ACS Methods Panel

Attachments D- ACS Third Mailing (Questionnaire Package)
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Attachment D1 - ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
Attachment D2 - ACS-14(L)SM(2013)(6-2013), ACS Follow-up Letter
Attachment D3 - ACS-34RM(04-04-2014), ACS Instruction Card
Attachment D4 - 6385_47(2014)(10-2013), ACS Return Envelope
Attachment D5 - ACS-10SM(2015)(6-2014), ACS FAQ Brochure
Attachment D6 - ACS-30(2015)(5-2014), ACS Instruction Guide Booklet
Attachment D7 - ACS-46(2012)(5-2011), ACS Stateside Outgoing
Envelope

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195011

DC

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

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

➜

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 may contact you if there is a question.
Last Name

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.

MI

First Name

Area Code + Number
If you need help or have questions
about completing this form, please call
1-800-354-7271. 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 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

ACS-1(2015)

FORM
(06-17-2014)

§.4S,¤
ACS-1(2015), Page 1, Base (Black)

ACS-1(2015), Page 1, Green Pantone 354 (18 & 100%)

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

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195029

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

§.4S>¤
ACS-1(2015), Page 2, Base (Black)

ACS-1(2015), Page 2, Green Pantone 354 (18 & 100%)

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

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195037

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

§.4SF¤
ACS-1(2015), Page 3, Base (Black)

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

3
ACS-1(2015), Page 3, Green Pantone 354 (18 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195045

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)

§.4SN¤
ACS-1(2015), Page 4, Base (Black)

MI

ACS-1(2015), Page 4, Green Pantone 354 (18 & 100%)

MI

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195052

Housing
➜

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

A

8 Does this house, apartment, or mobile

Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.

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

b. a flush toilet?

4 How many acres is this house or

c. a bathtub or shower?
d. a sink with a faucet?

Less than 1 acre ➔ SKIP to question 6

e. a stove or range?

1 to 9.9 acres

f. a refrigerator?

10 or more acres

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

5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?

A building with 3 or 4 apartments

None

A building with 5 to 9 apartments

$1 to $999

A building with 10 to 19 apartments

$1,000 to $2,499

A building with 20 to 49 apartments

$2,500 to $4,999

A building with 50 or more apartments

$5,000 to $9,999

Boat, RV, van, etc.

$10,000 or more

9 At this house, apartment, or mobile home –
do you or any member of this household
own or use any of the following computers?
• EXCLUDE GPS devices, digital music players,
and devices with only limited computing
capabilities, for example: household
appliances.
Yes
No
a. Desktop, laptop, netbook, or
notebook computer
b. Handheld computer,
smart mobile phone, or other
handheld wireless computer
c. Some other type of computer
Specify

6 Is there a business (such as a store or
2

About when was this building first built?
2000 or later – Specify year

barber shop) or a medical office on
this property?
Yes

10 At this house, apartment, or mobile home –

No
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

No

a. hot and cold running water?

mobile home on?

1

Yes

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

7 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.

Yes, with a subscription to an Internet
service
Yes, without a subscription to an Internet
service ➔ SKIP to question 12

No Internet access at this house, apartment,
or mobile home ➔ SKIP to question 12
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies, 11 At this house, apartment, or mobile home –
foyers, halls, or unfinished basements.
do you or any member of this household
subscribe to the Internet using –
Number of rooms
Yes
No
a. Dial-up service?

3

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

Year

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

c. Cable modem service?
d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite Internet service?
g. Some other service?
Specify service

§.4SU¤
ACS-1(2015), Page 5, Base (Black)

5
ACS-1(2015), Page 5, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195060

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

14 a. LAST MONTH, what was the cost
of electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars

$

.00

,

None

OR

1

any member of this household receive
benefits from the Food Stamp Program
or SNAP (the Supplemental Nutrition
Assistance Program)? Do NOT include
WIC, the School Lunch Program, or
assistance from food banks.
Yes

Included in rent or condominium fee

2

15 IN THE PAST 12 MONTHS, did you or

No

No charge or electricity not used

16 Is this house, apartment, or mobile home

3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?

4
5

Last month’s cost – Dollars

6 or more

$

.00

,

house, apartment, or mobile home?

Monthly amount – Dollars

Included in rent or condominium fee

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

Wood
Solar energy
Other fuel

$

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

Electricity

Coal or coke

Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.

OR

13 Which FUEL is used MOST for heating this

Fuel oil, kerosene, etc.

part of a condominium?

c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
Past 12 months’ cost – Dollars

$

.00

,
OR

No fuel used

Included in rent or condominium fee
No charge
d. IN THE PAST 12 MONTHS, what was the
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
home? If you have lived here less than 12
months, estimate the cost.

OR
None
No

17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented?
Occupied without payment of
rent? ➔ SKIP to C on the next page

Past 12 months’ cost – Dollars

$

.00

,
OR

Included in rent or condominium fee
No charge or these fuels not used

6

§.4S]¤
ACS-1(2015), Page 6, Base (Black)

.00

,

ACS-1(2015), Page 6, Green Pantone 354 (18 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195078

Housing (continued)
B

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

22 a. Do you or any member of this

23 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?

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

18 a. What is the monthly rent for this
house, apartment, or mobile home?

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

Yes, home equity loan

No ➔ SKIP to question 23a

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

Yes, second mortgage

Monthly amount – Dollars

$

.00

,

b. Does the monthly rent include any
meals?

No

19 About how much do you think this
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?

.00

,

20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars

$

,

$

.00

OR

No regular payment required ➔ SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?

,

No regular payment required

D

Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required

Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .

24 What are the total annual costs for

Amount – Dollars

,

Monthly amount – Dollars

.00

,
OR

Answer questions 19 – 23 if you or any
member of this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .

$

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

Monthly amount – Dollars

$

Yes

C

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

personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.

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

Annual costs – Dollars

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

$

,

.00

.00
E

OR
None

Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.

