Download:
pdf |
pdfOMB No. 1220-0141
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
R
EA
EN
UO
F TH E C
S
BU
US
U.S.
D
ENT OF C
TM
O
AR
CE
ER
M
M
EP
U.S. CENSUS BUREAU
Acting as a collecting agent for
U.S. Department of Labor
Bureau of Labor Statistics
Your Daily Expenses
Help us learn about the buying habits of people in the United States
Jeanette & LindaPastry Shop.jpg
Pierre-Vending
Machine.jpg
Stephen - Writing
Checks.jpg
Nhien & Jenny Flower Shop.jpg
George - Gas
Station.jpg
When you write down how you spend your money in this diary, you will
help us understand more about the products and services that are bought
by the people in the United States.
If you have comments regarding this survey, please send them to the Division of
Consumer Expenditure Surveys, 2 Massachusetts Avenue N.E., Room 3985,
Washington, DC 20212.
Please record your expenses and purchases
for the following period
Day
Date
1
2
3
4
5
6
7
I will return on: _______________________________________
If you have any questions, please call:
Field representative’s name:
Telephone:
Field representative supervisor’s name:
Telephone:
FORM CE-801
v1
(3-2016)
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
2/25/2016
General
General Instructions
Instructions
■
Fill out this diary for an entire week,
writing down EVERYTHING you and the
people on your list spend money on each
day – the products you buy, the services
you use, the household expenses you have
during the week – no matter how large or
small they are.
■
We recommend that you record your
expenses each day. Think about where you
went and what you’ve done.
■
Talk to the people on your list every day
to find out how they spent their money.
■
Include payments by
Cash
Check
Food Stamps
Credit/Debit Card
Money Order
WIC Voucher
■
Automatic
Withdrawal
Payroll
Deduction
Store Charge
Card
Gift Certificate
Keep receipts and other records so that
you will remember to record what you
bought or paid for. Use the pocket at the
back of the diary to store them.
Some record types include:
Receipts
Bills
Pay Stubs
Bank Statements
Catalog/Internet Purchases
Credit Card Statements
Include items that you bought for people
who are not on your list, such as gifts.
Do
Do NOT
NOT record
record
■
Expenses of people on your list while
they were away from home overnight.
■
Business or farm operating expenses
■
Sales tax, except for Meals, Snacks, and
Drinks Away from Home
FORM CE-801 v1 (3-2016)
2/29/2016
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
How to Fill Out
Your Diary
The diary is divided into 7 days and each
day is divided into 4 parts.
Enter each item in the appropriate part
for each day.
1. Food and Drinks for Home Consumption
■ Describe the item.
■
Mark whether the item was fresh, frozen,
bottled/canned, or other.
■
Enter the cost without tax and deduct any
discounts or coupons.
■
Mark the last column if the item was
purchased for someone not on your list
(e.g. gifts).
2. Meals, Snacks, and Drinks Away from
Home
■
Mark one of the four choices that best describes
the type of meal and describe briefly.
■
Mark one of the four choices that best
describes where you made the purchase.
■
Enter the total cost with tax and tip.
■
If alcohol was part of the purchase, check
whether it was wine, beer, and/or other
alcohol and enter the total cost of the alcohol.
3. Clothing, Shoes, Jewelry, and Accessories
■
■
■
Describe the item and enter the cost without
tax.
Mark the appropriate sex and age range of the
person for whom the item was bought.
Mark the last column if the item was purchased
for someone not on your list (e.g. gifts).
4. All Other Products, Services, and Expenses
■
Describe the item and enter the total cost
without tax.
■
Mark the last column if the item was purchased
for someone not on your list (e.g. gifts).
See back flap for answers to
Frequently Asked Questions
There is an Additional Pages section
on pages 18–22 in case you run out of
lines on any particular day.
If you are unsure about whether to
include an item or where to record an
item, write it down wherever it seems
best or make a note and ask your field
representative.
FORM CE-801 v1 (3-2016)
2-22-2016
Black Ink (40% and 100%)
CE-801, Pantone Blue 313 (20% and 100%)
Record Your Daily Expenses
The people on your list:
Record the purchases and expenses made by ALL of these people.
