Download:
pdf |
pdf13177019
DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
Puerto Rico Community Survey
Please complete this form and return
it as soon as possible after receiving
it in the mail.
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.
Start Here
➜
Please print today’s date.
Month
➜
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
MI
First Name
Area Code + Number
—
If you need help or have questions
about completing this form, please call
1-800-717-7381. The telephone call is free.
➜
How many people are living or staying at this address?
• INCLUDE everyone who is living or staying here for more than 2 months.
• INCLUDE yourself if you are living here for more than 2 months.
• INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
• DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people
➜
Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.
Telephone Device for the Deaf (TDD):
Call 1-800-786-9448. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-800-814-8385.
For more information about the Puerto Rico
Community Survey, visit our web site at:
http://www.census.gov/acs/
ACS-1(2017)PR
FORM
(05-04-2016)
§.2g4¤
ACS-1(2017)PR, Page 1, Base (Black)
ACS-1(2017)PR, Page 1, Pantone Purple U (15, 100%)
OMB No. 0607-0810
OMB No. 0607-0936
13177027
Person 1
Person 2
1 What is Person 2’s name?
(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.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1?
X
3
Person 1
4
Female
Month
Day
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Year of birth
Age (in years)
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
6 What is Person 2’s race? Mark (X) one or more boxes.
What is Person 1’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
2
Roomer or boarder
Stepson or stepdaughter
4 What is Person 2’s age and what is Person 2’s date of birth?
Question 6 about race. For this survey, Hispanic origins are not races.
6
Adopted son or daughter
Male
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Other relative
3 What is Person 2’s sex? Mark (X) ONE box.
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)
Son-in-law or daughter-in-law
Biological son or daughter
Parent-in-law
What is Person 1’s sex? Mark (X) ONE box.
Male
Husband or wife
Some other race – Print race. C
§.2g<¤
ACS-1(2017)PR, Page 2, Base (Black)
ACS-1(2017)PR, Page 2, Pantone Purple U (15, 100%)
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
13177035
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
Son-in-law or daughter-in-law
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Female
Male
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
Question 6 about race. For this survey, Hispanic origins are not races.
6
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)
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
MI
Husband or wife
Male
4
First Name
2 How is this person related to Person 1? Mark (X) ONE box.
How is this person related to Person 1? Mark (X) ONE box.
Parent-in-law
3
Last Name (Please print)
Month
Day
Year of birth
➜ 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 4 of Hispanic, Latino, or Spanish origin?
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
6 What is Person 4’s race? Mark (X) one or more boxes.
What is Person 3’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
Some other race – Print race. C
§.2gD¤
ACS-1(2017)PR, Page 3, Base (Black)
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
3
ACS-1(2017)PR, Page 3, Pantone Purple U (15, 100%)
13177043
Person 5
1
➜
What is Person 5’s name?
Last Name (Please print)
First Name
MI
If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.
Person 6
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
3
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Sex
Female
Female
Age (in years)
Person 8
What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Male
Month
Day
Last Name (Please print)
First Name
MI
Year of birth
Sex
Male
Female
Age (in years)
➜ 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 5 of Hispanic, Latino, or Spanish origin?
Person 9
Last Name (Please print)
First Name
MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Sex
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Male
Female
Person 10
Last Name (Please print)
6
Age (in years)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Male
Female
Person 11
Last Name (Please print)
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Sex
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Age (in years)
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race. C
Sex
4
Male
Female
Age (in years)
§.2gL¤
ACS-1(2017)PR, Page 4, Base (Black)
MI
ACS-1(2017)PR, Page 4, Pantone Purple U (15, 100%)
MI
13177050
Housing
➜
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
7 Does this house, apartment, or mobile
Answer questions 4 – 5 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 6a.
home have –
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
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.
2
b. a water heater?
4 How many cuerdas is this house or
c. a bathtub or shower?
d. a sink with a faucet?
Less than 1 cuerda ➔ SKIP to question 6a
e. a stove or range?
1 to 9.9 cuerdas
f. a refrigerator?
10 or more cuerdas
g. telephone service from
which you can both make
and receive calls? Include
cell phones.
