ACS-1 American Community Survey

13193016

DC

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

Start Here
Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it
back as soon as possible.

➜

➜

This form asks for information about the
people who are living or staying at the
address on the mailing label and about the
house, apartment, or mobile home located
at the address on the mailing label.

Please print today’s date.
Year
Month Day

Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name

First Name

MI

Area Code + Number
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.

—

➜

How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people

➜

Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.

¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

ACS-1(2013)KFI

FORM
(05-15-2012) Draft 5

§.4?1¤
ACS-1(X)PINT(2011)KFI, Page 1, Base (Black) Green Pantone 354 (20 and 40%)

OMB No. 0607-0810
Approval Expires 09/30/2014

13193024

Person 1

Person 2
1 What is Person 2’s name?
Last Name (Please print)

(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)

First Name

MI

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

1

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

2

First Name

MI

How is this person related to Person 1?
X

3

Person 1

4

Female

Month

Day

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Female

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Year of birth

Age (in years)

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this survey, Hispanic origins are not races.

5 Is Person 2 of Hispanic, Latino, or Spanish origin?

Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

6 What is Person 2’s race? Mark (X) one or more boxes.

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

White

Black, African Am., or Negro

Black, African Am., or Negro

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Some other race – Print race. C

2

Roomer or boarder

Stepson or stepdaughter

4 What is Person 2’s age and what is Person 2’s date of birth?

Question 6 about race. For this survey, Hispanic origins are not races.

6

Adopted son or daughter

Male

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5

Other relative

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

What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Son-in-law or daughter-in-law

Biological son or daughter

Parent-in-law

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

Husband or wife

Some other race – Print race. C

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ACS-1 KFI, Base (Black)

ACS-1 KFI, Page 2, Green Pantone 354 (20 and 40%)

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

13193032

Person 3
1

1 What is Person 4’s name?

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

2

Person 4

First Name

Last Name (Please print)

MI

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

Son-in-law or daughter-in-law

Husband or wife

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Brother or sister

Unmarried partner

Father or mother

Foster child

Father or mother

Foster child

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Parent-in-law

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

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

4

Female

Male

What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Month

Day

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Year of birth

Age (in years)

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this survey, Hispanic origins are not races.

6

Female

4 What is Person 4’s age and what is Person 4’s date of birth?

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5

MI

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

Parent-in-law

3

First Name

Question 6 about race. For this survey, Hispanic origins are not races.

5 Is Person 4 of Hispanic, Latino, or Spanish origin?

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

6 What is Person 4’s race? Mark (X) one or more boxes.

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

White

Black, African Am., or Negro

Black, African Am., or Negro

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Some other race – Print race. C

Some other race – Print race. C

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ACS-1 KFI, Base (Black)

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

3
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13193040

➜

Person 5
1

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

First Name

MI

If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them. C

Person 6
Last Name (Please print)

2

First Name

MI

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

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Sex

Male

Female

Age (in years)

Person 7
Last Name (Please print)

First Name

MI

Parent-in-law

3

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

4

Sex

Female

Month

Day

Age (in years)

Last Name (Please print)

First Name

MI

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this survey, Hispanic origins are not races.

5

Female

Person 8

What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Male

Is Person 5 of Hispanic, Latino, or Spanish origin?

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

First Name

MI

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Sex

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

6

Male

Female

Age (in years)

Person 10
Last Name (Please print)

First Name

MI

What is Person 5’s race? Mark (X) one or more boxes.
White
Sex

Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Male

Female

Person 11
Last Name (Please print)

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Sex

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

Age (in years)

Male

First Name

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race. C
Sex

4

Male

Female

Age (in years)

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ACS-1 KFI, Base (Black)

MI

ACS-1 KFI, Page 4, Green Pantone 354 (20 and 40%)

MI

13193057

Housing
➜

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

A

8 Does this house, apartment, or mobile

Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.

home have –

b. a flush toilet?

4 How many acres is this house or

Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses

c. a bathtub or shower?

1 to 9.9 acres

e. a stove or range?