Notes
FORM CE-801 v1 (3-2016)
CE-801V1 Black Ink (40% and 100%)
1-28-2016
Thank you for agreeing to fill out this diary.
We understand that this task takes time; however, your information is
very important to us and will be used for many purposes that affect all
Americans. Among the most important, it is used to help calculate the
Consumer Price Index, or CPI, which is a basic measure of the rate of
inflation.
Here are some of the uses of the Consumer Price Index:
♦ Provide cost-of-living wage adjustments for millions of American workers
♦ Adjust Social Security payments
♦ Determine the cost of school lunches
♦ Adjust Federal income-tax brackets
For more information about the survey, visit: http://www.bls.gov/cex and http://www.census.gov
Office Use: Place the barcode label here
Questions?
Some Frequently Asked Questions are answered on the flap attached to the back cover.
If you still have questions after reviewing these, please call your field representative.
1
FORM CE-801 v1 (3-2016)
§)""¤
080101
Black Ink (40% and 100%)
1-28-2016
Examples
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
bread
101
eggs
102
chicken wings
103
apples
104
beer
105
milk
106
orange juice
107
candy
108
vegetable oil
109
baby food
110
potato chips
111
frozen meals
112
Level of detail needed
BEEF – Specify the cut and
describe, such as round roast,
ground beef, etc.
PORK – Specify the cut and
describe, such as whole ham,
bacon, spareribs, etc.
OTHER FOOD – Give a complete
description, such as scalloped
potatoes.
1
frozen
bottled/
canned
3
4
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
1
2
3
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
X
X
X
X
X
ketchup
113
soup
114
soda
115
pork chops
116
shrimp
117
other
2
X
X
X
X
X
X
carbonated water
120
ground beef
121
coffee
122
bagels
123
wine
124
dog food
125
X
X
X
4
4
X
X
apple pie
119
X
X
without tax
1
49
1
50
6
78
2
80
4
29
2
99
3
99
2
50
2
99
4
95
2
79
8
97
1
59
4
96
1
98
6
36
11
20
3
50
X
4
99
X
2
cookies
118
X
X
X
Mark (X) If
purchased for
someone not
on your list
Cost
X
X
89
X
X
5
87
2
79
5
25
42
00
5
85
126
127
128
1 inside
2
Use the pocket on the
of3 the 4back
cover to store your receipts
until
you’re
1
2
3
4
ready to record your purchases.
129
130
1
2
3
4
1
2
3
4
131
132
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
133
134
135
136
2
FORM CE-801 v1 (3-2016)
§)"#¤
080102
Black Ink (10%, 50%, & 100%) CE-801, Page 5, Pantone Blue 313 (20%, 40%, & 100%) CE-801, Page 5, Pantone Yellow 101 (70%)
2-22-2016
Examples
Meals, Snacks and Drinks Away from Home
1
2
3
201
1
202
1
2
X
2
3
3
4
elem.school lunch - month
4
X soda
203
1
2
3
4
3
4
1
2
3
4
1
2
3
4
1
2
3
4
X
1
2
3
4
1
2
3
4
1
2
1
2
X drinks from cash bar
205
X
206
Total Cost
1 35
45
X
65
62
3
4
3
4
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
X
23
15 00
X
caterer - Family Reunion
00
X X
350 00
X
Enter the
total cost of
the alcohol
other
with tax & tip
X
buffet
X
204
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
2
1
X coffee
Full
Service
Places
beer
Fast Food
Take-out
Delivery
wine
Description
4
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
12
00
15
00
95
00
3
X X X
Clothing, Shoes, Jewelry, and Accessories
301
302
303
dress shirts
baseball cap
305
bib
306
307
308
SHOES – If sports shoes,
specify sport, such as football
cleats, etc.
wallet
304
without tax
Level of detail needed
running shoes
JEWELRY – Specify type of
jewelry, such as watches, etc.