5 IN THE PAST 12 MONTHS, what
8 At this house, apartment, or mobile home –
were the actual sales of all agricultural
products from this property?
None
do you or any member of this household
own or use any of the following types of
computer?
Yes
No
$1 to $999
a. Desktop or laptop
$1,000 to $2,499
b. Smartphone
$2,500 to $4,999
c. Tablet or other portable
wireless computer
$5,000 to $9,999
d. Some other type of computer
Specify
$10,000 or more
About when was this building first built?
2000 or later – Specify year
1990 to 1999
1980 to 1989
1970 to 1979
9 At this house, apartment, or mobile home –
6 a. How many separate rooms are in this
do you or any member of this household
have access to the Internet?
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
Yes, by paying a cell phone company or
Internet service provider
Yes, without paying a cell phone company
or Internet service provider ➔ SKIP to
question 11
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
No access to the Internet at this house,
apartment, or mobile home ➔ SKIP to
question 11
Number of rooms
1960 to 1969
10 Do you or any member of this household
1950 to 1959
1940 to 1949
1939 or earlier
3
No
a. running water?
mobile home on?
1
Yes
have access to the Internet using a –
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
Number of bedrooms
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
Year
Yes
No
a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service
§.2gS¤
ACS-1(2017)PR, Page 5, Base (Black)
5
ACS-1(2017)PR, Page 5, Pantone Purple U (10, 15, 50, 100%)
13177068
Housing (continued)
11 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
13 a. LAST MONTH, what was the cost
of electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars
$
.00
,
None
OR
14 IN THE PAST 12 MONTHS, did you or
any member of this household receive
benefits from the Nutritional Assistance
Program? Do NOT include WIC, the
School Lunch Program, or assistance
from food banks.
Yes
No
1
Included in rent or condominium fee
2
No charge or electricity not used
15 Is this house, apartment, or mobile home
part of a condominium?
3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
4
5
6 or more
Last month’s cost – Dollars
$
.00
,
12 Which FUEL is used MOST for heating this
Included in electricity payment
entered above
No charge or gas not used
Electricity
Wood
Solar energy
Other fuel
$
Included in rent or condominium fee
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Coal or coke
Monthly amount – Dollars
OR
house, apartment, or mobile home?
Fuel oil, kerosene, etc.
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.
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
,
No fuel used
OR
.00
,
OR
None
No
16 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented?
Included in rent or condominium fee
No charge
Occupied without payment of
rent? ➔ SKIP to C on the next page
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
6
§.2ge¤
ACS-1(2017)PR, Page 6, Base (Black)
ACS-1(2017)PR, Page 6, Pantone Purple U (15, 50, 100%)
13177076
Housing (continued)
B
Answer questions 17a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 18.
21 a. Do you or any member of this
22 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?
17 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 22a
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?
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
Monthly amount – Dollars
$
Yes
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
.00
,
$
No
OR
C
Answer questions 18 – 22 if you or any
member of this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .
18 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
,
19 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$
,
No regular payment required
D
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
Answer question 23 if this is a MOBILE
HOME. Otherwise, SKIP to E .
23 What are the total annual costs for
Amount – Dollars
$
.00
OR
No regular payment required ➔ SKIP to
question 22a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
,
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
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.
20 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
.00
,
OR
None
§.2gm¤
ACS-1(2017)PR, Page 7, Base (Black)
7
ACS-1(2017)PR, Page 7, Pantone Purple U (10, 15, 50, 100%)
13177084
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 Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
GED or alternative credential
Yes, born in Puerto Rico ➔ SKIP to question 10a
COLLEGE OR SOME COLLEGE
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Bachelor’s degree (for example: BA, BS)
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)
No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
Doctorate degree (for example: PhD, EdD)
F
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
c. How well does this person speak English?
Very well
Well
Not well
Not at all
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
9
For example: Korean, Italian, Spanish, Vietnamese
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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 Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
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)
Address
Development or condominium name
Number and street name
Name of city, town, or post office
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
8
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
§.2gu¤
ACS-1(2017)PR, Page 8, Base (Black)
ACS-1(2017)PR, Page 8, Pantone Purple U (10, 15, 50, 100%)
ZIP Code
13177092
Person 1 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer question 19 if this person is
15 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
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
g. Indian Health Service
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
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
Widowed
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
c. How long has this grandparent been
responsible for these grandchildren?
