Form 2017 ACS form 2017 ACS form 2017 ACS form

13197017

DC

U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

➜

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

Day

Year

O

N

Month

Please print the name and telephone number of the person who is
filling out this form. We will only contact you if needed for official
Census Bureau business.

A

TI

➜

Last Name

RM

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.

FO

First Name

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

ACS-1(INFO)(2017)

FORM
(03-14-2016)

§.4g2¤

MI

Area Code + N umber

IN

If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.

For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs

Please print today’s date.

A

Start Here

L

CO

PY

This booklet shows the
content of the
American Community Survey
questionnaire.

OMB No. 0607-0810
OMB No. 0607-0936

13197025

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.

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

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

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

Female

Male

CO

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

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

Is Person 1 of Hispanic, Latino, or Spanish origin?

TI

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

A

Yes, Puerto Rican

RM

Yes, Cuban

FO

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

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

IN

6

White
Black or African Am.

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

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

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

O

5

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

N

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

A

L

Month

Female

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

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)

Other relative

Parent-in-law

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

Son-in-law or daughter-in-law

Biological son or daughter

PY

1

Husband or wife

§.4g:¤

Some other race – Print race. C

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

13197033

Person 3
1 What is Person 4’s name?

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

2

First Name

Last Name (Please print)

MI

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

Female

Male

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

A

L

Age (in years)

Female

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

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.

CO

4

MI

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

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

Parent-in-law

3

First Name

PY

1

Person 4

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

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

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

Is Person 3 of Hispanic, Latino, or Spanish origin?

O

5

TI

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

A

Yes, Puerto Rican

RM

Yes, Cuban

FO

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

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

IN

6

White
Black or African Am.

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

N

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

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

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

§.4gB¤

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

Some other race – Print race. C

3

13197041

Person 5
1

➜

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.

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

First Name

MI

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

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

4

Sex

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.
Day

Last Name (Please print)

CO

Month

Female

Year of birth

L

Age (in years)

Male

PY

3

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

Age (in years)

Last Name (Please print)

First Name

Yes, Mexican, Mexican Am., Chicano

A

Yes, Puerto Rican

RM

Yes, Cuban

FO

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

Sex

Male

Female

Age (in years)

Person 10
Last Name (Please print)

First Name

MI

IN

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

Sex

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

Male

Female

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

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

Age (in years)

Person 11
Last Name (Please print)

Sex

Male

First Name

Female

Person 12
Last Name (Please print)

Sex

§.4gJ¤

MI

Age (in years)

First Name

Some other race – Print race. C

4

MI

TI

No, not of Hispanic, Latino, or Spanish origin

6

Female

MI

Person 9

O

5

Male

First Name

N

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

A

Sex

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

Age (in years)

Male

Female

Age (in years)

MI

13197058

Housing
➜

A

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

7 Does this house, apartment, or mobile

Answer questions 4 – 5 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 6a.

home have –

b. a bathtub or shower?

4 How many acres is this house or

Which best describes this building?
Include all apartments, flats, etc., even if
vacant.

c. a sink with a faucet?
d. a stove or range?

Less than 1 acre ➔ SKIP to question 6a

e. a refrigerator?

1 to 9.9 acres

A mobile home

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

10 or more acres

do you or any member of this household
own or use any of the following types of
computer?
Yes
No

None

A building with 5 to 9 apartments

$1 to $999

A building with 10 to 19 apartments

$1,000 to $2,499

A building with 20 to 49 apartments

$2,500 to $4,999

A building with 50 or more apartments

$5,000 to $9,999

Boat, RV, van, etc.

$10,000 or more

PY

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

A building with 3 or 4 apartments

a. Desktop or laptop

CO

b. Smartphone
c. Tablet or other portable
wireless computer

L

d. Some other type of computer
Specify

N

9 At this house, apartment, or mobile home –

O

About when was this building first built?

