practice at any time in the last 4 weeks; for
example, registered at a public or private employment office, went
to a job interview, placed or answered employment ads, or did
anything toward starting a business or professional practice.
37. If the person was expecting to report to a job within 30 days,
mark the "Yes, could have gone to work" box.
Mark the "No, because of own temporary illness" box only if the
person expects to be able to work within 30 days.
If the person could not have gone to work because he or she
was going to school, taking care of children, etc., mark the
"No, because of all other reasons (in school, etc.)" box.
38. Refer to the instructions for questions 29a–29b to determine what to
count as work. Mark the "Over 5 years ago or never worked" box
if the person: (1) never worked at any kind of job or business, either
full or part time, (2) never worked, with or without pay, in a family
business or farm, and (3) never served on active duty in the Armed
Forces.
39a–39b.
Refer to the instructions for questions 29a–29b to determine what to
count as work. Include paid vacation, paid sick leave, and military
service. Count every week in which the person worked at all, even for
an hour.
40. If the hours worked each week varied considerably in the past 12
months, give an approximate average of the hours worked each week.
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Attachment E
ANSWER PERSON QUESTIONS 41 THROUGH 46 IF THE PERSON
WORKED IN THE PAST 5 YEARS.
41. Mark the "an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?" box if the person
worked for a cooperative, credit union, mutual insurance company,
or similar organization.
Employees of foreign governments, the United Nations, and other
international organizations should mark the "a Federal
GOVERNMENT employee?" box.
If the person worked at a public school, college or university, mark
the appropriate government category; for example, mark the
"a state GOVERNMENT employee?" box for a state university, or
mark the "a local GOVERNMENT employee (city, county, etc.)?"
box for a county-run community college or a city-run public school.
42. If the person worked for a company, business, or government
agency, print the name of the company, not the name of the
person’s supervisor. If the person worked for an individual or a
business that had no company name, print the name of the
individual this person worked for. If the person worked in his or her
own un-named business, print "self-employed."
43. Print one or more words to describe the business, industry, or
individual employer named in question 42. If there is more than one
activity, describe only the major activity at the place where the person
worked. Enter what is made, what is sold, or what service is given.
Enter descriptions like the following: hospital, newspaper
publishing, mail order house, auto engine manufacturing, bank.
Do not enter: newspaper, order house, engine.
44. Mark one box to indicate the main type of business or industry
where this person works.
45. Print one or more words to describe the kind of work the
person did. If the person was a trainee, apprentice, or helper,
include that in the description.
Enter descriptions like the following: registered nurse,
personnel manager, supervisor of order department, secretary,
accountant, high school teacher, etc.
Do not enter single words such as: nurse, manager, teacher, etc.
46. Describe the most important activities or duties the person performed.
Enter descriptions like the following: patient care, directing
hiring policies, supervising order clerks, typing and filing, reconciling
financial records, etc.
ANSWER PERSON QUESTIONS 47 THROUGH 48 IF THIS PERSON IS 15
YEARS OLD OR OVER.
Mark the "Yes" or "No" box for each type of income, and enter the
amount received IN THE PAST 12 MONTHS for each "Yes" response.
If income from any source was received jointly by household members,
report, if possible, the appropriate share for each person; otherwise,
report the whole amount for only one person and mark the "No" box
for the other person.
When reporting income received jointly, DO NOT include the amount for
a person not listed on pages 2, 3, or 4.
DO NOT include the following as income in any item:
•
•
•
•
•
•

Refunds or rebates of any kind
Withdrawals from savings of any kind
Capital gains or losses from the sale of homes, shares of stock, etc.
Inheritances or insurance settlements
Any type of loan
Pay in-kind such as food, free rent