No
a. Married?
Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now
b. Widowed?
27 When did this person serve on active duty in the
c. Divorced?
17 a. Is this person deaf or does he/she have
22 How many times has this person been married?
serious difficulty hearing?
Once
September 2001 or later
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?
No
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
G
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Korean War (July 1950 to January 1955)
I
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
24 In the PAST 12 MONTHS, has this person given
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
birth to any children?
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
Yes
Yes
50 or 60 percent
No
No ➔ SKIP to question 26
70 percent or higher
§.2g}¤
ACS-1(2017)PR, Page 9, Base (Black)
9
ACS-1(2017)PR, Page 9, Pantone Purple U (10, 15, 50, 100%)
13177100
Person 1 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address
Development or condominium name
Number and street name
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
d. Name of municipio in Puerto Rico
or U.S. county
e. Enter Puerto Rico or name of U.S. state
or foreign country
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47
Yes ➔ SKIP to question 40
No
35 a. LAST WEEK, was this person on layoff from
50 to 52 weeks
a job?
Yes ➔ SKIP to question 35c
48 to 49 weeks
No
40 to 47 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
Within the past 12 months
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
f. ZIP Code
days?
this person work 50 or more weeks? Count
paid time off as work.
Yes
No, outside the city/town limits
38 When did this person last work, even for a few
39 a. During the PAST 12 MONTHS (52 weeks), did
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
No, because of all other reasons (in school, etc.)
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
27 to 39 weeks
14 to 26 weeks
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Yes ➔ SKIP to question 37
No
Taxicab
10
§.2h!¤
ACS-1(2017)PR, Page 10, Base (Black)
ACS-1(2017)PR, Page 10, Pantone Purple U (10, 15, 50, 100%)
13177118
Person 1 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, municipio, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
No
Name of company, business, or other employer
43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
$
,
,
No
$
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
Yes ➔
$
No
,
,
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
TOTAL AMOUNT for past
12 months
Loss
OR
None
44 Is this mainly – Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
No
$
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes ➔
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a Federal GOVERNMENT employee?
working WITHOUT PAY in family business
or farm?
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 2 on
the next page. If no one is listed as person 2 on
page 2, SKIP to page 28 for mailing instructions.
§.2h3¤
ACS-1(2017)PR, Page 11, Base (Black)
11
ACS-1(2017)PR, Page 11, Pantone Purple U (10, 15, 50, 100%)
13177126
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 Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
GED or alternative credential
Yes, born in Puerto Rico ➔ SKIP to question 10a
COLLEGE OR SOME COLLEGE
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Bachelor’s degree (for example: BA, BS)
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)
No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
Doctorate degree (for example: PhD, EdD)
F
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
c. How well does this person speak English?
Very well
Well
Not well
Not at all
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
9
For example: Korean, Italian, Spanish, Vietnamese
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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 Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
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)
Address
Development or condominium name
Number and street name
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
§.2h;¤
ACS-1(2017)PR, Page 12, Base (Black)
ACS-1(2017)PR, Page 12, Pantone Purple U (10, 15, 50, 100%)
ZIP Code
13177134
Person 2 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer question 19 if this person is
15 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
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
g. Indian Health Service
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
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
Widowed
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
c. How long has this grandparent been
responsible for these grandchildren?
No
a. Married?
Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now
b. Widowed?
27 When did this person serve on active duty in the
c. Divorced?
17 a. Is this person deaf or does he/she have
22 How many times has this person been married?
serious difficulty hearing?
Once
September 2001 or later
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?
No
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
G
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Korean War (July 1950 to January 1955)
I
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
24 In the PAST 12 MONTHS, has this person given
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
birth to any children?