10 or more acres

f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.

9 At this house, apartment, or mobile home –

None

do you or any member of this household
own or use any of the following computers?

$1 to $999

• EXCLUDE GPS devices, digital music players,
and devices with only limited computing
capabilities, for example: household
appliances.
Yes
No
a. Desktop, laptop, netbook, or
notebook computer

$1,000 to $2,499

A building with 5 to 9 apartments

$2,500 to $4,999

A building with 10 to 19 apartments

$5,000 to $9,999

A building with 20 to 49 apartments

$10,000 or more

A building with 50 or more apartments

About when was this building first built?

d. a sink with a faucet?

were the actual sales of all agricultural
products from this property?

A building with 3 or 4 apartments

2

Less than 1 acre ➔ SKIP to question 6

5 IN THE PAST 12 MONTHS, what

A building with 2 apartments

Boat, RV, van, etc.

No

a. hot and cold running water?

mobile home on?

1

Yes

b. Handheld computer,
smart mobile phone, or other
handheld wireless computer

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

2000 or later – Specify year

c. Some other type of computer
Specify C

Yes
No

1990 to 1999

7 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.

1980 to 1989
1970 to 1979
1960 to 1969
1940 to 1949

• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.

1939 or earlier

Number of rooms

1950 to 1959

3

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

Year

10 At this house, apartment, or mobile home –
do you or any member of this household
access the Internet?
Yes, with a subscription to an Internet
service
Yes, without a subscription to an Internet
service ➔ SKIP to question 12
No Internet access at this house, apartment,
or mobile home ➔ SKIP to question 12

11 At this house, apartment, or mobile home –
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
Number of bedrooms

do you or any member of this household
subscribe to the Internet using –
Yes

No

a. Dial-up service?
b. DSL service?
c. Cable modem service?
d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite Internet service?
g. Some other service?
Specify service C

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13193065

Housing (continued)

14 a. LAST MONTH, what was the cost

12 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?

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

.00

,

None

15 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits
from the Food Stamp Program or SNAP
(the Supplemental Nutrition Assistance
Program)? Do NOT include WIC, the School
Lunch Program, or assistance from food banks.
Yes

OR

No

1

Included in rent or condominium fee

2

No charge or electricity not used

16 Is this house, apartment, or mobile home
part of a condominium?

3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?

4
5
6 or more

13 Which FUEL is used MOST for heating this

Last month’s cost – Dollars
$

house, apartment, or mobile home?

.00

,

Monthly amount – Dollars

OR

Gas: from underground pipes serving the
neighborhood

Included in rent or condominium fee

Gas: bottled, tank, or LP

Included in electricity payment
entered above

Electricity

Wood
Solar energy
Other fuel
No fuel used

$

OR

No
c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
Past 12 months’ cost – Dollars
$

.00

,
OR

17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?

Included in rent or condominium fee

Rented?

No charge

Occupied without payment of
rent? ➔ SKIP to C on the next page

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

.00

,
OR

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

6

§.4?b¤

ACS-1(X)T(2010)KFI, Page 6, Base (Black)

.00

,
None

No charge or gas not used

Fuel oil, kerosene, etc.
Coal or coke

Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.

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13193073

Housing (continued)
B

22 a. Do you or any member of this

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

18 a. What is the monthly rent for this

$

.00

,

b. Does the monthly rent include any
meals?

C

household have a second mortgage
or a home equity loan on THIS
property?

Yes, mortgage, deed of trust, or similar
debt

Yes, home equity loan

Yes, contract to purchase

Yes, second mortgage and home
equity loan

Yes, second mortgage

No ➔ SKIP to question 23a

house, apartment, or mobile home?
Monthly amount – Dollars

23 a. Do you or any member of this

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

No ➔ SKIP to D

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

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

Monthly amount – Dollars
$

Yes

,

No

OR

Monthly amount – Dollars

.00

$

No regular payment required ➔ SKIP to
question 23a
Answer questions 19–23 if you or
someone else in this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .

OR
No regular payment required

c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?