21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars

$

.00

,
OR
None

§.4So¤
ACS-1(2015), Page 7, Base (Black)

7
ACS-1(2015), Page 7, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195086

Person 1

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

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

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Doctorate degree (for example: PhD, EdD)

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

F

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

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

Very well
Well
Not well
Not at all

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

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

Name of U.S. state or
Puerto Rico

program, or medical or law school)

8

§.4Sw¤
ACS-1(2015), Page 8, Base (Black)

ACS-1(2015), Page 8, Green Pantone 354 (10, 18, 50 & 100%)

ZIP Code

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195094

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 Has this person given birth to any children in

January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

the past 12 months?

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?

No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?

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?

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

§.4S¡¤
ACS-1(2015), Page 9, Base (Black)

9
ACS-1(2015), Page 9, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195102

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?

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

Person(s)

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
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

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

to go to work LAST WEEK?
a.m.
p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes

b. Name of city, town, or post office

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

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

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

K

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

Yes

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

No, outside the city/town limits

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

d. Name of county

a job?

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

50 to 52 weeks

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?
f. ZIP Code

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

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

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ACS-1(2015), Page 10, Base (Black)

ACS-1(2015), Page 10, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195110

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, 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.

§.4T+¤
ACS-1(2015), Page 11, Base (Black)

11
ACS-1(2015), Page 11, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195128

Person 2

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

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

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Doctorate degree (for example: PhD, EdD)

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

F

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

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

Very well
Well
Not well
Not at all

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

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

Name of U.S. state or
Puerto Rico

program, or medical or law school)

12

§.4T=¤
ACS-1(2015), Page 12, Base (Black)

ACS-1(2015), Page 12, Green Pantone 354 (10, 18, 50 & 100%)

ZIP Code

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195136

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 Has this person given birth to any children in

January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

the past 12 months?

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?

No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?

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?

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

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13
ACS-1(2015), Page 13, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195144

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?

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

Person(s)

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
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

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

to go to work LAST WEEK?
a.m.
p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes

b. Name of city, town, or post office

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

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

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

K

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

Yes

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

No, outside the city/town limits

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

d. Name of county

a job?

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

50 to 52 weeks

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?
f. ZIP Code

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

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

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Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195151

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, 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.

§.4TT¤
ACS-1(2015), Page 15, Base (Black)

15
ACS-1(2015), Page 15, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195169

Person 3

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

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

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Doctorate degree (for example: PhD, EdD)

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

F

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

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

Very well
Well
Not well
Not at all

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

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

Name of U.S. state or
Puerto Rico

program, or medical or law school)

16

§.4Tf¤
ACS-1(2015), Page 16, Base (Black)

ACS-1(2015), Page 16, Green Pantone 354 (10, 18, 50 & 100%)

ZIP Code

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195177

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.

c. How long has this grandparent been
responsible for these grandchildren?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
Attachment D1 -- ACS-1(2015)(06-17-2014),
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

6 to 11 months

ACS
Questionnaire
1 or 2Stateside
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

Less than 6 months

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 Has this person given birth to any children in

January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

the past 12 months?

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?

No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?

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?

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

§.4Tn¤
ACS-1(2015), Page 17, Base (Black)

17
ACS-1(2015), Page 17, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195185

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?

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

Person(s)

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
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

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

to go to work LAST WEEK?
a.m.
p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes

b. Name of city, town, or post office

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

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

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

K

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

Yes

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

No, outside the city/town limits

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

d. Name of county

a job?

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

50 to 52 weeks

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?
f. ZIP Code

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

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

§.4Tv¤
ACS-1(2015), Page 18, Base (Black)

ACS-1(2015), Page 18, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195193

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, 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

retail trade?
other (agriculture, construction, service,
government, etc.)?

TOTAL AMOUNT for past
12 months

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Continue with the questions for Person 4 on
the next page. If no one is listed as Person 4 on
page 3, SKIP to page 28 for mailing instructions.

§.4T~¤
ACS-1(2015), Page 19, Base (Black)

.00

,

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

manufacturing?
wholesale trade?

$

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.

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.

$

19
ACS-1(2015), Page 19, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195201

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 name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

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

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Doctorate degree (for example: PhD, EdD)

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

F

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

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

Very well
Well
Not well
Not at all

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

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

Name of U.S. state or
Puerto Rico

program, or medical or law school)

20

§.4U"¤
ACS-1(2015), Page 20, Base (Black)

ACS-1(2015), Page 20, Green Pantone 354 (10, 18, 50 & 100%)

ZIP Code

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195219

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 Has this person given birth to any children in

January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

the past 12 months?

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?

No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?

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?

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

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21
ACS-1(2015), Page 21, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195227

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?

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

Person(s)

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
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

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

to go to work LAST WEEK?
a.m.
p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes

b. Name of city, town, or post office

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

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

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

K

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

Yes

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

No, outside the city/town limits

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

d. Name of county

a job?

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

50 to 52 weeks

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?
f. ZIP Code

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

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

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ACS-1(2015), Page 22, Base (Black)

ACS-1(2015), Page 22, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195235

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, 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.

§.4UD¤
ACS-1(2015), Page 23, Base (Black)

23
ACS-1(2015), Page 23, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195243

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 name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

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

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Doctorate degree (for example: PhD, EdD)

10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?

F

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

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

Very well
Well
Not well
Not at all

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

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

Name of U.S. state or
Puerto Rico

program, or medical or law school)

24

§.4UL¤
ACS-1(2015), Page 24, Base (Black)

ACS-1(2015), Page 24, Green Pantone 354 (10, 18, 50 & 100%)

ZIP Code

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195250

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 Has this person given birth to any children in

January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

the past 12 months?

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?

No ➔ SKIP to question 29a
b. What is this person’s service-connected
disability rating?

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?

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

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ACS-1(2015), Page 25, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195268

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?

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

Person(s)

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
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

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

to go to work LAST WEEK?
a.m.
p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes

b. Name of city, town, or post office

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

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

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

K

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

Yes

Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

No, outside the city/town limits

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

d. Name of county

a job?

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

50 to 52 weeks

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?
f. ZIP Code

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

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

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Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195276

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, 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.