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
Yes
Yes
50 or 60 percent
No
No ➔ SKIP to question 26
70 percent or higher
§.2hC¤
ACS-1(2017)PR, Page 13, Base (Black)
13
ACS-1(2017)PR, Page 13, Pantone Purple U (10, 15, 50, 100%)
13177142
Person 2 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address
Development or condominium name
Number and street name
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
d. Name of municipio in Puerto Rico
or U.S. county
e. Enter Puerto Rico or name of U.S. state
or foreign country
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47
Yes ➔ SKIP to question 40
No
35 a. LAST WEEK, was this person on layoff from
50 to 52 weeks
a job?
Yes ➔ SKIP to question 35c
48 to 49 weeks
No
40 to 47 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
Within the past 12 months
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
f. ZIP Code
days?
this person work 50 or more weeks? Count
paid time off as work.
Yes
No, outside the city/town limits
38 When did this person last work, even for a few
39 a. During the PAST 12 MONTHS (52 weeks), did
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
No, because of all other reasons (in school, etc.)
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
27 to 39 weeks
14 to 26 weeks
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Yes ➔ SKIP to question 37
No
Taxicab
14
§.2hK¤
ACS-1(2017)PR, Page 14, Base (Black)
ACS-1(2017)PR, Page 14, Pantone Purple U (10, 15, 50, 100%)
13177159
Person 2 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, municipio, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
No
Name of company, business, or other employer
43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
$
,
,
No
$
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
Yes ➔
$
No
,
,
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
TOTAL AMOUNT for past
12 months
Loss
OR
None
44 Is this mainly – Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
No
$
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes ➔
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a Federal GOVERNMENT employee?
working WITHOUT PAY in family business
or farm?
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 3 on
the next page. If no one is listed as person 3 on
page 3, SKIP to page 28 for mailing instructions.
§.2h\¤
ACS-1(2017)PR, Page 15, Base (Black)
15
ACS-1(2017)PR, Page 15, Pantone Purple U (10, 15, 50, 100%)
13177167
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 Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
GED or alternative credential
Yes, born in Puerto Rico ➔ SKIP to question 10a
COLLEGE OR SOME COLLEGE
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Bachelor’s degree (for example: BA, BS)
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)
No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
Doctorate degree (for example: PhD, EdD)
F
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
c. How well does this person speak English?
Very well
Well
Not well
Not at all
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
9
For example: Korean, Italian, Spanish, Vietnamese
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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 Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
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)
Address
Development or condominium name
Number and street name
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
§.2hd¤
ACS-1(2017)PR, Page 16, Base (Black)
ACS-1(2017)PR, Page 16, Pantone Purple U (10, 15, 50, 100%)
ZIP Code
13177175
Person 3 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
g. Indian Health Service
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
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
Widowed
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
c. How long has this grandparent been
responsible for these grandchildren?
No
a. Married?
Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now
b. Widowed?
27 When did this person serve on active duty in the
c. Divorced?
17 a. Is this person deaf or does he/she have
22 How many times has this person been married?
serious difficulty hearing?
Once
September 2001 or later
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?
No
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
G
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Korean War (July 1950 to January 1955)
I
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
24 In the PAST 12 MONTHS, has this person given
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
birth to any children?
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
Yes
Yes
50 or 60 percent
No
No ➔ SKIP to question 26
70 percent or higher
§.2hl¤
ACS-1(2017)PR, Page 17, Base (Black)
17
ACS-1(2017)PR, Page 17, Pantone Purple U (10, 15, 50, 100%)
13177183
Person 3 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address
Development or condominium name
Number and street name
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
d. Name of municipio in Puerto Rico
or U.S. county
e. Enter Puerto Rico or name of U.S. state
or foreign country
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47
Yes ➔ SKIP to question 40
No
35 a. LAST WEEK, was this person on layoff from
50 to 52 weeks
a job?
Yes ➔ SKIP to question 35c
48 to 49 weeks
No
40 to 47 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
Within the past 12 months
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
f. ZIP Code
days?
this person work 50 or more weeks? Count
paid time off as work.
Yes
No, outside the city/town limits
38 When did this person last work, even for a few
39 a. During the PAST 12 MONTHS (52 weeks), did
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
No, because of all other reasons (in school, etc.)