D

Yes, taxes included in mortgage
payment

19 About how much do you think this
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?
Amount – Dollars
$

,

.00

,

20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$

.00

,

.00

,

No, taxes paid separately or taxes
not required

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

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

Annual costs – Dollars

Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance

Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .

$

E

,

.00

Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.

OR
None

21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$

.00

,
OR
None

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13193081

Person 1

11 What is the highest degree or level of school

this person has COMPLETED? Mark (X) ONE box.

➜

13 What is this person’s ancestry or ethnic origin?

If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

No schooling completed

(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?

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

In the United States – Print name of state.

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Regular high school diploma
GED or alternative credential

8

COLLEGE OR SOME COLLEGE

Is this person a citizen of the United States?

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

Yes, born in the United States ➔ SKIP to
question 10a

Some college credit, but less than 1 year of
college credit

Very well

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

1 or more years of college credit, no degree

Well

Associate’s degree (for example: AA, AS)

Not well

Yes, born abroad of U.S. citizen parent
or parents

Bachelor’s degree (for example: BA, BS)

Not at all

AFTER BACHELOR’S DEGREE

Yes, U.S. citizen by naturalization – Print year
of naturalization

Master’s degree (for example: MA, MS, MEng, 15
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

No, not a U.S. citizen

9

b. What is this language?

HIGH SCHOOL GRADUATE

When did this person come to live in the
United States? Print numbers in boxes.
Year

Doctorate degree (for example: PhD, EdD)

F

Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

12 This question focuses on this person’s

No, has not attended in the last 3
months ➔ SKIP to question 11

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical

engineering, elementary teacher education,
organizational psychology)

a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person
attending? Mark (X) ONE box.

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

8

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

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ZIP Code

13193099

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
condition, does this person have difficulty
Yes No
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

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

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced
Separated

Never served in the military ➔ SKIP to
question 29a

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

21 In the PAST 12 MONTHS did this person get –
Yes

g. Indian Health Service

No

Now on active duty
On active duty in the past, but not now

a. Married?

h. Any other type of health insurance
or health coverage plan – Specify C

b. Widowed?
c. Divorced?

22 How many times has this person been married?

serious difficulty hearing?

27 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later

Once

Yes

August 1990 to August 2001 (including
Persian Gulf War)

Two times

No

May 1975 to July 1990

Three or more times

Vietnam era (August 1964 to April 1975)

b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?

G

Less than 6 months

26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

17 a. Is this person deaf or does he/she have

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

20 What is this person’s marital status?

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

f. VA (including those who have ever
used or enrolled for VA health care)

c. How long has this grandparent been
responsible for these grandchildren?

February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

I

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

28 a. Does this person have a VA service-connected
disability rating?

24 Has this person given birth to any children in
the past 12 months?

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes

November 1941 or earlier

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
b. What is this person’s service-connected
disability rating?

No

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

No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

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

0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Yes

Yes

No

No ➔ SKIP to question 26

70 percent or higher

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13193107

Person 1 (continued)

J

29 a. LAST WEEK, did this person work for pay

Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

location, print where he or she worked most
last week.

Minute

:

a. Address (Number and street name)

38 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

Minutes

39 a. During the PAST 12 MONTHS (52 weeks), did

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

this person work 50 or more weeks? Count
paid time off as work.

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.

Yes
No, outside the city/town limits

35 a. LAST WEEK, was this person on layoff from
a job?

d. Name of county

Yes ➔ SKIP to question 35c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 48

f. ZIP Code

No ➔ SKIP to question 36

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Over 5 years ago or never worked ➔ SKIP to
question 47

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No

Taxicab

10

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13193115

Person 1 (continued)
L

45 What kind of work was this person doing?

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

41 Was this person –
Mark (X) ONE box.

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

Yes ➔
No

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

Yes ➔

,

.00

Yes ➔
No

TOTAL AMOUNT for past
12 months

Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

$

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
$
.00
No
,
,
Loss
TOTAL AMOUNT for past
None
OR
Loss
12 months
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $
No

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on
page 2, SKIP to page 28 for mailing instructions.