§.4Um¤
ACS-1(2015), Page 27, Base (Black)

27
ACS-1(2015), Page 27, Green Pantone 354 (10, 18, 50 & 100%)

Attachment D1 -- ACS-1(2015)(06-17-2014), ACS Stateside Questionnaire
13195284

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 American 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(2015) (06-17-2014)

28

§.4Uu¤
ACS-1(2015), Page 28, Base (Black)

ACS-1(2015), Page 28, Green Pantone 354 (18, 50 & 100%)

Attachment D2 -- ACS-14(L)SM(2013)(6-2013), ACS Follow-up Letter

ACS-14(L)SM (2013)
(6-2012)

DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

A message from the Director, U.S. Census Bureau...
About two weeks ago, the U.S. Census Bureau sent instructions for completing the American
Community Survey to your address. We asked you to help us with this very important survey by
completing it online. But we have not received your response yet.
If you have already completed the survey, thank you very much. If you have not, please complete
the survey soon using ONE of the following two options.
Option 1: Go to https://respond.census.gov/acs to complete the survey online.
Option 2: Fill out and mail back the enclosed questionnaire.
This survey is so important that a Census Bureau representative may attempt to contact you by
telephone or personal visit if we do not receive your response.
The information collected in this survey will help decide where new schools, hospitals, and fire
stations are needed. The information also is used to develop programs to reduce traffic
congestion, provide job training, and plan for the health care needs of the elderly.
The Census Bureau chose your address, not you personally, as part of a randomly selected
sample. You are required by U.S. law to respond to this survey. The Census Bureau is required by
U.S. law to keep your answers confidential. The enclosed brochure answers frequently asked
questions about the survey.
If you need help completing the survey, please use the enclosed guide or call our toll–free
number (1–800–354–7271).
Thank you.

Enclosures

census.gov

Attachment D3 -- ACS-34RM(04-04-2014), ACS Instruction Card

American Community Survey
U.S. Department of Commerce | Economics and Statistics Administration

Hay dos maneras para completar la Encuesta sobre la Comunidad
Estadounidense:
Opción 1 – Vaya a https://respond.census.gov/acs para completar la encuesta por Internet en
español. ATENCIÓN: Necesitará información que aparece en la etiqueta del cuestionario adjunto
para iniciar la sesión.

Opción 2 – Llene y devuelva por correo el cuestionario adjunto en el sobre de envío incluido.
Por favor, escoja SOLAMENTE una manera de responder. Si usted necesita ayuda para llenar la encuesta o tiene
preguntas acerca de la Encuesta sobre la Comunidad Estadounidense, llame sin cargo al 1-877-833-5625.
See other side for English.
ACS-34RM (04/04/2013)

ACS-34 RM (04_04_2013).indd 1

7/24/2013 5:28:31 PM

Attachment D3 -- ACS-34RM(04-04-2014), ACS Instruction Card

American Community Survey
U.S. Department of Commerce | Economics and Statistics Administration

Two Ways to Complete the American Community Survey:
Option 1 – Go to https://respond.census.gov/acs to complete the survey online. IMPORTANT: You
will need information from the address label on the enclosed questionnaire to log in.

Option 2 – Fill out the enclosed questionnaire and mail it back in the postage-paid envelope.

Please choose ONLY one way to respond. If you need help or have questions about the American Community Survey,
call the toll-free number 1–800–354–7271.
Vea el otro lado para español.
ACS-34RM (04/04/2013)

ACS-34 RM (04_04_2013).indd 2

7/24/2013 5:28:31 PM

Attachment D4 -- 6385_47(2014)(10-2013), ACS Return Envelope

C

AN EQUAL OPPORTUNITY EMPLOYER

OFFICIAL BUSINESS
Penalty for Private Use $300

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

6385-47(2014) (10-2013)

BUSINESS REPLY MAIL
FIRST-CLASS MAIL

PERMIT NO. 16081

WASHINGTON DC

POSTAGE WILL BE PAID BY THE U.S. CENSUS BUREAU

DIRECTOR
US CENSUS BUREAU
PO BOX 5240
JEFFERSONVILLE IN 47199-5240

FFATTFADDDTAADTFADDFAFTDFFAADFFFAFDTFDTAFATFDFATADTTFDFDTFFFFATTF

Attachment D5 -- ACS-10SM(2015)(6-2014), ACS FAQ Brochure

Frequently Asked
Questions

census.gov/acs
1-800-354-7271

AMERICAN
COMMUNITY
SURVEY

American
Community
Survey
Si necesita ayuda para completar su cuestionario,
llame sin cargo alguno al: 1-877-833-5625.

Issued June 2014
ACS-10SM(2015)

U.S. Department of Commerce
Economics and Statistics Administration
U.S. CENSUS BUREAU

census.gov

ACS-10SM(2015)(EG)_June2014.indd 1

6/24/2014 10:55:59 AM

Attachment D5 -- ACS-10SM(2015)(6-2014), ACS FAQ Brochure

Frequently Asked Questions
What is the American Community Survey?
The American Community Survey collects information
about population and housing characteristics for the
nation, states, cities, counties, metropolitan areas, and
communities on a continuous basis. Based on the
American Community Survey, the Census Bureau can
provide up-to-date data about our rapidly changing
country more often than once every 10 years when the
census is conducted.

How do I benefit by answering the
American Community Survey?
Communities need data about the well-being of children,
families, and the older population to provide services to
them. By responding to the American Community Survey
questionnaire, you are helping your community to
establish goals, identify problems and solutions, and
measure the performance of programs.
The data are also used to decide where to locate new
highways, schools, hospitals, and community centers; to
show a large corporation that a town has the workforce
the company needs; and in many other ways.

ACS-10SM(2015)(EG)_June2014.indd 2

Do I have to answer the questions on the
American Community Survey?
Yes. Your response to this survey is required by law
(Title 13, U.S. Code, Sections 141,193, and 221). Title 13,
as changed by Title 18, imposes a penalty for not
responding. We estimate this survey will take about 40
minutes to complete.

How will the Census Bureau use the
information that I provide?
The Census Bureau can use the information you provide
for statistical purposes only and cannot publish or release
information that would identify you and your household.
Your information will be used in combination with
information from other households to produce data for
your community. Similar data will be produced for
communities across the United States.