8 At this house, apartment, or mobile home –

5 IN THE PAST 12 MONTHS, what

A

A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments

2

6 a. How many separate rooms are in this

do you or any member of this household
have access to the Internet?

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.

TI

2000 or later – Specify year

RM

A

Yes, by paying a cell phone company or
Internet service provider
Yes, without paying a cell phone company
or Internet service provider ➔ SKIP to
question 11

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

1990 to 1999

FO

1980 to 1989

1960 to 1969
1950 to 1959

IN

1970 to 1979

1940 to 1949
1939 or earlier

3

Month

Year

No access to the Internet at this house,
apartment, or mobile home ➔ SKIP to
question 11

Number of rooms

10 Do you or any member of this household
have access to the Internet using a –

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

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

No

a. hot and cold running water?

mobile home on?

1

Yes

Yes

No

a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service

§.4g[¤

5

13197066

Housing (continued)

13 a. LAST MONTH, what was the cost

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

14 IN THE PAST 12 MONTHS, did you or

of electricity for this house,
apartment, or mobile home?

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.

Last month’s cost – Dollars

$

None

.00

,
OR

1

Yes

2

No charge or electricity not used

3

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

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

4
5

Last month’s cost – Dollars

$

.00

,

PY

6 or more

OR

12 Which FUEL is used MOST for heating this
house, apartment, or mobile home?

Monthly amount – Dollars

CO

L

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.

N

Fuel oil, kerosene, etc.

O

Coal or coke

TI

Wood

$

,

RM

Other fuel

A

Past 12 months’ cost – Dollars

Solar energy

.00

OR

No fuel used

FO

Included in rent or condominium fee

IN

$

Included in electricity payment
entered above
No charge or gas not used

A

Electricity

No charge

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

§.4gc¤

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.

Included in rent or condominium fee

Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP

6

No

Included in rent or condominium fee

.00

,
OR
None

No

16 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)?
Rented?
Occupied without payment of
rent? ➔ SKIP to C on the next page

13197074

Housing (continued)

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

Answer questions 17a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 18.

17 a. What is the monthly rent for this

house, apartment, or mobile home?

Monthly amount – Dollars

$

b. Does the monthly rent include any
meals?

Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase

Yes, home equity loan

No ➔ SKIP to question 22a

Yes, second mortgage and home
equity loan
No ➔ SKIP to D

$

Monthly amount – Dollars

OR

No regular payment required ➔ SKIP to
question 22a

CO

Answer questions 18 – 22 if you or any
member of this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .

A

L

c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required

TI

FO

THIS property?

,

.00

OR

IN

Annual amount – Dollars

$

D

None

OR

Answer question 23 if this is a MOBILE
HOME. Otherwise, SKIP to E .

23 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.

RM

19 What are the annual real estate taxes on

.00

No regular payment required

A

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

.00

,

,

O

house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?
Amount – Dollars

$

N

18 About how much do you think this

,

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

.00

,

No

$

Yes, second mortgage

Monthly amount – Dollars

Yes

C

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

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

.00

,

22 a. Do you or any member of this

PY

B

21 a. Do you or any member of this

Annual costs – Dollars

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

$
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.

20 What is the annual payment for fire,

hazard, and flood insurance on THIS
property?
Annual amount – Dollars

$

.00

,
OR
None

§.4gk¤

7

13197082

Person 1

11 What is the highest degree or level of school

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

➜

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
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school

Where was this person born?

English at home?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Yes
No ➔ SKIP to question 15a
b. What is this language?

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

For example: Korean, Italian, Spanish, Vietnamese

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

PY

Regular high school diploma

c. How well does this person speak English?

GED or alternative credential

CO

8

COLLEGE OR SOME COLLEGE

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

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

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

L

1 or more years of college credit, no degree

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

A

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

N

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

O

AFTER BACHELOR’S DEGREE

No, not a U.S. citizen
When did this person come to live in the
United States? If this person came to live in the

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

Year

Doctorate degree (for example: PhD, EdD)

A
TI

9

F

FO

this person attended school or college?