§.4@0¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)

.00

,

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.

,

.00

,

TOTAL AMOUNT for past
12 months

No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

11
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13193123

Person 2

11 What is the highest degree or level of school

this person has COMPLETED? Mark (X) ONE box.

➜

13 What is this person’s ancestry or ethnic origin?

If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

No schooling completed

(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?

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

In the United States – Print name of state.

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Regular high school diploma
GED or alternative credential

8

COLLEGE OR SOME COLLEGE

Is this person a citizen of the United States?

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

Yes, born in the United States ➔ SKIP to
question 10a

Some college credit, but less than 1 year of
college credit

Very well

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

1 or more years of college credit, no degree

Well

Associate’s degree (for example: AA, AS)

Not well

Yes, born abroad of U.S. citizen parent
or parents

Bachelor’s degree (for example: BA, BS)

Not at all

AFTER BACHELOR’S DEGREE

Yes, U.S. citizen by naturalization – Print year
of naturalization

Master’s degree (for example: MA, MS, MEng, 15
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

No, not a U.S. citizen

9

b. What is this language?

HIGH SCHOOL GRADUATE

When did this person come to live in the
United States? Print numbers in boxes.
Year

Doctorate degree (for example: PhD, EdD)

F

Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

12 This question focuses on this person’s

No, has not attended in the last 3
months ➔ SKIP to question 11

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical

engineering, elementary teacher education,
organizational psychology)

a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person
attending? Mark (X) ONE box.

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

12

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

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ZIP Code

13193131

Person 2 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
condition, does this person have difficulty
Yes No
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

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

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced
Separated

Never served in the military ➔ SKIP to
question 29a

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

21 In the PAST 12 MONTHS did this person get –
Yes

g. Indian Health Service

No

Now on active duty
On active duty in the past, but not now

a. Married?

h. Any other type of health insurance
or health coverage plan – Specify C

b. Widowed?
c. Divorced?

22 How many times has this person been married?

serious difficulty hearing?

27 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later

Once

Yes

August 1990 to August 2001 (including
Persian Gulf War)

Two times

No

May 1975 to July 1990

Three or more times

Vietnam era (August 1964 to April 1975)

b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?

G

Less than 6 months

26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

17 a. Is this person deaf or does he/she have

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

20 What is this person’s marital status?

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

f. VA (including those who have ever
used or enrolled for VA health care)

c. How long has this grandparent been
responsible for these grandchildren?

February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

I

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

28 a. Does this person have a VA service-connected
disability rating?

24 Has this person given birth to any children in
the past 12 months?

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes

November 1941 or earlier

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
b. What is this person’s service-connected
disability rating?

No

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

No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

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

0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Yes

Yes

No

No ➔ SKIP to question 26

70 percent or higher

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13193149

Person 2 (continued)

J

29 a. LAST WEEK, did this person work for pay

Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

location, print where he or she worked most
last week.

Minute

:

a. Address (Number and street name)

38 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

Minutes

39 a. During the PAST 12 MONTHS (52 weeks), did

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

this person work 50 or more weeks? Count
paid time off as work.

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.

Yes
No, outside the city/town limits

35 a. LAST WEEK, was this person on layoff from
a job?

d. Name of county

Yes ➔ SKIP to question 35c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 48

f. ZIP Code

No ➔ SKIP to question 36

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Over 5 years ago or never worked ➔ SKIP to
question 47

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No

Taxicab

14

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Person 2 (continued)
L

45 What kind of work was this person doing?

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

41 Was this person –
Mark (X) ONE box.

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

Yes ➔
No

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

Yes ➔

,

.00

Yes ➔
No

TOTAL AMOUNT for past
12 months

Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

$

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
$
.00
No
,
,
Loss
TOTAL AMOUNT for past
None
OR
Loss
12 months
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $
No

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on
page 3, SKIP to page 28 for mailing instructions.

§.4@Y¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)

.00

,

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.