Will the Census Bureau keep my
information confidential?
Yes. All of the information the Census Bureau collects
for this survey about you and your household is
confidential by law (Title 13, U.S. Code, Section 9). By
law, every Census Bureau employee—including the
Director as well as every field representative—has taken
an oath and is subject to a jail term, a fine, or both if he
or she discloses ANY information that could identify you
or your household.

Where can I find more information about
the American Community Survey or get
assistance?
You may visit our Web site census.gov/acs
or call 1-800-354-7271 if you need assistance or more
information.

We may combine your answers with information that
you gave to other agencies to enhance the statistical
uses of these data. This information will be given the
same protections as your survey information. Based on
the information that you provide, you may be asked to
participate in other Census Bureau surveys that are
voluntary.

6/24/2014 10:56:00 AM

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide
Booklet Draft #4 (5-13-2014)

Your Guide for

THE

American
Community
Survey

This guide gives helpful information on
completing your survey form. If you need more
help, call 1–800–354–7271. The telephone call is
free. After you have completed your survey
form, please return it in the postage-paid
envelope we have provided.

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

ACS-30(2015)
(5-2014)

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Page

Your Answers are Confidential
and Required by Law

2

How to Fill Out the
American Community Survey Form

3

Examples of Printed
and Marked Entries

3

Instructions for Completing
the Survey Question

3

What the Survey is
About – Some Questions
and Answers

16

Why the Census Bureau
Asks Certain Questions

16

Your Answers are Confidential and Required by Law
The law, Title 13, Sections 9, 141, 193, and 221 of the U.S. Code,
authorizing the American Community Survey, also provides that
your answers are confidential. No one except Census Bureau
employees may see your completed form and they can be fined
and/or imprisoned for any disclosure of your answers.
The same law that protects the confidentiality of your answers
requires that you provide the information asked in this survey
to the best of your knowledge.

ACS-30(2015) (5-2014)

Page 2

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

How to fill out the American Community Survey form
Use blue or black ink to complete the form. Please mark the category or
categories as they apply to your household. Some questions ask you to
print the information. See examples below.
Make sure you answer questions for each person in this household. If
anyone in the household, such as a roomer or boarder, does not want to
give you his or her personal information, print at least the person’s name
and answer questions 2 and 3. An interviewer may telephone to get
the information from that person.
There may be a question you cannot answer exactly. For example, you
may not know the age of an older person or the price for which your
house would sell. Ask someone else in your household; if no one knows,
give your best estimate.
Read these instructions and also follow the instructions provided
throughout the questionnaire. These instructions will help you understand
the questions and to answer them correctly. If you need assistance, call
1–800–354–7271. The telephone call is free.

Examples of printed and marked entries
14

a. Does this person speak a language other than
English at home?

X

Yes

No ➜ SKIP to question 15a

b. What is this language?

Korean
For example: Korean, Italian, Spanish, Vietnamese

23 In what year did this person last get married?
Year

2 0 0 8
Instructions for completing the survey questions
List the name of each person who lives at this address. If you are not sure
if you should list a person, see the guidelines on the front page of the
form. If you are still not sure, call 1–800–354–7271 for help.
In the space labeled Person 1, print the name of the household member
living or staying here in whose name the house or apartment is owned,
being bought, or rented.
If there is no such person, any adult household member can be Person 1.
If there are more than 5 people in your household, please provide the
name of each additional person on page 4. For each additional person
listed on page 4, you should also provide this person’s sex and age.
Complete this form for the first five people listed on pages 2, 3, and 4, and
mail it back in the enclosed envelope as soon as possible. An interviewer
may telephone to obtain information for the additional persons.
If no one is living or staying at this address for more than 2 months,
complete questions 1, 2, 4, 6, 7, and 8 on page 5. If the home is for rent or
rented, but not yet occupied, also complete question 18 on page 7. If the
home is for sale only or sold, but not yet occupied, also complete question
19 on page 7.

ACS-30(2015) (5-2014)

Page 3

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Answer person questions 1 through 6 for the first five people
listed on pages 2, 3, and 4 of the questionnaire.
1. Print the person’s Last Name, First Name, and Middle Initial (MI) in
the spaces provided.
2. If the person is related to Person 1 by birth, marriage, or adoption,
but is not the "Husband or wife," "Biological son or daughter,"
"Adopted son or daughter," "Stepson or stepdaughter,"
"Brother or sister," "Father or mother," "Grandchild,"
"Parent-in-law," "Son-in-law or daughter-in-law," of Person 1,
mark the "Other relative" box. Therefore, a niece or nephew of
Person 1 would be categorized as "Other relative."
If a person is not related to Person 1, mark the applicable box. A
"Roomer or boarder" is someone who occupies room(s) and makes
cash or non-cash payment(s). A "Housemate or roommate" is
someone sharing the house/apartment (but who is not romantically
involved) with Person 1. A "Housemate or roommate" is also 15
years old or over and shares living quarters primarily to share
expenses. An "Unmarried partner," also known as a domestic
partner, is a person who shares a close personal relationship with
Person 1. A "Foster child" is someone under the age of 21 who is
involved in the formal foster care system. For all other people who are
not related to person 1, mark the "Other nonrelative" box.
3. Mark one box to indicate this person’s biological sex.
4. For each person, print this person’s age and month, day, and year of
birth. Print the age at the last birthday. Do not round the age up if
this person is close to having a birthday. If the exact age is not known,
provide an estimate. Print "0" for babies less than 1 year old.
Please answer BOTH question 5 about Hispanic origin and
question 6 about race. For this survey, Hispanic origins are not
races.
5. A person is of Hispanic, Latino, or Spanish origin if the person’s origin
(ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban,
Argentinean, Colombian, Costa Rican, Dominican, Ecuadorian,
Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other
Spanish-speaking countries of Central or South America or from Spain.
The term Mexican Am. refers to persons of Mexican-American origin or
ancestry.
If you mark the "Yes, another Hispanic, Latino, or Spanish origin"
box, print the name of the specific origin.
If a person is not of Hispanic, Latino, or Spanish origin, answer this
question by marking the "No, not of Hispanic, Latino, or Spanish
origin" box.
This question should be answered for all persons.
6. Mark all boxes for the appropriate races.
The concept of race, as used by the Census Bureau, reflects
self-identification by individuals according to the race or races with
which they identify.
The instruction before question 5, For this survey, Hispanic origins are
not races, reflects the federal government’s treatment of Hispanic origin
and race as separate and distinct concepts. People who identify their
origin as Hispanic, Latino, or Spanish may be of any race.
People may choose to provide two or more races either by marking two
or more race response boxes, by providing multiple write-in responses, or
by some combination of marking boxes and writing in responses.
If you mark the "American Indian or Alaska Native" box, print the
name of the person’s enrolled or principal tribe(s) in the space
provided (for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat
Traditional Government, and so on).