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

IN

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

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

RM

United States more than once, print latest year.

10 a. At any time IN THE LAST 3 MONTHS, has

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

14 a. Does this person speak a language other than

Kindergarten

7

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

Yes, public school, public college

Well
Not well
Not at all

15 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)

12 This question focuses on this person’s

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

Very well

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)

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

§.4gs¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13197090

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

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.

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
Yes No
condition, does this person have difficulty
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)
b. Insurance purchased directly from
Yes
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

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

Now married

e. TRICARE or other military health care

Separated

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

Never married ➔ SKIP to I

5 or more years

26 Has this person ever served on active duty in the

Widowed

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

PY

Divorced

Yes

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

No

a. Married?

L

b. Widowed?

CO

21 In the PAST 12 MONTHS did this person get –

g. Indian Health Service

A

c. Divorced?

Once

TI
O

serious difficulty hearing?

N

22 How many times has this person been married?

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

Two times

No

Three or more times

RM

A

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?

No

IN

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

FO

Yes

G

Less than 6 months

18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?

I

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

24 In the PAST 12 MONTHS, has this person given
birth to any children?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

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?

Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now

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
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

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

Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent

Yes

Yes

50 or 60 percent

No

No ➔ SKIP to question 26

70 percent or higher

§.4g{¤

9

13197108

Person 1 (continued)

J

29 a. LAST WEEK, did this person work for pay
at a job (or business)?

36 During the LAST 4 WEEKS, has this person been

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

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30

32 How many people, including this person,

No – Did not work (or retired)

usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

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
to go to work LAST WEEK?
Hour

Minute

:

a. Address (Number and street name)

days?

p.m.

34 How many minutes did it usually take this

person to get from home to work LAST WEEK?

CO

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

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

a.m.

PY

WEEK? If this person worked at more than one
location, print where he or she worked most
last week.

Minutes

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

N

K

O

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

A

L

b. Name of city, town, or post office

TI

Yes
No, outside the city/town limits

A

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

d. Name of county

RM

a job?

IN

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

Taxicab

§.4h)¤

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

39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
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

No

40 to 47 weeks

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Within the past 12 months

Yes ➔ SKIP to question 35c

FO

e. Name of U.S. state or foreign country

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

33 What time did this person usually leave home

30 At what location did this person work LAST

10

37 LAST WEEK, could this person have started a

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
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

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

13197116

Person 1 (continued)
L

45 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

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

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

Yes ➔
No

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.

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

CO

L

working WITHOUT PAY in family business
or farm?

42 For whom did this person work?

O

RM

$

No

,

,

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.)?

§.4h1¤

$

.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.

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a

FO

IN

Name of company, business, or other employer

.00

,

TOTAL AMOUNT for past
12 months

N

A

No

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

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

$

TOTAL AMOUNT for past
12 months

Yes ➔

TI

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

No

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

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.

A

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

PY

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

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.)

a Federal GOVERNMENT employee?

$

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

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

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

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief

$

Yes ➔

$

No

,

,

to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

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

.00

TOTAL AMOUNT for past
12 months

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.

11

13197124

Person 2

IN

FO

RM

A

TI

O

N

A

L

CO

PY

The balance of the questionnaire
has questions for Person 2,
Person 3, Person 4, and Person 5.
The questions are the same as
the questions for Person 1.

12

§.4h9¤

IN
FO
RM
A
TI
O
N
A
L
CO
PY

13197272

§.4ii¤

27

13197280

Mailing
Instructions
➜ Please make sure you have...

• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions

PY

• answered all Person questions for each person.

N

A

L

• 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

CO

➜ Then...

A

IN

FO

RM

Thank you for participating in
the American Community Survey.

TI

O

• make sure the barcode above your address shows
in the window of the return envelope.

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 and 0607-0936,
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 and 0607-0936" 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(INFO)(2017) (03-14-2016)

28

§.4iq¤