EYEWEAR – Specify prescription
or non-prescription.
necklace
Was the item for:
Cost
What did you buy or pay for?
non-prescription sunglasses
75 00
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
X
69 00
X
29 00
X
14 99
X
1
3
50
250 00
X
X
59 00
child’s costume (returned for refund)
Mark (X) If
purchased for
someone not
on your list
X
X
15 00
X
All Other Products, Services, and Expenses
What did you buy or pay for?
401
cold medicine (non-prescription)
402
gasoline
403
highway tolls
404
Music CD
405
cigarettes
406
dry cleaning (clothes)
407
lottery tickets
408
bus fare
409
piano lessons
410
electric drill
411
Netflix subscription
412
413
Level of detail needed
DOCTOR BILLS – Specify type of doctor
visited, such as an internist, orthodontist, etc.
MEDICINE – Specify if prescription or
non-prescription.
TOOLS – Specify if power or hand tool.
DRY-CLEANING – Specify whether household
item (such as drapes) or apparel.
Cost
without tax
6
95
12
86
2
00
10
99
8
99
15
50
1
00
1
50
Mark (X) If
purchased for
someone not
on your list
X
X
150 00
65
00
9
99
veterinarian fees
85
00
Donation
50
00
3
FORM CE-801 v1 (3-2016)
§)"$¤
080103
CE-801 v1, Pantone Blue 313 (20%, 40%, and 100%), Pantone Yellow 101 (70%)
2-29-2016
DAY 1
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
4
FORM CE-801 v1 (3-2016)
§)"%¤
080104
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 1
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)"&¤
080105
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
5
DAY 2
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
6
FORM CE-801 v1 (3-2016)
§)"’¤
080106
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 2
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)"(¤
080107
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
7
DAY 3
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
8
FORM CE-801 v1 (3-2016)
§)")¤
080108
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 3
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)"*¤
080109
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
9
DAY 4
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
10
FORM CE-801 v1 (3-2016)
§)"+¤
080110
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 4
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)",¤
080111
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
11
DAY 5
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
12
FORM CE-801 v1 (3-2016)
§)"-¤
080112
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 5
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)".¤
080113
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
13
DAY 6
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
14
FORM CE-801 v1 (3-2016)
§)"/¤
080114
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 6
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)"0¤
080115
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
15
DAY 7
ENTER
DAY/DATE
See pages 2-3 for examples. If you need additional space, use pages 18–22.
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
fresh
frozen
Cost
bottled/
canned
other
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
2
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
without tax
Mark (X) If
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
16
FORM CE-801 v1 (3-2016)
§)"1¤
080116
Black Ink (10%, 50%, & 100%), Pantone Blue 313 (20%, 40% and 100%)
2-25-2016
FR USE:
DAY 7
None
VC
Meals, Snacks, and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
Cost
What did you buy or pay for?
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
What did you buy or pay for?
Cost
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
FORM CE-801 v1 (3-2016)
§)"2¤
080117
2-25-2016
CE-801, Page 8, Pantone Blue 313 (20%, 40%, and 100%)
17
Additional Pages
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) if
purchased for
someone not
on your list
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
18
FORM CE-801 v1 (3-2016)
§)"3¤
080118
2-25-2016
CE-801, Page 40, Pantone Blue - PMS-313
Additional Pages
Meals, Snacks and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
beer
Description
wine
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
201
202
203
204
205
206
Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
Cost
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
301
302
303
304
305
306
307
308
All Other Products, Services, and Expenses
Cost
What did you buy or pay for?
without tax
Mark (X) If
purchased for
someone not
on your list
401
402
403
404
405
406
407
408
409
410
411
412
413
19
FORM CE-801 v1 (3-2016)
§)"4¤
080119
CE-801, Page 41, Pantone Blue - PMS-313
2-23-2016
Additional Pages
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
Cost
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
without tax
Mark (X) if
purchased for
someone not
on your list
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
20
FORM CE-801 v1 (3-2016)
§)"5¤
080120
2-25-2016
CE-801, Page 40, Pantone Blue - PMS-313
Additional Pages
Meals, Snacks and Drinks Away from Home
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Description
Fast Food
Take-out
Delivery
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
Enter the
total cost of
the alcohol
207
208
209
210
211
212
Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
Cost
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
309
310
311
312
313
314
315
316
All Other Products, Services, and Expenses
Cost
What did you buy or pay for?
