Form CE 801 CE 801 Your Daily Expenses

Consumer Expenditure Surveys: Quarterly Interview and Diary

Attachment D - CE 801 2015

The Diary

OMB: 1220-0050

Document [pdf]
Download: pdf | pdf
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

R

EA
EN
UO
F TH E C

S

BU

US

U.S.
D

ENT OF C
TM
O
AR

CE
ER
M
M

EP

U.S. CENSUS BUREAU

Acting as a collecting agent for
U.S. Department of Labor
Bureau of Labor Statistics

Your Daily Expenses
Help us learn about the buying habits of people in the United States

Pierre-Vending
Machine.jpg

Jeanette & LindaPastry Shop.jpg

Stephen - Writing
Checks.jpg

Nhien & Jenny Flower Shop.jpg

George - Gas
Station.jpg

When you write down how you spend your money in this diary, you will help us understand
more about the products and services that are bought by the people in the United States.
By law (title 13, U.S. Code), we must keep your information confidential; we use it for statistical purposes only.
If you have comments regarding this survey, please send them to the Division of Consumer Expenditure Surveys,
2 Massachusetts Avenue N.E., Room 3985, Washington, DC 20212.

Please record your expenses and purchases
for the following period
Day

Date

1
2
3
4
5
6
7

I will return on: _______________________________________
If you have any questions, please call:
Field representative’s name:

Telephone:

Field representative supervisor’s name:

Telephone:
FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

OMB No. 1220-0050

Examples
(continued on other side)

1. Food and Drinks Away from Home
■
■
■

■

Fast Food, Take-out, Delivery, Concession
(you pay BEFORE you eat/drink)
Full Service Places (you pay AFTER you eat/drink)
Vending Machines or Mobile Vendors (include
vending machines, carts, & trucks that move from
place to place)
Employer and School Cafeterias
Includes elementary school pre-payments

2. Food and Drinks for Home Consumption
■
■
■
■
■
■
■
■
■
■
■
■
■

■

■
■

Grain Products (cake mixes, cereal, cornmeal, flour,
pasta, rice, spaghetti, etc.)
Bakery Products (cakes, cookies, frozen waffles, pies,
white bread, other bread, etc.)
Beef (briskets, ground beef, round & other roasts,
sirloin, etc.)
Pork (bacon, ham, pork chops, sausage, etc.)
Poultry (chicken parts, duck, whole turkey, etc.)
Other meats (bologna, frankfurters, lamb, liverwurst,
organ meats, salami, etc.)
Fish & Seafood (fish, shellfish, etc.)
Oils, Fats & Dressings (salad dressing, shortening,
vinegar, etc.)
Eggs & Dairy Products (butter, cream, cheese, ice
cream, skim milk, powdered milk, etc.)
Fruits & Fruit Juices (apples, bananas, cranberry
juice, oranges, orange juice, etc.)
Sugar, Sugar Substitutes & Sweets (artificial
sweeteners, candy, gum, jams, jellies, etc.)
Vegetables & Vegetable juices (beans, corn, lettuce,
potatoes, tomatoes, tomato juice, etc.)
Other Food Items (baby food, pet food, frozen foods,
gourmet/specialty items, sauces, seasonings, soups,
etc.)
Non-Alcoholic Beverages (carbonated &
non-carbonated waters, cola & other carbonated
beverages, fruit-flavored beverages, instant & ground
coffee, tea, etc.)
Alcoholic Beverages (beer, champagne, liqueurs,
whiskey, wine, etc.)
Food & Beverages Purchases as Gifts for someone
not on your list (candy, cheese, fruit baskets, wine, etc.)

3. Clothing, Shoes, Jewelry, and Accessories
■
■
■
■
■
■

Casual, Sportswear, Formal (dress, pants, shirt, shorts,
suit, sweater, etc.)
Undergarments & Sleep Clothes (hosiery, lingerie,
pajamas, socks, etc.)
Outdoor, Work, School, Costumes (coat, jacket,
thermals, uniform, windbreaker, etc.)
Shoes (boots, dress, sandals, slippers, sneakers, etc.)
Sports-team Clothes & Sports Shoes (cleats, golf
shoes, ski boots, team uniform, etc.)
Jewelry, Accessories, & Sewing Items (belt, buttons,
hairpiece, hat, ring, thread, umbrella, etc.)