ACS-30(2015) (5-2014)

Page 4

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

If you mark the "Other Asian" box, print the name of the specific
Asian group(s) in the space provided (for example, Pakistani,
Cambodian, Hmong, Thai, Laotian, Bangladeshi, and so on).
If you mark the "Other Pacific Islander" box, print the name of the
specific Pacific Islander group(s) in the space provided (for example,
Tongan, Fijian, Marshallese, Palauan, Tahitian, Papua New Guinean,
and so on).
If you mark the "Some other race" box, print the race(s) or group(s)
in the space provided.
This question should be answered for all persons.
Answer housing questions 1 through 24 for the house,
apartment, or mobile home at the address on the mailing label.
1.

Mark only one category.
Count both occupied and vacant apartments in the house or building.
Do not count stores or office space.
Detached means there is open space on all sides, or the house is joined
only to a shed or garage. Attached means that the house is joined to
another house or building by at least one wall that goes from ground
to roof. An example of "A one-family house attached to one or
more houses" is a house in a row of houses attached to one another,
sometimes referred to as a townhouse.
A mobile home that has had one or more rooms added or built onto it
should be considered as "A one-family house detached from any
other house." If only a porch or shed has been added to a mobile
home, it should be considered as a mobile home.
Towable RVs, such as travel trailers or fifth-wheel trailers, should be
considered as "A mobile home." Self-propelling RVs or motorhomes
should be considered as a "Boat, RV, van, etc."

2.

Mark the box that corresponds to the year in which the original
construction was completed, not the time of any later
remodeling, additions, or conversions.
If the building was first built in 2000 or later, enter the exact year it
was built.
If you live on a boat or in a mobile home, enter the year corresponding
to the model year in which it was manufactured.
If you do not know the year the building was first built, give your best
estimate.

3.

Enter the month and year that Person 1 listed on page 2 last
moved into this house, apartment, or mobile home.

4.

Complete this question if you live in a one-family house or in a
mobile home; include only land that you own or rent.
The number of acres is the acreage on which the house or mobile home
is located; include adjoining land you rent for your use.

6.

Complete this question if you live in a one-family house or mobile
home. A business, such as a grocery store or barber shop, is easily
recognized from the outside and usually has a separate entrance.
A medical office is a doctor’s or dentist’s office regularly visited by
patients.

ACS-30(2015) (5-2014)

Page 5

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

7b. Include all rooms intended to be used as bedrooms in this house,
apartment, or mobile home, even if they are currently being used for other
purposes.
Enter "0" for an efficiency or studio apartment that does not have a
separate bedroom. Your response to question 7b should be smaller than
the number of rooms reported in question 7a.
8a. Mark "Yes" to "hot and cold running water" even if the unit has hot
water only part of the time.
8d. Mark "Yes" to "sink with a faucet" if the sink is inside the house,
apartment or mobile home and the water can be turned on and off with a
faucet.
8e. Mark "Yes" to "a stove or range" if the stove or range is inside the
house, apartment or mobile home. Portable cooking equipment is not
considered a stove or range.
8g. Mark "Yes" to "telephone service ..." if (1) there is a telephone in
working order, and someone receives service at this house, apartment, or
mobile home; or (2) if someone has a cell phone from which you can both
make and receive calls. If service has been discontinued because of
nonpayment or any other reason, mark the "No" box.
9.

Mark the "Yes" or "No" box for each part of question 9.
DO NOT include devices such as portable book readers, Internet movie
players, portable gaming devices, and other devices with limited
computing capabilities.
Desktop, laptop, netbook, or notebook computer are types of
computers that operate primarily with a keyboard.
"Handheld computer, smart mobile phone, or other handheld
wireless computer" are types of computers that can be used by holding
in one hand. Some handheld computers, such as smartphones, are able to
make phone calls while others cannot.
"Some other type of computer" are devices with advanced capabilities,
such as tablet computers. These devices often feature “touch screen”
operations and have applications that allow them to function like a
desktop or a laptop computer.

10.

Mark only one box.
Access to the Internet with a subscription to an Internet service includes
any service that any member of the household obtains directly through a
contract agreement with an Internet service provider, or through payments
to a landlord, the government, or someone else. Access to the Internet
without a subscription to an Internet service includes services that do not
require an account or contract agreement.

11.

Mark the "Yes" or "No" box for each part of question 11.
"Dial-up service" is a type of Internet service that uses a regular
telephone line to connect to the Internet. "DSL service" is a broadband
Internet service that uses a regular telephone line and, unlike dial-up,
allows users to be online and use the phone at the same time. "Cable
modem service" is a broadband Internet service that uses a cable TV line.
"Fiber-optic service" is a broadband Internet service that uses a
fiber-optic line. "Mobile broadband plan for a computer or a cell
phone" include wireless broadband Internet service that can be accessed
through a portable modem in a computer or cell phone. "Satellite
Internet service" is a broadband Internet service that uses a satellite dish.

12.

Include company cars, vans or SUVs (including police cars and taxicabs) and
company trucks of one-ton (2,000 pounds) capacity or less that are
regularly kept at home are used by household members for nonbusiness
purposes. DO NOT count (1) cars or trucks permanently out of working
order, or (2) motorcycles or other recreational vehicles.

13.

Mark one category for the fuel used MOST to heat this house, apartment,
or mobile home. In buildings containing more than one apartment, you
may obtain this information from the owner, manager, or janitor.
"Solar energy" is provided by a system that collects, stores, and
distributes heat from the sun. "Other fuel" includes any fuel not listed
separately, such as purchased steam, fuel briquettes, and waste material.