without tax
Mark (X) If
purchased for
someone not
on your list
414
415
416
417
418
419
420
421
422
423
424
425
426
21
FORM CE-801 v1 (3-2016)
§)"6¤
080121
CE-801, Page 41, Pantone Blue - PMS-313
2-25-2016
Additional Pages
Food and Drinks for Home Consumption
Is this item:
Mark (X) one
What did you buy or pay for?
1
2
bottled/
other
canned
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
fresh
frozen
Mark (X) if
purchased for
someone not
on your list
Cost
without tax
175
176
177
178
179
180
Meals, Snacks and Drinks Away from Home
If alcoholic
beverages
included,
mark (X) all
that apply
Mark (X) one that best describes
where you made this purchase
Full
Service
Places
Vending
Employer
Machines
or School
or Mobile
Cafeteria
Vendors
Total Cost
with tax & tip
Enter the
total cost of
the alcohol
other
Fast Food
Take-out
Delivery
wine
Description
beer
snack/other
dinner
lunch
breakfast
Mark (X) one that
best describes
the type of meal
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
1
2
3
4
1
2
3
213
214
215
216
217
218
Clothing, Shoes, Jewelry, and Accessories
What did you buy or pay for?
Cost
without tax
Was the item for:
Child
Under 2
Boy
2-15
Girl
2-15
Man Woman
16 &
16 &
over
over
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Mark (X) If
purchased for
someone not
on your list
317
318
319
320
321
322
All Other Products, Services, and Expenses
Cost
What did you buy or pay for?
without tax
Mark (X) If
purchased for
someone not
on your list
427
428
429
430
431
432
22
FORM CE-801 v1 (3-2016)
§)"7¤
080122
CE-801, Page 41, Pantone Blue - PMS-313
2-29-2016
Keep your records in this pocket.
(These records are only for your reference; we will not keep them.)
■
■
■
■
■
■
FORM CE-801 v1 (3-2016)
Receipts
Bills
Pay Stubs
Bank Statements
Catalog/Internet Purchases
Credit Card Statements
Frequently
requently Asked
sked Questions
uestions
(continued on other side)
1. How detailed should my descriptions be?
Refer to pages 2–3 for examples of the level of
detail needed in each part. Do not use brand
names.
2. How should I record multiple quantities?
If the items are identical, you can combine
them on the same line and enter the total cost
of all the items. See examples on pages 2 and 3.
3. How should I record pre-payments such
as a subway fare card?
Record the expense when you pay for it, not
when you use it.
4. How should I record credit card
purchases?
Record the individual expense on the day that
you use your credit card to pay for something,
not on the day you pay your entire credit card
bill.
5. Should I record automatic deductions
taken from my paycheck or bank
account?
Yes, record automatic deductions (such as
health insurance premiums taken out of your
account or paycheck) only if they are deducted
that week. Write them in the section called All
Other Products, Services, and Expenses.
6. Should I record typical monthly bills?
Yes, record typical monthly bills only if you pay
them during the week that you have the diary.
Write them in the section called All Other
Products, Services, and Expenses.
7. What should I do when I use coupons,
discount cards, or loyalty cards?
Subtract the discount from the original price
and write the amount that you paid.
8. Can I just give you receipts instead of
writing the information down?
No, we need you to actually write the
information in the diary. We encourage you to
save your receipts to review them with your
field representative at the end of the week. You
can use the pocket on the inside of the back
cover to store your receipts until you’re ready
to record your purchases.
9. How should I record items if I don’t
know whether it includes tax?
Write down the amount paid.
10. What if I make a contribution or
charitable donation?
Record money contributions or donations in
the section called All Other Products, Services,
and Expenses.
