Individuals/Households - Households

APPENDIX D3. HOUSEHOLD SURVEY INCOME WORKSHEET

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Thank you for participating in the National School Meals Study (NSMS). Your input will be very important and helpful.

This worksheet can be used to help prepare you for one component of the NSMS household survey. Completing this worksheet prior to your interview will help make the interview proceed more quickly. You will be asked to provide documentation for income reported. The interviewer will be the only person to review the documentation. He/she will not make copies nor take the documentation.

A1. Adults Living in your Household

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, YEAR> 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 0584-0530. 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

Think about all the sources of the income or payments received by the adults listed in question A2 in [Application Month, Year]. 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, Year], circle the corresponding number for that payment in column A. Next, record the initials of the person or persons receiving that payment in column C. The table continues onto the next 3 pages.

Column A SOURCE #	Column B TYPE OF INCOME OR BENEFITS PAYMENT	Column C Initials of Adult(s) Receiving this Payment or Income
Source 1	Income for paid work If you have your own business, only include the salary you pay yourself as personal income or regular earnings. Do not include the business profits or losses. For military service members, include Military Basic Pay. For deployed service members, include only the amount made available to the household.
Source 2	Unemployment Compensation Money that substitutes for wages or salary, paid to recently unemployed workers under a program administered by a government or labor union.
Source 3	Workers Compensation Benefits Payment that is required by law to be made to an employee who is injured or disabled in connection with work.
Source 4	Strike Benefits Money paid to strikers by a union to enable them to be supported during a strike.
Source 5	Social Security or Railroad Retirement Railroad retirement program provides retirement, survivor unemployment and sickness benefits to individuals who have spent a substantial portion of their career in railroad employment, as well as to workers’ families. Social Security Retirement is a federal insurance program that provides benefits to retired people and those who are unemployed or disabled.
Source 6	Pensions (public or private), Annuities, or Survivor’s Benefits A pension is a fund into which a sum of money is added during an employee's employment years, and from which payments are drawn to support the person's retirement from work in the form of periodic payments. An annuity is a contract between you and an insurance company that requires the insurer to make payments to you, either immediately or in the future. You buy an annuity by making either a single payment or a series of payments. Similarly, your payout may come either as one lump-sum payment or as a series of payments over time. Survivor's benefits are for widows and widowers receiving monthly Social Security benefits based on their deceased spouse’s earnings records.
Source 7	Military Cash Benefits Cash benefits for housing, food, or clothing allowances, including the Basic Allowance for Housing (BAH). Do not include combat pay, or benefits from the Family Substance Supplemental Allowance (FSSA) or the Military Housing Privatization Initiative (MHPI). For deployed service members, only include the amount made available to the household.
Source 8	Veteran’s Benefits Benefits you receive based on military service.
Source 9	Government Disability Benefits from Supplementary Security Income (SSI) SSI program pays benefits to disabled adults and children who have limited income and resources.
Source 10	Private Disability Benefits Providing benefits to employees who are unable to work due to disability, by paying all or part of their salaries from an insurance policy that can be provided by an employer as an employee benefit, or an insurance policy that can be purchased by an individual directly from an insurance company.
Source 11	Alimony Payments Payments made in a lump sum or on a continuing basis to provide financial support to a spouse before or after a marital separation or divorce. Alimony does NOT include child support, noncash property settlements, payments to keep up the payer’s property or use of the payer’s property.
Source 12	Child Support Payments Ongoing payment made by a parent to contribute to the costs of raising her or his child following the end of a marriage or other relationship.
Source 13	Interest and Dividends Income A dividend is a distribution of a portion of a company's earnings, decided by the board of directors, to a class of its shareholders. Dividends can be issued as cash payments, as shares of stock, or other property. Interest earned on investments is interest income.
Source 14	Net rental income The amount someone pays you to use your property, after you subtract the expenses you have for the property.
Source 15	Profit or Loss from Nonfarm Business, Partnership, or Professional Practice This is profit or loss not included in the salary you pay yourself as personal income or regular earnings.
Source 16	Profit or Loss from a Farm Income gained or loss from growing crops, raising livestock, breeding fish or operating a ranch.
Source 17	Financial Aid to College Students Include money used for room and board; do NOT include money used for tuition, books, and fees, or Pell Grants, Supplemental Education Opportunity Grants, State Student Incentive Grants, National Direct Student Loans, PLUS, College Work Study, or Byrd Honor Scholarship Programs.
Source 18	Regular Payments or Withdrawals from Large Awards or Settlements Include income from legal settlements, inheritance, prize winnings, or bonuses.
Source 19	Regular Contributions from Persons Outside the Household Include cash gifts or other financial assistance from friends or family.
Source 20	Other Income, such as Net Royalties, Trust Income, or 401K.
Source 21	General Assistance Benefits State or county programs serving low-income individuals who do not have minor children, are not disabled enough to qualify for (or do not yet receive) Supplemental Security Income (SSI), and are not elderly.
Source 22	Housing Subsidy (do not include Federal housing subsidies) Subsidized housing is owned and operated by private owners who receive subsidies in exchange for renting to low- and moderate-income people. Owners may be individual landlords or for-profit or nonprofit corporations. This does not include subsidized housing programs overseen by the U.S. Dept. of Housing and Urban Development (HUD) such as Section 8 or the Rural Rental Assistance program managed by the USDA.
Source 23	Federal Black Lung Program Provides compensation to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment, and to survivors of coal miners whose deaths are attributable to the disease and provides eligible miners with medical coverage for the treatment of lung diseases related to pneumoconiosis.
Source 24	Other Public Benefits, not including TANF or SNAP Other benefits such as Women, Infants and Children (WIC) or State Children’s Health Insurance (SCHIP) Do not include TANF or SNAP benefits.
Source 25	Select if you have no source of income or benefits.