(continued on other side)
FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

CE-801, Pantone Blue 313 (20% and 100%)

Examples
(continued on other side)

4. All Other Products, Services, and Expenses
■

Clothing Services (alterations, dry cleaning, shoe
repairs, storage, tailoring, etc.)

■

Medicines, Medical Supplies & Services (bandages,
canes & other medical equipment, doctor & dentist
services, prescription eyeglasses, health insurance,
prescription drugs, ointments, vitamins, wheelchairs,
etc.)

■

Tobacco & Smoking Supplies (cigarettes, cigars, pipes,
smoking accessories, tobacco, etc.)

■

Gasoline, Oil, & Additives (brake fluid, coolants,
gasoline, motor oil, etc.)

■

Personal Care Products & Services (cosmetics, dental
products, deodorants, hair care products, hand soap,
men’s & women’s haircuts, perfume, shaving products,
skin care products, etc.)

■

Housekeeping Supplies & Services (bathroom tissue,
brooms, laundry & cleaning detergents, light bulbs,
maid service, mops, paper towels, sponges, etc.)

■

Housewares & Small Household Appliances
(blenders, coffee makers, cooking utensils,
dinnerware, glassware, irons, utensils, pots & pans,
telephones, & toasters, etc.)

■

Home Furnishings, Decorative Items, Linens, & Major
Appliances (art work, clocks, curtains, lamps, picture
frames, pillows, plants, refrigerators, rugs, sheets,
sofas, stoves, table cloths, tables, towels, vases, etc.)

■

Home Maintenance, Hardware, Lawn Supplies &
Services (hand tools, improvement & repair
equipment, lawn/garden equipment, nails, power
tools, screws, supplies, services, etc.)

■

Housing Expenses (cable service, electricity, garbage
removal, heating/cooling, insurance, maintenance
fees, mortgage payments, property taxes, rent,
telephone, etc.)

■

Entertainment/Amusements & Sports/Recreation
(admissions to movies, clubs, sporting & cultural
events, camping, CDs, concert tickets, hunting, sports
& exercise equipment, tapes, toys, TVs, video/stereo
equipment, video purchase/rental, etc.)

■

Transportation Expenses (airline fares, buses, car
rental, commuter fares, new & used cars,
maintenance and repair, parking fees, taxis, tolls, train
fares, etc.)

■

School Expenses (daycare, high school & college
tuition, room & board, school supplies, textbooks, etc.)

■

All Other Expenses (alteration and repair of
household furnishings, ATM service fees, babysitting,
books, club dues, diaper services, donations, legal &
accounting fees, magazines, newspapers, pet supplies
& veterinary services, photographic supplies, postage,
sewing goods, shipping & handling, stationery, etc.)

(continued on other side)
FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

CE-801, Pantone Blue 313 (20% and 100%)

Record Your Daily Expenses
The people on your list:
Record the purchases and expenses made by ALL of these people.

Notes

FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

Thank you for agreeing to fill out this diary.
We understand that this task takes time; however, your information is
very important to us and will be used for many purposes that affect all
Americans. Among the most important, it is used to help calculate the
Consumer Price Index, or CPI, which is a basic measure of the rate of
inflation.
Here are some of the uses of the Consumer Price Index:
♦ Provide cost-of-living wage adjustments for millions of American workers
♦ Adjust Social Security payments
♦ Determine the cost of school lunches
♦ Adjust Federal income-tax brackets
For more information about the survey, visit: http://www.bls.gov/cex and http://www.census.gov

Office Use: Place the barcode label here

Questions?
Some Frequently Asked Questions are answered on the flap attached to the back cover.
If you still have questions after reviewing these, please call your field representative.
1

FORM CE-801 (5-5-2014)

§)""¤
080101

Black Ink (40% and 100%)

General Instructions
■

Fill out this diary for an entire week, writing down EVERYTHING you and the
people on your list spend money on each day – the products you buy, the
services you use, the household expenses you have during the week – no matter
how large or small they are.

■

We recommend that you record your expenses each day.
Think about where you went and what you’ve done.

■

Talk to the people on your list every day to find out how they spent their money.