ACS-30(2015) (5-2014)

Page 6

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

14a–14d.
If your house, apartment, or mobile home is rented, enter the costs for
utilities and fuels only if you pay for them in addition to the
monthly rent.
If you live in a condominium, enter the costs for utilities and fuels only
if you pay for them in addition to your condominium fee.
If your fuel and utility costs are included in your rent or condominium
fee, mark the "Included in rent or condominium fee" box.
DO NOT enter any dollar amounts.
For items 14a and 14b, report LAST MONTH’S costs. For items 14c
and 14d, report total costs for the PAST 12 MONTHS.
Estimate as closely as possible if you do not know exact costs. If you
have lived in this house, apartment, or mobile home less than one year,
estimate the costs for the PAST 12 MONTHS in 14c and 14d.
Report amounts even if your bills are unpaid or paid by someone
else. If the bills include utilities or fuel used also by another
apartment or a business establishment, estimate the amounts for
your house or apartment only. If gas and electricity are billed together,
enter the combined amount in 14a and mark the "Included in
electricity payment entered above" box in 14b.
15.

On October 1, 2008, the federal Food Stamp Program was
renamed SNAP (Supplemental Nutrition Assistance Program).
Some states may have their own specific name for this program. If
you or any member of this household received benefits from the
government to buy food for your family using a benefit card,
mark the "Yes" box.

16.

A condominium is housing in which the apartments, houses, or
mobile homes in a building or development are individually owned,
but the common areas, such as lobbies and halls, are jointly owned.
Occupants of a cooperative should mark the "No" box.
A condominium fee is normally assessed by the condominium owners’
association for the purpose of improving and maintaining the common
areas. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see the
instruction for question 18a on how to change it to a monthly amount.

17.

Housing is owned if the owner or co-owner lives in it.
If the house, apartment, or mobile home is mortgaged or there is a
contract to purchase, mark the "Owned by you or someone in this
household with a mortgage or loan? Include home equity
loans." If there is no mortgage or other debt, mark the "Owned by
you or someone in this household free and clear (without a
mortgage or loan)?" box. If the house, apartment, or mobile home is
owned but the land is rented, mark one of the owned categories. If the
mobile home is owned without an installment loan, but there is a
mortgage on the land, mark the "Owned by you or someone in this
household with a mortgage or loan? Include home equity
loans." box.
If any money rent is paid, even if the rent is paid by people who are
not members of your household, or paid by a federal, state, or local
government agency, mark the "Rented?" box.
If the unit is not owned or being bought by a member of this
household and if money rent is not paid or contracted, mark the
"Occupied without payment of rent?" box. The unit may be owned
by friends or relatives who live elsewhere and who allow you to occupy
this house, apartment, or mobile home without charge. A house or
apartment may be provided as part of wages or salary. Examples are:
caretaker’s or janitor’s house or apartment; parsonages; tenant farmer
or sharecropper houses for which the occupants do not pay rent; or
military housing.

ACS-30(2015) (5-2014)

Page 7

Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

18a. Report the rent agreed to or contracted for, even if the rent for your
house, apartment, or mobile home is unpaid or paid by someone else.
If rent is paid:

Multiply
rent by:

By the day . . . . . . . . 30
By the week . . . . . . . 4
Every other week . . . 2

If rent is paid:

Divide
rent by:

4 times a year . . . . . . . 3
2 times a year . . . . . . 6
Once a year . . . . . . . . 12

18b. If meals are included in the monthly rent payment, or you must
contract for meals or a meal plan in order to live in this house,
apartment, or mobile home, mark the "Yes" box.
Answer housing questions 19 through 23 if you or any member of
this household owns or is buying this house, apartment, or
mobile home.
19.

Enter your best estimate of the value of the property; that is, how
much you think the property would sell for if it were on the market.
If this is a house, include the value of the house, the land it is on,
and any other structures on the same property. If the house is
owned but the land is rented, estimate the combined value of the
house and the land. If this is a condominium unit, estimate the value
for the condominium, including your share of the common
elements. If this is a mobile home, include the value of the mobile
home and the value of the land only if you own the land.

20.

Report taxes for all taxing jurisdictions (city or town, county,
state, school district, etc.) even if they are included in your
mortgage payment, not yet paid or paid by someone else, or are
delinquent. DO NOT include taxes past due from previous years.

21.

When premiums are paid other than on a yearly basis, convert to
a yearly basis. Enter the yearly amount even if no payment was
made during the past year.

22a. Mortgages includes all types of loans secured by real estate, including
reverse mortagages.
22b. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see the
instructions for 18a to change it to a monthly amount.
Include payments on first mortgages and contracts to purchase only.
Report payments for second or junior mortgages and home equity
loans in 23b.
If there is a reverse mortgage, mark the “No regular payment
required” box.
If this is a mobile home, report payments on installment loans but
do not include personal property taxes, site rent, registration fees, and
license fees on the mobile home and site. Report these fees in item 24.
23a. A second mortgage or home equity loan is also secured by real estate.
You must have a first mortgage in order to have a second mortgage.
You may have a home equity loan and other mortgages on the
property or the home equity loan may be the only mortgage.
23b. Enter the monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see
instructions for 18a to change it to a monthly amount. Include
payments on all second or junior mortgages or home equity loans.
Answer housing question 24 if this is a moblie home that you
own or are buying.
24.