,

.00

,

TOTAL AMOUNT for past
12 months

No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

15
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13193164

Person 3

11 What is the highest degree or level of school

this person has COMPLETED? Mark (X) ONE box.

➜

13 What is this person’s ancestry or ethnic origin?

If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

No schooling completed

(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?

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

In the United States – Print name of state.

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Regular high school diploma
GED or alternative credential

8

COLLEGE OR SOME COLLEGE

Is this person a citizen of the United States?

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

Yes, born in the United States ➔ SKIP to
question 10a

Some college credit, but less than 1 year of
college credit

Very well

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

1 or more years of college credit, no degree

Well

Associate’s degree (for example: AA, AS)

Not well

Yes, born abroad of U.S. citizen parent
or parents

Bachelor’s degree (for example: BA, BS)

Not at all

AFTER BACHELOR’S DEGREE

Yes, U.S. citizen by naturalization – Print year
of naturalization

Master’s degree (for example: MA, MS, MEng, 15
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

No, not a U.S. citizen

9

b. What is this language?

HIGH SCHOOL GRADUATE

When did this person come to live in the
United States? Print numbers in boxes.
Year

Doctorate degree (for example: PhD, EdD)

F

Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

12 This question focuses on this person’s

No, has not attended in the last 3
months ➔ SKIP to question 11

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical

engineering, elementary teacher education,
organizational psychology)

a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person
attending? Mark (X) ONE box.

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

16

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

§.4@a¤

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ZIP Code

13193172

Person 3 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
condition, does this person have difficulty
Yes No
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

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

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced
Separated

Never served in the military ➔ SKIP to
question 29a

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

21 In the PAST 12 MONTHS did this person get –
Yes

g. Indian Health Service

No

Now on active duty
On active duty in the past, but not now

a. Married?

h. Any other type of health insurance
or health coverage plan – Specify C

b. Widowed?
c. Divorced?

22 How many times has this person been married?

serious difficulty hearing?

27 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later

Once

Yes

August 1990 to August 2001 (including
Persian Gulf War)

Two times

No

May 1975 to July 1990

Three or more times

Vietnam era (August 1964 to April 1975)

b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?

G

Less than 6 months

26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

17 a. Is this person deaf or does he/she have

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

20 What is this person’s marital status?

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

f. VA (including those who have ever
used or enrolled for VA health care)

c. How long has this grandparent been
responsible for these grandchildren?

February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

I

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

28 a. Does this person have a VA service-connected
disability rating?

24 Has this person given birth to any children in
the past 12 months?

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes

November 1941 or earlier

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
b. What is this person’s service-connected
disability rating?

No

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

No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

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

0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Yes

Yes

No

No ➔ SKIP to question 26

70 percent or higher

§.4@i¤
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17
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13193180

Person 3 (continued)

J

29 a. LAST WEEK, did this person work for pay

Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

location, print where he or she worked most
last week.

Minute

:

a. Address (Number and street name)

38 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

Minutes

39 a. During the PAST 12 MONTHS (52 weeks), did

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

this person work 50 or more weeks? Count
paid time off as work.

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.

Yes
No, outside the city/town limits

35 a. LAST WEEK, was this person on layoff from
a job?

d. Name of county

Yes ➔ SKIP to question 35c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 48

f. ZIP Code

No ➔ SKIP to question 36

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Over 5 years ago or never worked ➔ SKIP to
question 47

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No

Taxicab

18

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13193198

Person 3 (continued)
L

45 What kind of work was this person doing?

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

41 Was this person –
Mark (X) ONE box.

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

Yes ➔
No

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

Yes ➔

,

.00

Yes ➔
No

TOTAL AMOUNT for past
12 months

Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

$

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
$
.00
No
,
,
Loss
TOTAL AMOUNT for past
None
OR
Loss
12 months
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $
No

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on
page 3, SKIP to page 28 for mailing instructions.

§.4@¥¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)

.00

,

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.

,

.00

,

TOTAL AMOUNT for past
12 months

No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

19
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13193206

Person 4

11 What is the highest degree or level of school

this person has COMPLETED? Mark (X) ONE box.