■

Include payments by:
Cash
Check
Food Stamps

■

Credit/Debit Card
Money Order
WIC Voucher

Automatic Withdrawal/Payroll Deduction
Store Charge Card
Grocery Certificate

Keep receipts and other records so that you will remember to record what you
bought or paid for. Use the pocket at the back of the diary to store them.
Some record types include:
Receipts
Utility Bills
Pay Stubs

Bank Statements
Telephone Bills

Catalog/Internet Order Invoices
Credit Card Statements

Include items that you bought for people who are not on your list, such as gifts.

Refer to the flap
attached to the
front cover for
Examples of Expenses.

Refer to the flap
attached to the
back cover for answers to
Frequently Asked Questions.

Do NOT record:
♦ Expenses of people on your list while they were away from home overnight.
♦ Business or farm operating expenses
♦ Sales tax for:
Part 2. Food and Drinks for Home Consumption
Part 3. Clothing, Shoes, Jewelry, and Accessories
Part 4. All Other Products, Services, and Expenses
2

FORM CE-801 (5-5-2014)

§)"#¤
080102

Black Ink

CE-801, Page 2, Pantone Blue 313 (20%, 40%, and 100%)

How to Fill Out Your Diary
The diary is divided into 7 days and each day is divided into 4 parts.
Enter each item in the appropriate part for each day.
These are the 4 parts within each day of the diary:
1. Food and Drinks Away from Home
■ Mark one of the four choices that best describes the type of meal and describe briefly.
■ Mark one of the four choices that best describes where you made the purchase.
■ Enter the total cost with tax and tip.
■ If alcohol was part of the purchase, check whether it was wine, beer, and/or other
alcohol and enter the total cost of the alcohol.

2. Food and Drinks for Home Consumption
■ Describe the item.
■ Mark whether the item was fresh, frozen, bottled/canned, or other.
■ Enter the cost without tax and deduct any discounts or coupons.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

3. Clothing, Shoes, Jewelry, and Accessories
■ Describe the item and enter the cost without tax.
■ Mark the appropriate sex and age range of the person for whom the item was bought.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

4. All Other Products, Services, and Expenses
■ Describe the item and enter the total cost without tax.
■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

There is an "Additional Pages" section on pages 36–44 in case you
run out of lines on any particular day.

Look on the next 4 pages for examples and tips
on how to record your purchases.

*Please Note: If you are unsure about whether to include an item or
where to record an item, write it down wherever it seems best or
make a note and ask your field representative.

3

FORM CE-801 (5-5-2014)

§)"$¤
080103

Black Ink

CE-801, Page 3, Pantone Blue 313 (20%, 40%, and 100%)

EXAMPLE1
Day

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

101

1

2

3

4

1

2

3

4

X

102
1

X

2

3

If alcoholic
Mark (X) one that best describes
Include tax & tip beverages
where you made this purchase for part 1 only.
included,

☛

bagel, juice

1

pizza

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

1

2

1

X

105
106

X

107
108

X

4

2

3

4

2

3

4

1

2

3

4

1

2

3

1

2

3

1

2

3

1

2

1

sandwich, soda

X chips
elem.school lunch - month

X soda
buffet

Total Cost

X

X

3

X

with tax & tip

X

X

5 57
1 35
X

70
X

4
4

23

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

X

4

2

3

4

1

2

3

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

4

1

2

3

4

3

4

1

2

3

4

1

2

3

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

1

2

3

4

1

2

3

1

2

3

4

1

2

3

1

2

3

4

1

2

3

X

1

62

3

3

110

2

00
65

E
L
P
M
A
EX
1

45

2

4

X drinks from cash bar

2

5 15

1

3

109

1

2 79

4
4

mark (X) all
that apply

caterer - Family Reunion

111
112
113
114

X

X

15 00
350 00

Enter the
total cost of
the alcohol

other

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

X

4

1
104

Full
Service
Places

☛ Level of detail needed:
briefly describe the meal.

X coffee

103

Fast Food
Take-out
Delivery
Concession

beer

(See examples above
and on the flap)

wine

Description

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

X X

12

00

15

00

95

00

3

X X X

☛

If alcohol was included
in the purchase, mark
whether it was wine, beer,
and/or other and enter the
1 the
2 alcohol.
3
total cost of

115
116
117
118
119
120

☛

Use the pocket on the inside of the back
cover to store your receipts until you’re ready
to record your purchases.