C. Provide Documentation for Income and Payments

The interviewer will ask to look at documentation or a statement that describes income or payments for each income earner in the household. Please have documents available for the interviewer to see during the interview.

The table below describes acceptable documents to have available for the interview.

Type of Income	Personal Documents to Review
Wages and Salary (including base and overtime rates, bonuses, and incentives)	(a) Pay stubs (b) Earnings statement or W-2 form identifying employee and showing amount earned period of time covered by employment. (c) Statement indicating contact with employer by phone or in person specifying amount be earned per pay period. (d) Income tax return
Tips/gratuities and self- employment	(a) Notarized statement from applicant or form 1040/1040A showing amount earned (b) Income tax return
Unemployment or Worker’s Compensation	(a) Copy of check issued by agency. (b) Award letter signed by agency. (c) Signed and dated verification form showing amount and period received. (d) Print out of online statement. (e) 1099-G Tax Form
Social Security, Pensions, or Retirement	(a) Social Security retirement benefit letters. (b) Statement of benefits received. (c) Pension award notice. (d) Signed and dated verification form from agency or organization paying the pension.
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. (d) 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. (d) Dated and signed verification form completed by savings institution showing amount received and time period covered.
Other Income (such as rental income)	(a) Information or statement showing the amount received, how often it is received, and the date it was received. (b) Income tax return
Income maintenance or welfare program	(a) Copy of check issued by agency. (b) Award letter signed by agency. (c) Signed and dated verification form signed showing amount and period received.
Housing Voucher/Subsidy	(a) Proof of income from housing voucher/subsidy/assistance. (b) Annual or monthly certification letter.
No Income	A brief note explaining how you provide food, clothing, and housing for the household and when you expect to receive an income.
SNAP, TANF, or FDPIR	(a) Certification notice or benefits case number. (b) Dated and signed letter from SNAP or welfare office stating that these benefits are received.

If you have any questions, contact the NSMS at 1-855-820-6138 or [email protected].

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