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DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
Start Here
Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it
back as soon as possible.
➜
Month
➜
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.
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
Day
Year
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.
Last Name
First Name
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(X)ACOWP1
FORM
(4-23-2018)Draft1
§.4{.¤
MI
➜
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. 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.
OMB No. 0607-0725
13199021
Person 1
(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.)
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
1
Yes, Mexican, Mexican Am., Chicano
What is Person 1’s name?
Last Name (Please print)
First Name
Yes, Puerto Rican
MI
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
2
How is this person related to Person 1?
X
Person 1
6
What is Person 1’s race? Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
3
What is Person 1’s sex? Mark (X) ONE box.
Male
Female
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
4
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)
Month
Day
Year of birth
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
2
§.4{6¤
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
13199039
Person 2
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 2’s name?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 2’s race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3
What is Person 2’s sex? Mark (X) ONE box.
Male
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
§.4{H¤
3
13199039
Person 3
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 3’s ame?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 3’s race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3 What is Person 3’s sex? Mark (X) ONE box.
Male
Female
4 What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
4
§.4{H¤
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
13199039
Person 4
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 4’s name?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 4’s race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3 What is Person 4's sex? Mark (X) ONE box.
Male
Female
4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
§.4{H¤
5
13199039
Person 5
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 5’s name?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 5's race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3 What is Person 5's sex? Mark (X) ONE box.
Male
Female
4 What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
6
§.4{H¤
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
13199039
Person 6
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 6’s name?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 6 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 6’s race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3 What is Person 6's sex? Mark (X) ONE box.
Male
Female
4 What is Person 6's age and what is Person 6’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
§.4{H¤
7
13199039
Person 7
1
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
What is Person 7’s name?
Question 6 about race. For this survey, Hispanic origins are not races.
First Name
Last Name (Please print)
MI
5 Is Person 7 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
2
How is this person related to Person 1? Mark (X) ONE box.
Yes, Mexican, Mexican Am., Chicano
Opposite-sex husband/wife/spouse
Yes, Puerto Rican
Opposite-sex unmarried partner
Yes, Cuban
Same-sex husband/wife/spouse
Yes, another Hispanic, Latino, or Spanish origin – Print, for example,
Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
6 What is Person 7's race? Mark (X) one or more boxes AND print origins.
Stepson or stepdaughter
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C
Brother or sister
Father or mother
Grandchild
Parent-in-law
Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc. C
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
American Indian or Alaska Native – Print name of enrolled or principal tribe(s),
for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C
Foster child
Other nonrelative
3 What is Person 7's sex? Mark (X) ONE box.
Male
Female
4 What is Person 7’s age and what is Person 7’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
8
§.4{H¤
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
13199054
Housing
➜
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
Answer questions 4 – 5 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 6a.
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
2
4 How many acres is this house or
Less than 1 acre ➔ SKIP to question 6a
1 to 9.9 acres
10 or more acres
5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
d. a stove or range?
e. a refrigerator?
8 Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.
Yes
No
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. Desktop or laptop
A building with 50 or more apartments
$5,000 to $9,999
Boat, RV, van, etc.
$10,000 or more
b. Smartphone
c. Tablet or other portable
wireless computer
d. Some other type of computer
Specify
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
Year
No
c. a sink with a faucet?
None
About when was this building first built?
Yes
a. hot and cold running water?
A building with 3 or 4 apartments
2000 or later – Specify year
3
home have –
b. a bathtub or shower?
mobile home on?
1
7 Does this house, apartment, or mobile
9 At this house, apartment, or mobile home –
do you or any member of this household
own or use any of the following types of
computers?
Yes
No
6 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms
10 At this house, apartment, or mobile home –
do you or any member of this household
have access to the internet?