121
1

2

3

4

122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
4

FR USE:

None

TR

VC

FORM CE-801 (5-5-2014)

§)"%¤
080104

Black Ink (10%, 50%, & 100%)

CE-801, Page 4, Pantone Blue 313 (20%, 40%, & 100%)

CE-801, Page 4, Pantone Yellow 101 (70%)

SUN

MON

TUE

WED

THU

FRI

EXAMPLE1
Day

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

☛

Do not
include
tax for
fish
parts 2, 3, & 4.
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

1

chicken wings
apples
beer
skim milk
orange juice
candy
vegetable oil

frozen

other

2

3

4

2

3

4

1

2

3

4

BEEF – Specify the cut and describe, such as
round roast, ground beef, etc.

1

2

3

4

PORK – Specify the cut and describe, such as
whole ham, bacon, spareribs, etc.

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

1

2

3

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

wheat bread
eggs

fresh

Total Cost

bottled/
canned

☛ Level of detail needed:

1

BREAD – Specify if white, wheat, rye, etc.

CHICKEN – Specify if whole or parts, such as
chicken legs, chicken wings, etc.
SOFT DRINKS – Specify if soda or other
type: if not cola, specify if carbonated or non.

X
X
X
X

X

X
X

COFFEE – Specify if ground or instant.

E
L
P
M
A
EX

OTHER FOOD – Give a complete description,
such as scalloped potatoes.

baby food (5 jars)
potato chips
frozen meals (3 boxes)
ketchup

X

X

soda (2 bottles)
pork chops
shrimp

X

X

X

ground beef
ground coffee
bagels
wine
dog food

X

X
X

4

4

X

cookies
X

apple pie

☛

List food & drinks from
specialty food stores in this part
(i.e. bakery, liquor store, farmers’
market, convenience store, etc.)

X
X

1

49

1

50

6

78

2

80

4

29

2

99

3

99

2

50

2

99

4

95

2

79

8

97

1

59

4

96

1

98

6

36

11

20

3

50

X

4

99

X

2

X

soup (4 cans)

carbonated water

X

without tax

Mark (X) If
purchased for
someone not
on your list

X

X

4

89
X

X

5

87

2

79

5

25

42

00

5

85

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
5

FORM CE-801 (5-5-2014)

§)"&¤
080105

Black Ink (10%, 50%, & 100%)

CE-801, Page 5, Pantone Blue 313 (20%, 40%, & 100%)

CE-801, Page 5, Pantone Yellow 101 (70%)

EXAMPLE1
Day

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
shirt
sweater
shorts

Examples:

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

Was the
item for:

without tax

male female

3 dress-shirts ($25 each)

301

1 dress-shirt

302

non-prescription sunglasses

304
305
306

Level of detail needed:

SHOES – If sports shoes, specify
sport, such as football cleats, etc.

baseball cap

JEWELRY – Specify type of jewelry,
such as watches, etc.

bib

ACCESSORIES – If eyewear, specify
prescription or non-prescription.

2

Under
16 &
2–15
2
Over
1
2
3

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3
3

1

X

1

CLOTHING – Specify type of clothing
and give a description of the item.

running shoes

303

☛

75 00
30 00

child’s costume (returned for refund)
wallet

308

necklace

309

14 99

X

50

trouser socks

312
313
314
315
316

X

1

2

2

1

2

3

1

2

1

2

3

1

2

1

2

3

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

X
1

29 00

X

X

99

99

X
X

X

E
L
P
M
A
EX
4

X

2

15 00

3

X

X

1

311

X

250 00

scarf

310

X

X

1
307

X
X

59 00

Mark (X) If
purchased for
someone not
on your list

X

X

69 00

3

Age

X

X

X
X

X

317
318
319
320
321
322

☛

323

If you run out of space in any
section, continue listing the items
under that section on the Additional
Pages in the back (p. 36–44)

324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
6

FORM CE-801 (5-5-2014)

§)"’¤
080106

Black Ink (10%, 50%, & 100%)

CE-801, Page 6, Pantone Blue 313 (20%, 40%, & 100%)

CE-801, Page 6, Pantone Yellow 101 (70%)

SUN

MON

TUE

WED

THU

FRI

EXAMPLE1
Day

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

401

cold medicine (non-prescription)

402

gasoline

403

highway tolls

☛ Level of detail needed:

404

Music CD

DOCTOR BILLS – Specify type of doctor visited, such
as an internist, orthodontist, etc.