Report an amount even if your bills are unpaid or are paid
by someone else.
Include payments for personal property taxes, land or site rent,
registration fees and license fees. DO NOT include real estate taxes
already reported in 20. Report the total annual amount even if you
make payments in two or more installments. Estimate as closely as
possible if you don’t know exact costs.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Answer person questions 7 through 17 for all persons on pages 2, 3,
and 4.
Questions 7 – 48 are a continuation of the questions for each person. (Questions
1 – 6 appear on pages 2, 3, and 4 of the questionnaire.)
7. For people born in the United States:
Mark the "In the United States" box and then print the name of the state in
which the person was born. If the person was born in Washington, D.C., print
"District of Columbia."
For people born outside the United States:
Mark the "Outside the United States" box, and then print the name of the
foreign country or Puerto Rico, Guam, etc. where the person was born. Use
current boundaries, not boundaries at the time of the person’s birth. For
example, specify Czech Republic or Slovakia, not Czechoslovakia; North or
South Korea, not Korea. Specify the particular country, not region. For
example, specify Jamaica, not West Indies; Kenya, not East Africa.
8. If the person was born in the United States (50 states and the District of
Columbia), mark the "Yes, born in the United States" box. If the person
was born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas,
mark the "Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas" box. Although not listed, if the person was born in
American Samoa, mark "Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas" box. If the person was born outside the
United States (50 states and the District of Columbia) or at sea and had at
least one parent who was a U.S. citizen at the time of the person’s birth,
mark the "Yes, born abroad of U.S. citizen parent or parents" box. Mark
the "Yes, U.S. citizen by naturalization" box only if this person was born
outside the United States (50 states and the District of Columbia) and has
completed the naturalization process and is now a United States citizen. In
the box below "Print year of naturalization," enter the four-digit year this
person completed the formal naturalization process. If this person is not a
U.S. citizen, mark the "No, not a U.S. citizen" box. Legal Permanent
Residents (LPRs) or "green card" holders, or other non-naturalized
immigrants or visitors to the U.S. are not citizens of the United States and
therefore should mark the "No, not a U.S. citizen" box.
10a. A public school is any school or college that is supported and controlled
primarily by a local, county, state, or federal government. Schools are
private if supported and controlled primarily by religious organizations
or other private groups. Home school applies to parental guided
education outside of a public or private school for grades 1–12.
10b. Only record grades that the person attended in the LAST 3 MONTHS.
If this is currently a summer month, do not record grades the person
will attend in the future.
11. Mark only ONE box to indicate the highest grade or level of schooling
the person has COMPLETED or the highest degree the person received.
Report schooling completed in foreign or ungraded schools as the equivalent
level of schooling in the regular American school system.
Mark the "GED or alternative credential" box for persons who did not
receive a regular high school diploma but completed high school by receiving
a GED or other formal recognition of high school completion from a school
or governmental authority.
If the person has not completed any college courses for credit, mark the
highest level completed below the college level. If the person has not
completed enough credit to be counted as a sophomore, mark the "Some
college credit, but less than 1 year of college credit" box.
For the "Professional degree beyond a bachelor’s degree" category, do
not include certificates or diplomas for training in specific trades or
occupations such as computer and electronics technology, medical assistant, or
cosmetology. DO NOT include post-bachelor’s certificates that are related to
occupational training in such fields as teaching, accounting, or engineering.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

12. Answer this question only if the person has a bachelor’s degree or
higher and print the specific major of this person’s BACHELOR
DEGREE. If this person has more than one bachelor’s degree or more
than one major, print the names of the specific majors for all of this
person’s bachelor’s degree(s).
13. Print the ancestry group(s). Ancestry refers to the person’s ethnic
origin or descent, "roots," or heritage. Ancestry may also refer to the
country of birth of the person or the person’s parents or ancestors
before their arrival in the United States. Answer this question for ALL
persons, regardless of race, Hispanic origin, or place of birth.
Do not report a religious group as a person’s ancestry.
A person may report two ancestry groups (for example: German, Irish).
14a. Mark the"Yes" box if the person sometimes or always speaks a
language other than English at home.
Mark the "No" box if the person speaks only English, or if a non-English
language is spoken only at school or is limited to a few expressions
or slang.
14b. If this person speaks more than one non-English language and cannot
determine which is spoken more often, report the one the person first
learned to speak.
15a. If the person did not live in the United States or Puerto Rico one year
ago, mark the "No, outside the United States and Puerto Rico"
box and print the name of the foreign country, or U.S. Virgin Islands,
Guam, etc., where the person lived. Be specific when printing the name
of the foreign country; for example, specify Czech Republic or Slovakia,
not Czechoslovakia; North or South Korea, not Korea. Specify the
particular country, not region. For example, specify Jamaica, not West
Indies; Kenya, not East Africa. Then SKIP to question 16.
If the person lived somewhere else in the United States or Puerto Rico
one year ago, mark the "No, different house in the United States
or Puerto Rico" box.
15b. Include the house or structure number; street name; street type (for
example, St., Road, Ave.); and the street direction (if a direction such
as "North" is part of the address). For example, print 1239 N. Main St.
or 1239 Main St., N.W., not just 1239 Main. If the person lived in
Puerto Rico, the address should also include the name of the
development or condominium.
If the only known address is a post office box, give a description of the
residence location. For example, print the name of the building where
the person lived, the nearest intersection, the name of a military base
or installation, or the nearest street where the residence was located,
etc. DO NOT give a post office box number.
Print the name of the U.S. county or the name of the municipio in
Puerto Rico. If the person lived in Louisiana, print the parish name in
the "Name of U.S. county or municipio in Puerto Rico" space. If
the person lived in Alaska, print the borough or census area name, if
known. If the person lived in New York City and the county name is
not known, print the borough name. If the person lived in an
independent city (not in any county) or in Washington, D.C., leave the
"Name of U.S. county or municipio in Puerto Rico" space blank.
16. Mark the "Yes" or "No" box for each part of question 16.
If the person reports any other type of coverage plan in 16h, specify the type
of coverage or name of the plan in the write-in box. DO NOT include plans
that cover only one type of health care (such as dental plans) or plans that only
cover a person in case of an accident or disability.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Answer person questions 18a through 18c if this person is 5 years
old or over.
18a–18c.
Mark the "Yes" or "No" box to indicate if the person has serious difficulty
with any of the activities listed in parts a, b, and c because of a physical,
mental, or emotional condition.
Answer person questions 19 through 48 if this person is 15 years old or
over.
20. Mark the "Now married" box for a married person regardless of whether
his or her spouse is living in the household unless they are separated. If the
person’s only marriage was annulled, mark the "Never married" box.
Mark the “Divorced” box only if the person has received a divorce decree.
21c. Mark the "Yes" box only if the person has received a divorce decree in the
PAST 12 MONTHS.
22. Do not count marriages that ended in annulment.
23. Enter the four-digit year when the person last got married, even if the
person is now widowed, divorced, or separated.
Answer question 24 if this person is female and is 15–50 years old.
24. Mark the "Yes" box if the person has given birth to at least one child born
alive in the PAST 12 MONTHS, even if the child died or no longer lives
with the mother. Do not consider miscarriages, or stillborn children, or any
adopted, foster, or stepchildren.
26. Active duty means full-time service, other than active duty for training, as a
member of the Army, Navy, Air Force, Marine Corps, Coast Guard, or as a
commissioned officer of the Public Health Service or the National Oceanic
and Atmospheric Administration, or its predecessors, the Coast and Geodetic
Survey or Environmental Science Service Administration. Active duty also
applies to a person who is a cadet attending one of the five United States
Military Service Academies. For a person with service in the military Reserves
or National Guard, mark the “Only on active duty for training in the
Reserves or National Guard" box if the person has never been called up
for active duty, mobilized, or deployed. For a person whose only service was
as a civilian employee or civilian volunteer for the Red Cross, USO, Public
Health Service, or War or Defense Department, mark the "Never served in
the military" box. For Merchant Marine service, count only the service
during World War II as active duty and no other period of service.
27. Mark as many responses as apply.
28a. Mark the "Yes" box if the person has a Department of Veterans Affairs (VA)
service-connected disability rating.
28b. Mark the "0 percent" box if the person has received a service-connected
disability rating of zero. DO NOT mark the box showing "0 percent" to
indicate no rating.
29a–29b.
Count as work – Mark the "Yes" box if this person performed:
• Work for someone else for wages, salary, piece rate, commission, tips, or
payments "in kind" (for example, food or lodging received as payment
for work performed).
• Work in own business, professional practice, or farm.
• Any work in a family business or farm, paid or not.
• Any part-time work including babysitting, paper routes, etc.
• Active duty in the Armed Forces.
Do not count as work – Mark the "No" box if this person’s activities were
limited to the following:
• Housework or yard work at home.
• Unpaid volunteer work.
• School work done as a student.
• Work done as a resident or inmate of an institution facility (like a nursing
facility or correctional facility).
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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