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 12
No access to the internet at this house,
apartment, or mobile home ➔ SKIP to
question 12
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would 11 Do you or any member of this household
list if this house, apartment, or mobile home
have access to the internet using a –
were for sale or rent. If this is an
Yes
No
efficiency/studio apartment, print "0".
a. cellular data plan for a
smartphone or other mobile
Number of bedrooms
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
§.4{W¤
9
13199062
Housing (continued)
12 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
14 a. LAST MONTH, what was the cost
of electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars
$
.00
,
None
OR
1
No
No charge or electricity not used
16 Is this house, apartment, or mobile home
3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
4
5
Last month’s cost – Dollars
6 or more
$
.00
,
house, apartment, or mobile home?
Monthly amount – Dollars
Wood
Solar energy
Other fuel
c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
Past 12 months’ cost – Dollars
$
.00
,
OR
No fuel used
Included in rent or condominium fee
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
§.4{_¤
$
Included in electricity payment
entered above
No charge or gas not used
Electricity
Coal or coke
Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.
Included in rent or condominium fee
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Fuel oil, kerosene, etc.
part of a condominium?
OR
13 Which FUEL is used MOST for heating this
10
any member of this household receive
benefits from the Food Stamp Program
or SNAP (the Supplemental Nutrition
Assistance Program)? Do NOT include
WIC, the School Lunch Program, or
assistance from food banks.
Yes
Included in rent or condominium fee
2
15 IN THE PAST 12 MONTHS, did you or
.00
,
OR
None
No
17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented?
Occupied without payment of
rent? ➔ SKIP to C on the next page
13199070
Housing (continued)
B
Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.
22 a. Do you or any member of this
23 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
18 a. What is the monthly rent for this
house, apartment, or mobile home?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
Yes, home equity loan
No ➔ SKIP to question 23a
Yes, second mortgage and home
equity loan
No ➔ SKIP to D
Yes, second mortgage
Monthly amount – Dollars
$
.00
,
b. Does the monthly rent include any
meals?
No
19 About how much do you think this
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?
.00
,
20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$
,
Monthly amount – Dollars
.00
$
.00
OR
No regular payment required ➔ SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
,
No regular payment required
D
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .
24 What are the total annual costs for
Amount – Dollars
,
,
OR
Answer questions 19 – 23 if you or any
member of this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .
$
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?
Monthly amount – Dollars
$
Yes
C
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
Annual costs – Dollars
Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance
$
,
.00
.00
E
OR
None
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.
21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
.00
,
OR
None
§.4{g¤
11
13199088
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
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
(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
English at home?
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
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
GED or alternative credential
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
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
Very well
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
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.
c. How well does this person speak English?
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
For example: Korean, Italian, Spanish, Vietnamese
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)
12
§.4{y¤
Name of U.S. county or
municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
ZIP Code
13199096
Person 1 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
c. Does this person have difficulty dressing or
bathing?
Yes
h. Any other type of health insurance
or health coverage plan – Specify
G
17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
I
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
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.
Less than 6 months
6 to 11 months
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Now married
Widowed
Never served in the military ➔ SKIP to
question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty
22 In the PAST 12 MONTHS, did this person get –
Yes
Yes
a. Married?
No
b. Widowed?
No
c. Divorced?
23 How many times has this person been married?
No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
c. How long has this grandparent been
responsible for these grandchildren?
5 or more years
21 What is this person’s marital status?
Never married ➔ SKIP to J
Yes
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?
3 or 4 years
Separated
Yes
grandchildren under the age of 18 living in
this house or apartment?
No
No ➔ SKIP to question 18a
serious difficulty hearing?
26 a. Does this person have any of his/her own
1 or 2 years
Divorced
18 a. Is this person deaf or does he/she have
No
Yes
Yes
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
20 Because of a physical, mental, or emotional
Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.
given birth to any children?
Yes
No
g. Indian Health Service
25 In the PAST 12 MONTHS, has this person
No ➔ SKIP to question 27
No
f. VA (including those who have
enrolled for VA health care)
Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.