405

cigarettes

MEDICINE – Specify if prescription or non-prescription.

6

95

12

86

2

00

10

99

8

99

15

50

1

00

1

50

Mark (X) If
purchased for
someone not
on your list

X

X

TOOLS – Specify if power or hand tool.
406

dry cleaning

407

lottery tickets

408

bus fare

409

piano lessons

410

electric drill

411

postage stamps

412

video rental

413

car speakers

414

car oil change

415

board game

DRY-CLEANING – Specify whether household item
(such as drapes) or apparel.

E
L
P
M
A
EX

416

area rug (exchanged for a different area rug)

417

concert tickets

150 00
65

00

6

80

4

00

140 00
48

50

8

97

20

99

39

99

100 00
3

X

99

418

dog leash dog toy (exchange)

6

99

419

ATM service fee

2

00

420

Health insurance

250

00 last column of

421

Mortgage payment

875

a purchase
00 ifwas
made for

422

Telephone bill

120

not
00 someone
on your list.

423

veterinarian fees

424

Shipping and Handling for internet purchase

425

Donation

☛ Mark the

parts 2, 3, & 4

85

00

6

95

50

00

X

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
7

FORM CE-801 (5-5-2014)

§)"(¤
080107

Black Ink (10%, 50%, & 100%)

CE-801, Page 7, Pantone Blue 313 (20%, 40%, & 100%)

CE-801, Page 7, Pantone Yellow 101 (70%)

Day 1

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
8

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)")¤
080108

CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)

SUN

MON

TUE

WED

THU

FRI

Day 1

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
9

FORM CE-801 (5-5-2014)

§)"*¤
080109

CE-801, Page 9, Pantone Blue - PMS 313

Day 1

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
10

FORM CE-801 (5-5-2014)

§)"+¤
080110

CE-801, Page 10, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 1

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
11

FORM CE-801 (5-5-2014)

§)",¤
080111

CE-801, Page 11, Pantone Blue - PMS-313

Day 2

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
12

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"-¤
080112

CE-801, Page 12, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 2

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
13

FORM CE-801 (5-5-2014)

§)".¤
080113

CE-801, Page 13, Pantone Blue - PMS 313

Day 2

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
14

FORM CE-801 (5-5-2014)

§)"/¤
080114

CE-801, Page 14, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 2

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
15

FORM CE-801 (5-5-2014)

§)"0¤
080115

CE-801, Page 15, Pantone Blue - PMS-313

Day 3

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
16

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"1¤
080116

CE-801, Page 16, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 3

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
17

FORM CE-801 (5-5-2014)

§)"2¤
080117

CE-801, Page 17, Pantone Blue - PMS 313

Day 3

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
18

FORM CE-801 (5-5-2014)

§)"3¤
080118

CE-801, Page 18, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 3

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
19

FORM CE-801 (5-5-2014)

§)"4¤
080119

CE-801, Page 19, Pantone Blue - PMS-313

Day 4

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
20

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"5¤
080120

CE-801, Page 20, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 4

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
21

FORM CE-801 (5-5-2014)

§)"6¤
080121

CE-801, Page 21, Pantone Blue - PMS 313

Day 4

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
22

FORM CE-801 (5-5-2014)

§)"7¤
080122

CE-801, Page 22, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 4

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
23

FORM CE-801 (5-5-2014)

§)"8¤
080123

CE-801, Page 23, Pantone Blue - PMS-313

Day 5

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
24

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"9¤
080124

CE-801, Page 24, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 5

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
25

FORM CE-801 (5-5-2014)

§)":¤
080125

CE-801, Page 25, Pantone Blue - PMS 313

Day 5

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
26

FORM CE-801 (5-5-2014)

§)";¤
080126

CE-801, Page 26, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 5

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
27

FORM CE-801 (5-5-2014)

§)"<¤
080127

CE-801, Page 27, Pantone Blue - PMS-313

Day 6

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
28

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"=¤
080128

CE-801, Page 28, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 6

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
29

FORM CE-801 (5-5-2014)

§)">¤
080129

CE-801, Page 29, Pantone Blue - PMS 313

Day 6

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
30

FORM CE-801 (5-5-2014)