➜

13 What is this person’s ancestry or ethnic origin?

If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

No schooling completed

(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?

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

In the United States – Print name of state.

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Regular high school diploma
GED or alternative credential

8

COLLEGE OR SOME COLLEGE

Is this person a citizen of the United States?

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

Yes, born in the United States ➔ SKIP to
question 10a

Some college credit, but less than 1 year of
college credit

Very well

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

1 or more years of college credit, no degree

Well

Associate’s degree (for example: AA, AS)

Not well

Yes, born abroad of U.S. citizen parent
or parents

Bachelor’s degree (for example: BA, BS)

Not at all

AFTER BACHELOR’S DEGREE

Yes, U.S. citizen by naturalization – Print year
of naturalization

Master’s degree (for example: MA, MS, MEng, 15
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

No, not a U.S. citizen

9

b. What is this language?

HIGH SCHOOL GRADUATE

When did this person come to live in the
United States? Print numbers in boxes.
Year

Doctorate degree (for example: PhD, EdD)

F

Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

12 This question focuses on this person’s

No, has not attended in the last 3
months ➔ SKIP to question 11

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical

engineering, elementary teacher education,
organizational psychology)

a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person
attending? Mark (X) ONE box.

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

20

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

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ZIP Code

13193214

Person 4 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
condition, does this person have difficulty
Yes No
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

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

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced
Separated

Never served in the military ➔ SKIP to
question 29a

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

21 In the PAST 12 MONTHS did this person get –
Yes

g. Indian Health Service

No

Now on active duty
On active duty in the past, but not now

a. Married?

h. Any other type of health insurance
or health coverage plan – Specify C

b. Widowed?
c. Divorced?

22 How many times has this person been married?

serious difficulty hearing?

27 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later

Once

Yes

August 1990 to August 2001 (including
Persian Gulf War)

Two times

No

May 1975 to July 1990

Three or more times

Vietnam era (August 1964 to April 1975)

b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?

G

Less than 6 months

26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

17 a. Is this person deaf or does he/she have

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

20 What is this person’s marital status?

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

f. VA (including those who have ever
used or enrolled for VA health care)

c. How long has this grandparent been
responsible for these grandchildren?

February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

I

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

28 a. Does this person have a VA service-connected
disability rating?

24 Has this person given birth to any children in
the past 12 months?

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes

November 1941 or earlier

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
b. What is this person’s service-connected
disability rating?

No

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

No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

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

0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Yes

Yes

No

No ➔ SKIP to question 26

70 percent or higher

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13193222

Person 4 (continued)

J

29 a. LAST WEEK, did this person work for pay

Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

location, print where he or she worked most
last week.

Minute

:

a. Address (Number and street name)

38 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

Minutes

39 a. During the PAST 12 MONTHS (52 weeks), did

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

this person work 50 or more weeks? Count
paid time off as work.

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.

Yes
No, outside the city/town limits

35 a. LAST WEEK, was this person on layoff from
a job?

d. Name of county

Yes ➔ SKIP to question 35c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 48

f. ZIP Code

No ➔ SKIP to question 36

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Over 5 years ago or never worked ➔ SKIP to
question 47

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No

Taxicab

22

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13193230

Person 4 (continued)
L

45 What kind of work was this person doing?

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

41 Was this person –
Mark (X) ONE box.

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

Yes ➔
No

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

Yes ➔

,

.00

Yes ➔
No

TOTAL AMOUNT for past
12 months

Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

$

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
$
.00
No
,
,
Loss
TOTAL AMOUNT for past
None
OR
Loss
12 months
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $
No

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on
page 4, SKIP to page 28 for mailing instructions.

§.4A?¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)

.00

,

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.

,

.00

,

TOTAL AMOUNT for past
12 months

No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

23
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13193248

Person 5

11 What is the highest degree or level of school

this person has COMPLETED? Mark (X) ONE box.

➜

13 What is this person’s ancestry or ethnic origin?

If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

No schooling completed

(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?