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Attachment E
47a. Include wages and salaries before deductions from ALL jobs. Be
sure to include any tips, commissions, or bonuses. Owners of
incorporated businesses should enter their salary here. Military
personnel should include base pay plus cash housing and/or
subsistence allowance, flight pay, uniform allotments, reenlistment
bonuses.
47b. Include NONFARM profit (or loss) from self-employment in sole
proprietorships and partnerships. Mark the "Loss" box if there is
a loss. Exclude profit (or loss) of incorporated businesses the
person owns.
Include FARM profit (or loss) from self-employment in sole
proprietorships and partnerships. Mark the "Loss" box if there is a
loss. Exclude profit (or loss) of incorporated farm businesses the
person owns. Also exclude amounts from land rented for cash but
include amounts from land rented for shares.
47c. Include interest received or credited to checking and saving
accounts, money market funds, certificates of deposit (CDs), IRAs,
KEOGHs, and government bonds.
Include dividends received, credited, or reinvested from ownership
of stocks or mutual funds.
Include profit (or loss) from royalties and the rental of land,
buildings or real estate, or from roomers or boarders. Mark the
"Loss" box if there is a loss. Income received by self-employed
persons whose primary source of income is from renting property or
from royalties should be included in question 47b above. Include
regular payments from an estate or trust fund.
47d. Include amounts, before Medicare deductions, of Social Security
and/or Railroad Retirement payments to retired persons, to
dependents of deceased insured workers, and to disabled workers.
47e. Include Supplemental Security Income (SSI) received by elderly,
blind, or disabled persons.
47f. Include any cash assistance or welfare payments received by check
or electronic transfer from the state or local welfare office, even if
received for only one month or less than a year. Include benefits
received on behalf of children. These payments are sometimes
referred to as Temporary Assistance for Needy Families (TANF), Aid
to Families with Dependent Children (AFDC), Aid to Dependent
Children (ADC), Welfare or welfare to work, General Assistance,
General Relief, Emergency Assistance, and Diversion Payments.
Do not include Supplemental Security Income (SSI), food assistance
(such as food stamps and benefits from the Supplemental Nutrition
Assistance Program, or SNAP), rental assistance, education
assistance, child care assistance, transportation assistance, or energy
assistance (such as Low Income Home Energy Assistance Program, or
LIHEAP).
47g. Include retirement, survivor or disability benefits received from
companies and unions, federal, state, and local governments, and
the U.S. military. Include regular income from annuities and IRA or
KEOGH retirement plans.
47h. Include Veterans’ (VA) disability compensation and educational
assistance payments (VEAP); unemployment compensation, worker’s
compensation, child support or alimony; and all other regular
payments such as Armed Forces transfer payments, assistance from
private charities, regular contributions from persons not living in the
household.
48.

Add the total entries (subtracting losses) for 47a through 47h for the
PAST 12 MONTHS and enter that number in the space provided. Mark
the "Loss" box if there is a loss. Print the total amount in dollars.

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Attachment E
What the Survey Is About -Some Questions and Answers
Why are we taking a survey?
The Census Bureau is conducting the American Community Survey to
provide more timely data than data we typically collect only once every
10 years during the decennial census.
What does the Census Bureau do with the information you provide?
The American Community Survey will be the source of summarized data
that we make available to federal, state, and local governments, and
also to the public. The data will enable your community leaders from
government, business, and non-profit organizations to plan more
effectively.
How was this address selected?
Your address was scientifically selected to represent a cross section of
other households in your community. Households in the sample are
required to complete the survey form. Please return it in the
postage-paid envelope as soon as possible.

Why the Census Bureau Asks Certain
Questions -Here are reasons we ask some of the questions on the survey.
Name
Names help make sure that everyone in a household is included, but that
no one is listed twice.
Value or rent
Government and planning agencies use answers to these questions in
combination with other information to develop housing programs to
meet the needs of people at different economic levels.
Plumbing and Kitchen facilities
This question helps provide information on the quality of housing. The
data are used with other statistics to show how the "level of living"
compares in various areas and how it changes over time.
Place of birth
This question provides information used to study long-term trends about
where people move and to study migration patterns and differences in
growth patterns.
Job
Answers to the questions about the jobs people hold provide information
on the extent and types of employment in different areas of the country.
From this information, communities can develop training programs, and
business and local governments can determine the need for new
employment opportunities.
Income
Income helps determine how well families or persons live. Income
information makes it possible to compare the economic levels of different
areas, and how economic levels for a community change over time.
Funding for many government programs is based on the answers to these
questions.
Education
Responses to the education questions in the survey help to determine the
number of new public schools, education programs, and daycare services
required in a community.
Disability
Questions about disability provide the means to allocate federal funding
for healthcare services and new hospitals in many communities.
Journey to work
Answers to these questions help communities plan road improvements,
develop public transportation services, and design programs to ease traffic
problems.

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