§)"?¤
080130

CE-801, Page 30, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 6

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
31

FORM CE-801 (5-5-2014)

§)"@¤
080131

CE-801, Page 31, Pantone Blue - PMS-313

Day 7

SUN

MON

TUE

WED

THU

FRI

SAT

1. Food and Drinks Away from Home
Examples:

breakfast buffet
carry-out lunch
dinner & cocktails at restaurant

pizza delivery
Chinese takeout
child’s school lunch

beer at happy hour
pretzels at ballgame
wine at tavern

croissant from café
ice cream from truck
wedding reception caterer

soda from vending machine
hot dog from convenience store
popcorn and soda at movies

Please unfold the LEFT FLAP to see Additional Examples

Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

Enter the
total cost of
the alcohol

other

Fast-Food
Take-out
Delivery
Concession

If alcoholic
beverages
included,
mark (X) all
that apply
beer

Description
(see examples above
and on the flap)

Mark (X) one that best describes
where you made this purchase

wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.
32

FORM CE-801 (5-5-2014)

FR USE:

None

TR

VC

§)"A¤
080132

CE-801, Page 32, Pantone Blue - PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 7

SAT

2. Food and Drinks for Home Consumption
Examples:

eggs
whole milk
sugar

cereal
white bread
cooking oil

tea
cola
ground coffee

beer
liquor
oranges

apple juice
tomato juice
carbonated water

ground beef
bacon
lettuce

chicken parts
whole chicken
baby food

fish
shellfish
pet food

Please unfold the RIGHT FLAP to see Frequently Asked Questions
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples above and on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) If
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.
33

FORM CE-801 (5-5-2014)

§)"B¤
080133

CE-801, Page 33, Pantone Blue - PMS 313

Day 7

SUN

MON

TUE

WED

THU

FRI

SAT

3. Clothing, Shoes, Jewelry, and Accessories
Examples:

shirt
sweater
shorts

suit
dress
pants

sandals
sneakers
shoe repairs

soccer cleats
team uniform
ski boots

gloves
slippers
dance costume

watch
necklace
belt

pajamas
lingerie
socks

coat
jacket
windbreaker

Please unfold the LEFT FLAP to see Additional Examples
What did you buy or pay for?
(see examples above and on the flap)

Total Cost
without tax

Was the
item for:

Age

Under
16 &
2–15 Over
male female
2
1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

Mark (X) If
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.
34

FORM CE-801 (5-5-2014)

§)"C¤
080134

CE-801, Page 34, Pantone Blue- PMS-313

SUN

MON

TUE

WED

THU

FRI

Day 7

SAT

4. All Other Products, Services, and Expenses
Examples:

cigarettes
gasoline
utility gas bill

prescription drugs
cordless telephone
dry clean (curtains)

movie tickets
DVD rental
bus fare

phone bill
car insurance
brake work

hand soap
dish soap
power tools

paper towels
bath towel
rent

textbooks
cook book
airline fares

computer cables
cable TV bill
color television

Please unfold the RIGHT FLAP to see Frequently Asked Questions
What did you buy or pay for?

Total Cost

(see examples above and on the flap)

without tax

Mark (X) If
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.
35

FORM CE-801 (5-5-2014)

§)"D¤
080135

CE-801, Page 35, Pantone Blue - PMS-313

Additional Pages
1. Food and Drinks Away from Home
Mark (X) one that best describes
where you made this purchase
Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost
with tax & tip

beer

(see examples on the flap)

Fast-Food
Take-out
Delivery
Concession

Enter the
total cost of
the alcohol

other

Description

If alcoholic
beverages
included,
mark (X) all
that apply
wine

snack/other

dinner

lunch

breakfast

Mark (X) one that
best describes
the type of meal

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123

36

FORM CE-801 (5-5-2014)

§)"E¤
080136

CE-801, Page 36, Pantone Blue - PMS-313

Additional Pages
1. Food and Drinks Away from Home
Mark (X) one that best describes
where you made this purchase
Full
Service
Places

Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors

Total Cost

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

1

2

3

4

1

2

3

4

1

2

3

Enter the
total cost of
the alcohol

other

beer

(see examples on the flap)

with tax & tip
wine

breakfast

snack/other

Fast-Food
Take-out
Delivery
Concession

dinner

Description

If alcoholic
beverages
included,
mark (X) all
that apply

lunch

Mark (X) one that
best describes
the type of meal

124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146

37

FORM CE-801 (5-5-2014)

§)"F¤
080137

CE-801, Page 37, Pantone Blue - PMS-313

Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one

What did you buy or pay for?