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
27 to 39 weeks
14 to 26 weeks
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Yes ➔ SKIP to question 37
No
Taxicab
18
§.2ht¤
ACS-1(2017)PR, Page 18, Base (Black)
ACS-1(2017)PR, Page 18, Pantone Purple U (10, 15, 50, 100%)
13177191
Person 3 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, municipio, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
No
Name of company, business, or other employer
43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
$
,
,
No
$
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
Yes ➔
$
No
,
,
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
TOTAL AMOUNT for past
12 months
Loss
OR
None
44 Is this mainly – Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
No
$
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes ➔
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a Federal GOVERNMENT employee?
working WITHOUT PAY in family business
or farm?
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 4 on
the next page. If no one is listed as person 4 on
page 3, SKIP to page 28 for mailing instructions.
§.2h|¤
ACS-1(2017)PR, Page 19, Base (Black)
19
ACS-1(2017)PR, Page 19, Pantone Purple U (10, 15, 50, 100%)
13177209
Person 4
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 4 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 Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
GED or alternative credential
Yes, born in Puerto Rico ➔ SKIP to question 10a
COLLEGE OR SOME COLLEGE
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Bachelor’s degree (for example: BA, BS)
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)
No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
Doctorate degree (for example: PhD, EdD)
F
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
c. How well does this person speak English?
Very well
Well
Not well
Not at all
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
9
For example: Korean, Italian, Spanish, Vietnamese
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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 Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
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)
Address
Development or condominium name
Number and street name
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)
20
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
§.2i*¤
ACS-1(2017)PR, Page 20, Base (Black)
ACS-1(2017)PR, Page 20, Pantone Purple U (10, 15, 50, 100%)
ZIP Code
13177217
Person 4 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
g. Indian Health Service
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
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
Widowed
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
c. How long has this grandparent been
responsible for these grandchildren?
No
a. Married?
Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now
b. Widowed?
27 When did this person serve on active duty in the
c. Divorced?
17 a. Is this person deaf or does he/she have
22 How many times has this person been married?
serious difficulty hearing?
Once
September 2001 or later
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?
No
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
G
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Korean War (July 1950 to January 1955)
I
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
24 In the PAST 12 MONTHS, has this person given
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
birth to any children?
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
Yes
Yes
50 or 60 percent
No
No ➔ SKIP to question 26
70 percent or higher
§.2i2¤
ACS-1(2017)PR, Page 21, Base (Black)
21
ACS-1(2017)PR, Page 21, Pantone Purple U (10, 15, 50, 100%)
13177225
Person 4 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address
Development or condominium name
Number and street name
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
d. Name of municipio in Puerto Rico
or U.S. county
e. Enter Puerto Rico or name of U.S. state
or foreign country
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47
Yes ➔ SKIP to question 40
No
35 a. LAST WEEK, was this person on layoff from
50 to 52 weeks
a job?
Yes ➔ SKIP to question 35c
48 to 49 weeks
No
40 to 47 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
Within the past 12 months
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
f. ZIP Code
days?
this person work 50 or more weeks? Count
paid time off as work.
Yes
No, outside the city/town limits
38 When did this person last work, even for a few
39 a. During the PAST 12 MONTHS (52 weeks), did
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
No, because of all other reasons (in school, etc.)
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
27 to 39 weeks
14 to 26 weeks
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Yes ➔ SKIP to question 37
No
Taxicab
22
§.2i:¤
ACS-1(2017)PR, Page 22, Base (Black)
ACS-1(2017)PR, Page 22, Pantone Purple U (10, 15, 50, 100%)
13177233
Person 4 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, municipio, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
No
Name of company, business, or other employer
43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
$
,
,
No
$
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
Yes ➔
$
No
,
,
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
TOTAL AMOUNT for past
12 months
Loss
OR
None
44 Is this mainly – Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
No
$
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes ➔
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a Federal GOVERNMENT employee?
working WITHOUT PAY in family business
or farm?
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 5 on
the next page. If no one is listed as person 5 on
page 4, SKIP to page 28 for mailing instructions.
