Individuals/Households

APPENDIX C23. NAMES SURVEY INCOME WORKSHEET

National Assessment of Meal Eligibility and Services (NAMES) Study

Survey Income Worksheet

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Thank you for participating in the NAMES Household Survey. Your input will be very important and helpful.

This worksheet can be used to help prepare you for one component of the NAMES household survey. Completing this worksheet prior to your interview will help make the interview proceed more quickly. In addition to the information provided on this worksheet, you will be asked to provide documentation for ALL income reported. The interviewer will only review the documentation. He/she will not make copies nor take the documentation.

A. Adults Living in your Household

A1. Including yourself, how many adults live in your household? When we say adult, we mean any person 18 years of age or older.

____________

A2. Including yourself, List the names of the adults in your household that earned income from a paid job or received benefit payments in [APPLICATION MONTH] and contributed to your household’s finances.

Name 1: Name 5:

Name 2: Name 6:

Name 3: Name 7:

Name 4: Name 8:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

B. Household Income and Payments

B1. Think about all the sources of the income or payments received by the adults listed at Question A2 in [APPLICATION MONTH]. The table below lists many kinds of income and payments that people might receive.

If any of the adults you listed in Question A2 received the payment type listed in column B in [APPLICATION MONTH], circle the corresponding number for that payment in column A. Next, record the name(s) of the person or persons receiving that payment in column C. The table continues on the next page.

Column A Number	Column B Type of Income or Payments	Column C Name(s) of Adult(s) Receiving this Income or Payment
	Income for paid work (do not include business profits or losses)
	Unemployment Compensation
	Workers Compensation Benefits
	Strike Benefits
	Social Security or Railroad Retirement
	Private Pension, Annuities, or Survivor’s Benefits
	Military Cash Benefits
	Veteran’s Benefits
	Government Disability Benefits from Supplementary Security Income (SSI)
	Private Disability Benefits
	Alimony Payments
	Child Support Payments
	Interest and Dividends Income
	Rental Income
	Profit or Loss from Nonfarm Business, Partnership, or Professional Practice
	Profit or Loss from a Farm
	Financial Aid to College Students
	Regular Payments or Withdrawals from Large Awards or Settlements
	Regular Contributions from Persons Outside the Household
	Other Income, such as Net Royalties, Trust income, 401K, Prize Winnings, or Bonuses
	General Assistance Benefits
	Housing Voucher/Subsidy, (do not include military housing subsidies)
	Black Lung Benefits
	Other Public Benefits, not including TANF or SNAP
	Temporary Assistance to Needy Families or TANF
	Supplemental Nutrition Assistance Program or SNAP or Food Stamps

C. Provide and Confirm Details about Income and Payments

C1. During the interview you will be asked to provide details about the income and payment amounts you have reported in Section B. The details you will be asked include:

• Gross dollar amount of earned wages or salary, or benefit payments and

• How often the payment is received, (i.e., weekly, or monthly and so on)

C2. The interviewer will also ask to look at documentation or a statement that describes income or payments. Please refer to the table on the next page to gather acceptable documents to have available for the interviewer to see during the interview.

Please Note: The interviewer is only reviewing the documents and recording some information from them but he or she will not take or copy the documents. The table on the next page describes the acceptable documents for our purposes.

Type of Income	Personal Documents to Review	Written Documents from a Third Party
Wages and Salary (including base and overtime rates, bonuses, and incentives)	Pay stubs, earnings statement or W-2 form identifying employee and showing amount earned period of time covered by employment.	Statement indicating contact with employer by phone or in person and specifying amount to be earned per pay period.
Tips/gratuities and self- employment	Notarized statement from applicant or form 1040/1040A showing amount earned.	None
Social Security, Pensions, or Retirement	Social Security retirement benefit letters, statement of benefits received, or pension award notice.	Signed and dated verification form from agency or organization paying the pension.
Unemployment or Worker’s Compensation	(a) Copy of check issued by agency (b) Award letter signed by agency Online statement, printed out.	Signed and dated verification form showing amount and period received.
Income maintenance, AFDC, welfare, Social Security	(a) Copy of check issued by agency (b) Award letter signed by agency	Signed and dated verification form signed showing amount and period received
Child Support Payments	(a) Copy of payment records furnished by court, signed and dated, showing amount received (b) Copy of divorce decree showing amount of support (c) Copy of uncashed check	Written statement from paying parent
Interest and Dividends	(a) Passbook showing interest received and period covered. (b) Income tax return (c) Dividend statement from bond holder of stock company.	Dated and signed verification form completed by savings institution showing amount received and time period covered.
Other Income (such as rental income)	Information or statement showing the amount received how often it is received, and the date it was received.	None
No Income	A brief note explaining how you provide food, clothing, and housing for the household and when you expect to receive an income.	None
SNAP, TANF, or FDPIR	Certification notice or benefits case number. Annual or monthly certification letter.	Dated and signed letter from SNAP or welfare office stating that these benefits are received
Housing Voucher/ Subsidy	Proof of income from housing voucher/subsidy/assistance. Annual or monthly certification letter.

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