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

(see examples on the flap)

fresh

frozen

without tax

Mark (X) if
purchased for
someone not
on your list

201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227

38

FORM CE-801 (5-5-2014)

§)"G¤
080138

CE-801, Page 38, Pantone Blue - PMS-313

Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) if
purchased for
someone not
on your list

228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254

39

FORM CE-801 (5-5-2014)

§)"H¤
080139

CE-801, Page 39, Pantone Blue - PMS-313

Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples on the flap)

Total Cost

1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

without tax

Mark (X) if
purchased for
someone not
on your list

255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281

40

FORM CE-801 (5-5-2014)

§)"I¤
080140

CE-801, Page 40, Pantone Blue - PMS-313

Additional Pages
2. Food and Drinks for Home Consumption
Is this item:
Mark (X) one

What did you buy or pay for?
(see examples on the flap)
1

2

bottled/
other
canned
3
4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

fresh

frozen

Mark (X) if
purchased for
someone not
on your list

Total Cost
without tax

282
283
284
285
286
287
288
289
290
291
292
293
294
295

3. Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
(see examples on the flap)

Was the
item for:

Total Cost
without tax

Age:

1

Under
2–15 16 &
female
2
Over
2
1
2
3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

male

Mark (X) if
purchased for
someone not
on your list

301
302
303
304
305
306
307
308
309

41

FORM CE-801 (5-5-2014)

§)"J¤
080141

CE-801, Page 41, Pantone Blue - PMS-313

Additional Pages
3. Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
(see examples on the flap)

Was the
item for:

Total Cost
without tax

Age:

1

Under 2–15 16 &
female
Over
2
2
1
2
3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

male

Mark (X) if
purchased for
someone not
on your list

310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336

42

FORM CE-801 (5-5-2014)

§)"K¤
080142

CE-801, Page 42, Pantone Blue - PMS-313

Additional Pages
4. All Other Products, Services, and Expenses
What did you buy or pay for?

Total Cost

(see examples on the flap)

without tax

Mark (X) if
purchased for
someone not
on your list

401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427

43

FORM CE-801 (5-5-2014)

§)"L¤
080143

CE-801, Page 43, Pantone Blue - PMS-313

Additional Pages
4. All Other Products, Services, and Expenses
What did you buy or pay for?

Total Cost

(see examples on the flap)

without tax

Mark (X) if
purchased for
someone not
on your list

428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454

44

FORM CE-801 (5-5-2014)

§)"M¤
080144

CE-801, Page 44, Pantone Blue - PMS-313

Keep your records in this pocket.
(These records are only for your reference; we will not keep them.)
■
■
■
■
■
■
■

FORM CE-801 (5-5-2014)

Receipts
Bank Statements
Credit Card Statements
Pay Stubs
Catalog/Internet Order Invoices
Utility Bills
Telephone bills

Frequently
requently Asked
sked Questions
uestions
(continued on other side)

10. What if I make a contribution or
charitable donation?
Record money contributions or donations in the
section called All Other Products, Services, and
Expenses (Part 4).

11. What about gift certificates or gift
cards?
If you buy a gift certificate to give to someone,
write down the cost of it under the appropriate
section (e.g. a certificate to a clothing store
would go under Clothing, Shoes, Jewelry, and
Accessories (Part 3) and a certificate to a
department store would go under All Other
Products, Services, and Expenses (Part 4)). If
you buy something using a gift card, write
down the full amount for your purchase
ignoring the gift card.

12. What do I do about returns & exchanges?
If an item is bought and returned during the
diary week, it can be erased or crossed out. If it
was bought outside the week and returned
during the week, do not make an entry. If an
item is exchanged during the week, change the
entry. If the new cost is different, cross out the
old cost and write in the new cost (see
examples on page 7).

13. Should I record subsidized/reimbursed
expenses?
Yes, but if someone not on your list pays for or
helps pay for an expense or if you will be
reimbursed for an expense, only record any
extra amount that you or someone on your list
has to pay.