§.2iB¤
ACS-1(2017)PR, Page 23, Base (Black)
23
ACS-1(2017)PR, Page 23, Pantone Purple U (10, 15, 50, 100%)
13177241
Person 5
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 5 from page 4,
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 Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
GED or alternative credential
Yes, born in Puerto Rico ➔ SKIP to question 10a
COLLEGE OR SOME COLLEGE
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Bachelor’s degree (for example: BA, BS)
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)
No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
Doctorate degree (for example: PhD, EdD)
F
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
c. How well does this person speak English?
Very well
Well
Not well
Not at all
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
9
For example: Korean, Italian, Spanish, Vietnamese
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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 Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
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)
Address
Development or condominium name
Number and street name
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)
24
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
§.2iJ¤
ACS-1(2017)PR, Page 24, Base (Black)
ACS-1(2017)PR, Page 24, Pantone Purple U (10, 15, 50, 100%)
ZIP Code
13177258
Person 5 (continued)
H
16 Is this person CURRENTLY covered by any of the
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
g. Indian Health Service
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
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
Widowed
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
c. How long has this grandparent been
responsible for these grandchildren?
No
a. Married?
Never served in the military ➔ SKIP to
question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a
Now on active duty
On active duty in the past, but not now
b. Widowed?
27 When did this person serve on active duty in the
c. Divorced?
17 a. Is this person deaf or does he/she have
22 How many times has this person been married?
serious difficulty hearing?
Once
September 2001 or later
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
Year
glasses?
No
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
G
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Korean War (July 1950 to January 1955)
I
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
24 In the PAST 12 MONTHS, has this person given
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
birth to any children?
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
Yes
Yes
50 or 60 percent
No
No ➔ SKIP to question 26
70 percent or higher
§.2i[¤
ACS-1(2017)PR, Page 25, Base (Black)
25
ACS-1(2017)PR, Page 25, Pantone Purple U (10, 15, 50, 100%)
13177266
Person 5 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address
Development or condominium name
Number and street name
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
d. Name of municipio in Puerto Rico
or U.S. county
e. Enter Puerto Rico or name of U.S. state
or foreign country
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47
Yes ➔ SKIP to question 40
No
35 a. LAST WEEK, was this person on layoff from
50 to 52 weeks
a job?
Yes ➔ SKIP to question 35c
48 to 49 weeks
No
40 to 47 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
Within the past 12 months
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
f. ZIP Code
days?
this person work 50 or more weeks? Count
paid time off as work.
Yes
No, outside the city/town limits
38 When did this person last work, even for a few
39 a. During the PAST 12 MONTHS (52 weeks), did
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
No, because of all other reasons (in school, etc.)
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
27 to 39 weeks
14 to 26 weeks
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
Yes ➔ SKIP to question 37
No
Taxicab
26
§.2ic¤
ACS-1(2017)PR, Page 26, Base (Black)
ACS-1(2017)PR, Page 26, Pantone Purple U (10, 15, 50, 100%)
13177274
Person 5 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, municipio, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
No
Name of company, business, or other employer
43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
$
,
,
No
$
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
Yes ➔
$
No
,
,
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
TOTAL AMOUNT for past
12 months
Loss
OR
None
44 Is this mainly – Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
No
$
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
Yes ➔
.00
,
TOTAL AMOUNT for past
12 months
Yes ➔
a Federal GOVERNMENT employee?
working WITHOUT PAY in family business
or farm?
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Now continue with the mailing instructions
on page 28.
§.2ik¤
ACS-1(2017)PR, Page 27, Base (Black)
27
ACS-1(2017)PR, Page 27, Pantone Purple U (10, 15, 50, 100%)
13177282
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ Then...
• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the Puerto Rico Community Survey.
For Census Bureau Use
POP
EDIT
EDIT CLERK
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810 and 0607-0936,
U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810 and 0607-0936" as the subject. Please
DO NOT RETURN your questionnaire to this address.
Use the enclosed preaddressed envelope to return your
completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2017)PR (05-04-2016)
28
§.2is¤
ACS-1(2017)PR, Page 28, Base (Black)
ACS-1(2017)PR, Page 28, Pantone Purple U (15, 50, 100%)
| File Type | application/pdf |
| File Modified | 2018-06-07 |
| File Created | 2016-05-18 |