Yes
Yes
e. TRICARE or other military health care
J
28 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)
Once
May 1975 to July 1990
Two times
Vietnam era (August 1964 to April 1975)
Three or more times
February 1955 to July 1964
24 In what year did this person last get married?
Year
On active duty in the past, but not now
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§.4{£¤
13
13199120
Person 2
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 2 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
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
(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
English at home?
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
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
GED or alternative credential
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
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
Very well
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
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.
c. How well does this person speak English?
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
For example: Korean, Italian, Spanish, Vietnamese
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)
14
§.4|5¤
Name of U.S. county or
municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
ZIP Code
13199138
Person 2 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
c. Does this person have difficulty dressing or
bathing?
Yes
h. Any other type of health insurance
or health coverage plan – Specify
G
17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
I
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
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.
Less than 6 months
6 to 11 months
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Now married
Widowed
Never served in the military ➔ SKIP to
question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty
22 In the PAST 12 MONTHS, did this person get –
Yes
Yes
a. Married?
No
b. Widowed?
No
c. Divorced?
23 How many times has this person been married?
No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
c. How long has this grandparent been
responsible for these grandchildren?
5 or more years
21 What is this person’s marital status?
Never married ➔ SKIP to J
Yes
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?
3 or 4 years
Separated
Yes
grandchildren under the age of 18 living in
this house or apartment?
No
No ➔ SKIP to question 18a
serious difficulty hearing?
26 a. Does this person have any of his/her own
1 or 2 years
Divorced
18 a. Is this person deaf or does he/she have
No
Yes
Yes
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
20 Because of a physical, mental, or emotional
Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.
given birth to any children?
Yes
No
g. Indian Health Service
25 In the PAST 12 MONTHS, has this person
No ➔ SKIP to question 27
No
f. VA (including those who have
enrolled for VA health care)
Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.
Yes
Yes
e. TRICARE or other military health care
J
28 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)
Once
May 1975 to July 1990
Two times
Vietnam era (August 1964 to April 1975)
Three or more times
February 1955 to July 1964
24 In what year did this person last get married?
Year
On active duty in the past, but not now
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§.4|G¤
15
13199161
Person 3
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 3 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
(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
English at home?
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
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
GED or alternative credential
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
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
Very well
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
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.
c. How well does this person speak English?
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
For example: Korean, Italian, Spanish, Vietnamese
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)
16
§.4|^¤
Name of U.S. county or
municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
ZIP Code
13199179
Person 3 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
c. Does this person have difficulty dressing or
bathing?
Yes
h. Any other type of health insurance
or health coverage plan – Specify
G
17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
I
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
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.
Less than 6 months
6 to 11 months
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Now married
Widowed
Never served in the military ➔ SKIP to
question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty
22 In the PAST 12 MONTHS, did this person get –
Yes
Yes
a. Married?
No
b. Widowed?
No
c. Divorced?
23 How many times has this person been married?
No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
c. How long has this grandparent been
responsible for these grandchildren?
5 or more years
21 What is this person’s marital status?
Never married ➔ SKIP to J
Yes
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?
3 or 4 years
Separated
Yes
grandchildren under the age of 18 living in
this house or apartment?
No
No ➔ SKIP to question 18a
serious difficulty hearing?
26 a. Does this person have any of his/her own
1 or 2 years
Divorced
18 a. Is this person deaf or does he/she have
No
Yes
Yes
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
20 Because of a physical, mental, or emotional
Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.
given birth to any children?
Yes
No
g. Indian Health Service
25 In the PAST 12 MONTHS, has this person
No ➔ SKIP to question 27
No
f. VA (including those who have
enrolled for VA health care)
Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.
Yes
Yes
e. TRICARE or other military health care
J
28 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)
Once
May 1975 to July 1990
Two times
Vietnam era (August 1964 to April 1975)
Three or more times
February 1955 to July 1964
24 In what year did this person last get married?
Year
On active duty in the past, but not now
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§.4|p¤
17
| File Type | application/pdf |
| File Modified | 2018-04-24 |
| File Created | 2017-12-19 |