14. What should I do about shipping &
handling costs?
Include the shipping & handling cost in the total
price of the item. If the shipping & handling
covered multiple items, include the shipping &
handling in the total price of one item from the
order.

15. What’s the difference between a
concession stand and a mobile vendor?
A concession stand has to stay in a permanent
location and a mobile vendor does not. Some
mobile vendors may seem permanent because
they are usually in the same location, but they
are still considered mobile vendors because
they have the option to change locations.
(continued on other side)
FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

CE-801, Pantone Blue 313 (20% and 100%)

Frequently
requently Asked
sked Questions
uestions
(continued on other side)

1. How detailed should my descriptions be?
Refer to pages 4–7 for examples of the level of
detail needed in each part. Do not use brand
names.

2. How should I record multiple quantities?
If the items are identical, you can combine them
on the same line and enter the total cost of all
the items. See examples on pages 5 and 6.

3. How should I record pre-payments such
as a subway fare card?
Record the expense when you pay for it, not
when you use it.

4. How should I record credit card
purchases?
Record the individual expense on the day that
you use your credit card to pay for something,
not on the day you pay your entire credit card
bill.

5. Should I record automatic deductions
taken from my paycheck or bank
account?
Yes, record automatic deductions (such as
health insurance premiums taken out of your
account or paycheck) only if they are deducted
that week. Write them in the section called All
Other Products, Services, and Expenses (Part 4).

6. Should I record typical monthly bills?
Yes, record typical monthly bills only if you pay
them during the week that you have the diary.
Write them in the section called All Other
Products, Services, and Expenses (Part 4).

7. What should I do when I use coupons,
discount cards, or loyalty cards?
Subtract the discount from the original price and
write the amount that you paid.

8. Can I just give you receipts instead of
writing the information down?
No, we need you to actually write the
information in the diary. We encourage you to
save your receipts to review them with your
field representative at the end of the week. You
can use the pocket on the inside of the back
cover to store your receipts until you’re ready to
record your purchases.

9. How should I record items if I don’t
know whether it includes tax?
Write down the amount paid.
(continued on other side)
FORM CE-801 (5-5-2014)

Black Ink (40% and 100%)

CE-801, Panton Blue 313 (20% and 100%)

Car Dashboard& CD.jpg

Coffee.jpg

Gifts.jpg

Haircut.jpg

Money.jpg

Pizza.jpg

Daily Reminder List
Please review the list of expenses below with the people on your list at the end of each day.
If you have forgotten to record any expense, please do so on the appropriate page.
Did you or anyone on your list pay for . . .
■
■
■

■
■
■
■
■
■
■
■
■
■
■
■
■
■
■

meals, drinks, or snacks from restaurants, fast food, cafeterias,
vending machines, concession stands, etc.?
catered events or meal plans?
food & drinks from a grocery store or other speciality food store
such as a bakery, candy shop, or liquor store?
clothing, shoes, jewelry, accessories or clothing services such as dry cleaning?
personal care items or services such as cosmetics, soaps, haircuts, etc.?
housekeeping supplies or services for home decoration/maintenance?
toys, books, electronics, hobby supplies, etc.?
cigarettes, tobacco, or other smoking supplies?
commuting costs such as public transportation, parking fees, gasoline, or tolls?
medicine or medical/dental services?
entertainment or recreational activities?
typical bills such as utility bills, cable bills, telephone bills, etc.?
automatic deductions from a paycheck such as insurance premiums?
bank/ATM service fees?
credit card interest or finance charges?
internet or catalog orders?
fees for lessons or instructions?
gifts, contributions, donations?

For more specific examples of expenses, please refer to the flap attached to the front cover.
RO
code

Vegetables.jpg

FORM CE-801 (5-5-2014)

Control Number
Survey
code

PSU
state

PSU
county

Hand Swiping Credit
Card.jpg

Frame

Sample
Designation

Kid with Toys
.jpg

Sequence
#1

Sequence
#2

Clothing.jpg

HH
No.

CU
No.

Spinoff
Indicator

Hammer and Nail
.jpg

Week
1

2

Newspaper.jpb


File Typeapplication/pdf
File Titleuntitled
File Modified2014-06-12
File Created2014-05-05

© 2024 OMB.report | Privacy Policy