(continued on other side)
FORM CE-801 v1 (3-2016)
Black Ink (40% and 100%)
2-29-2016
CE-801, Panton Blue 313 (20% and 100%)
Frequently
requently Asked
sked Questions
uestions
(continued on other side)
11. What about gift certificates or gift
cards?
If you buy a gift certificate to give to someone,
write down the cost of it under the appropriate
section (e.g. a certificate to a clothing store
would go under Clothing, Shoes, Jewelry, and
Accessories and a certificate to a department
store would go under All Other Products,
Services, and Expenses. If you buy something
using a gift card, write down the full amount
for your purchase ignoring the gift card.
12. What do I do about returns & exchanges?
If an item is bought and returned during the
diary week, it can be erased or crossed out. If it
was bought outside the week and returned
during the week, do not make an entry. If an
item is exchanged during the week, change the
entry. If the new cost is different, cross out the
old cost and write in the new cost (see
examples on page 3).
13. Should I record subsidized/reimbursed
expenses?
Yes, but if someone not on your list pays for
or helps pay for an expense or if you will be
reimbursed for an expense, only record any
extra amount that you or someone on your list
has to pay.
14. What should I do about shipping &
handling costs?
Include the shipping & handling cost in the total
price of the item. If the shipping & handling
covered multiple items, include the shipping &
handling in the total price of one item from the
order.
15. What’s the difference between a
concession stand and a mobile vendor?
A concession stand has to stay in a permanent
location and a mobile vendor does not. Some
mobile vendors may seem permanent because
they are usually in the same location, but they
are still considered mobile vendors because
they have the option to change locations.
16. How do I categorize the establishment for
Meals, Snacks, and Drinks Away from Home?
■ Fast food, Take-out, Delivery, Concession
You pay BEFORE you eat/drink
■ Full Services Places
You pay after you eat/drink
■ Vending Machines or Mobile Vendors
Include vending machines, carts, and
trucks that move from place to place
■ Employer and School Cafeterias
Includes school meal pre-payments
FORM CE-801 v1 (3-2016)
2-23-2016
Black Ink (40% and 100%)
CE-801V1flp2, Panton Blue 313 (20% and 100%)
Car Dashboard& CD.jpg
Coffee.jpg
Gifts.jpg
Money.jpg
Haircut.jpg
Pizza.jpg
Daily Reminder List
Please review the list of expenses below with the people on your list at the end of each day.
If you have forgotten to record any expense, please do so on the appropriate page.
Did you or anyone on your list pay for . . .
■ meals, drinks, or snacks from restaurants, fast food, cafeterias,
vending machines, concession stands, etc.?
■ catered events or meal plans?
■ food & drinks from a grocery store or other speciality food store
such as a bakery, candy shop, or liquor store?
■ clothing, shoes, jewelry, accessories or clothing services such as dry cleaning?
■ personal care items or services such as cosmetics, soaps, haircuts, etc.?
■ housekeeping supplies or services for home decoration/maintenance?
■ toys, books, electronics, hobby supplies, etc.?
■ cigarettes, tobacco, or other smoking supplies?
■ commuting costs such as public transportation, parking fees, gasoline, or tolls?
■ medicine or medical/dental services?
■ entertainment or recreational activities?
■ typical bills such as utility bills, cable bills, telephone bills, etc.?
■ automatic deductions from a paycheck such as insurance premiums?
■ bank/ATM service fees?
■ credit card interest or finance charges?
■ internet or catalog orders?
■ fees for lessons or instructions?
■ gifts, contributions, donations?
RO
code
Control Number
Vegetables.jpg
FORM CE-801 v1 (3-2016)
2-22-2016
PSU code
Spinoff
Segment No. Segment No.
Suffix
Hand Swiping Credit
Card.jpg
Sample
Designation
Kid with Toys
.jpg
Serial No.
Serial No.
Suffix
Clothing.jpg
Week
HH No. CU No. Indicator
1
Hammer and Nail
.jpg
2
Newspaper.jpb
| File Type | application/pdf |
| File Title | ce801v1_p24_reminder_back.g |
| File Modified | 2016-02-29 |
| File Created | 2016-02-25 |