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

In the United States – Print name of state.

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Regular high school diploma
GED or alternative credential

8

COLLEGE OR SOME COLLEGE

Is this person a citizen of the United States?

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

Yes, born in the United States ➔ SKIP to
question 10a

Some college credit, but less than 1 year of
college credit

Very well

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

1 or more years of college credit, no degree

Well

Associate’s degree (for example: AA, AS)

Not well

Yes, born abroad of U.S. citizen parent
or parents

Bachelor’s degree (for example: BA, BS)

Not at all

AFTER BACHELOR’S DEGREE

Yes, U.S. citizen by naturalization – Print year
of naturalization

Master’s degree (for example: MA, MS, MEng, 15
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

No, not a U.S. citizen

9

b. What is this language?

HIGH SCHOOL GRADUATE

When did this person come to live in the
United States? Print numbers in boxes.
Year

Doctorate degree (for example: PhD, EdD)

F

Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

12 This question focuses on this person’s

No, has not attended in the last 3
months ➔ SKIP to question 11

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical

engineering, elementary teacher education,
organizational psychology)

a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person
attending? Mark (X) ONE box.

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

24

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

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ZIP Code

13193255

Person 5 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
condition, does this person have difficulty
Yes No
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

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

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced
Separated

Never served in the military ➔ SKIP to
question 29a

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

21 In the PAST 12 MONTHS did this person get –
Yes

g. Indian Health Service

No

Now on active duty
On active duty in the past, but not now

a. Married?

h. Any other type of health insurance
or health coverage plan – Specify C

b. Widowed?
c. Divorced?

22 How many times has this person been married?

serious difficulty hearing?

27 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later

Once

Yes

August 1990 to August 2001 (including
Persian Gulf War)

Two times

No

May 1975 to July 1990

Three or more times

Vietnam era (August 1964 to April 1975)

b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?

G

Less than 6 months

26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

17 a. Is this person deaf or does he/she have

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

20 What is this person’s marital status?

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

f. VA (including those who have ever
used or enrolled for VA health care)

c. How long has this grandparent been
responsible for these grandchildren?

February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

I

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

28 a. Does this person have a VA service-connected
disability rating?

24 Has this person given birth to any children in
the past 12 months?

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes

November 1941 or earlier

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
b. What is this person’s service-connected
disability rating?

No

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

No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

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

0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Yes

Yes

No

No ➔ SKIP to question 26

70 percent or higher

§.4AX¤
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25
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13193263

Person 5 (continued)

J

29 a. LAST WEEK, did this person work for pay

Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

location, print where he or she worked most
last week.

Minute

:

a. Address (Number and street name)

38 When did this person last work, even for a few
a.m.
p.m.

days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.

Minutes

39 a. During the PAST 12 MONTHS (52 weeks), did

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

this person work 50 or more weeks? Count
paid time off as work.

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.

Yes
No, outside the city/town limits

35 a. LAST WEEK, was this person on layoff from
a job?

d. Name of county

Yes ➔ SKIP to question 35c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 48

f. ZIP Code

No ➔ SKIP to question 36

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Over 5 years ago or never worked ➔ SKIP to
question 47

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No

Taxicab

26

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13193271

Person 5 (continued)
L

45 What kind of work was this person doing?

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

41 Was this person –
Mark (X) ONE box.

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

Yes ➔
No

If net income was a loss, mark the "Loss" box to
the right of the dollar amount.

Yes ➔

,

.00

Yes ➔
No

TOTAL AMOUNT for past
12 months

Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

$

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm 48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
$
.00
No
,
,
Loss
TOTAL AMOUNT for past
None
OR
Loss
12 months
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $
No

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

Now continue with the mailing instructions
on page 28.

§.4Ah¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)

.00

,

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.

,

.00

,

TOTAL AMOUNT for past
12 months

No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔ $

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

27
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13193289

Mailing
Instructions
➜ Please make sure you have...

• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ Then...

• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2013)KFI (05-15-2012) Draft 5

28

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