30. Include the building or structure number; street name; street type
(for example, St., Road, Ave.); and the street direction (if a direction
such as "North" is part of the address). For example, print 1239 N.
Main St. or 1239 Main St., N.W., not just 1239 Main.
If the only known address is a post office box, give a description of
the work location. For example, print the name of the building or
shopping center where the person works, the nearest intersection,
or the nearest street where the workplace is located, etc. DO NOT
give a post office box number.
If the person worked at a military installation or military base that
has no street address, report the name of the military installation or
base, and a description of the work location (such as building
number, building name, nearest street or intersection).
If the person worked at several locations, but reported to the same
location each day to begin work, print the street address of the location
where he or she reported. If the person did not report to
the same location each day to begin work, print the address of the
location where he or she worked most of the time last week.
If the person’s employer operates in more than one location (such as
a grocery store chain or public school system), print the street address
of the location or branch where the person worked. If the street
address of a school is not known, print the name of the school, and a
description of the location (such as nearest street or intersection).
If the person worked on a college or university campus and the street
address of the workplace is not known, print the name of the
building where he or she worked, and a description of the location
(such as nearest street or intersection).
If the person worked in a foreign country or Puerto Rico, Guam, etc.,
print the name of the country on the state or foreign country line.
31. Mark only one box to indicate the method of transportation used to
travel the longest distance to work LAST WEEK.
• Mark the "Car, truck, or van" box if the person drove a station
wagon, company car, light truck of 1-ton capacity or less, truck cab,
mini bus, or private limousine (NOT for hire).
• Mark the "Streetcar or trolley car" box if the person took light
rail or other vehicle that operates on tracks or rails with overhead
electrical wires.
• Mark the "Subway or elevated" box if the person took a subway,
or other vehicle that operates on tracks or rails with complete
separation from other vehicle and pedestrian traffic.
• Mark the "Railroad" box if the person took Amtrak, or any other
commuter train with occasional railroad crossings for vehicle and
pedestrian traffic.
• Mark the "Taxicab" box if the person took a limousine such as an
airport limousine for which a fare is charged.
• Mark the "Motorcycle" box if the person rode a motorbike,
moped, motor scooter, or similar vehicle that is motor driven.
• Mark the "Bicycle" box if the person rode a bicycle or other
vehicle that is pedaled.
• Mark the "Walked" box ONLY if the person walked all the way to
work and used no other means of transportation.
• Mark the "Worked at home" box if the person worked on a farm
where he/she lives, or an office or shop in the person’s own home.
• Mark the "Other method" box if the person took an airplane,
helicopter, horse, horse and buggy, boat (other than public ferries),
large motor home, dog sled, large truck or truck rig, All-Terrain Vehicle
(ATV), snow machine/snowmobile, Segway® or other self-balancing
electric vehicle, skateboard, inline skates, or motorized chair.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Answer person question 32 if you marked "car, truck, or van" in
question 31.
32.

If the person was driven to work by someone who then drove back
home or to a non-work destination, print "1" in the box labeled
“Person(s)”.
DO NOT include persons who rode to school or some other non-work
destination in the count of persons who rode in the vehicle.

33.

Give the time of day the person usually left home to go to work.
DO NOT give the time that the person usually began his or her work.
If the person usually left home to go to work sometime between
12:00 o’clock midnight and 12:00 o’clock noon, mark "a.m."
If the person usually left home to go to work sometime between
12:00 o’clock noon and 12:00 o’clock midnight, mark "p.m."

34.

Travel time is from door to door. Enter a one-way commute time
for this person’s usual daily commute from home to work Last
Week. Include time waiting for public transportation or picking
up passengers in a carpool.

Answer person questions 35a through 38 if the person did NOT
work last week.
35a. Persons are on layoff if they are waiting to be recalled to a job
from which they were temporarily separated for business-related
reasons.
35b. If the person works only during certain seasons or on a day-by-day
basis when work is available, mark the "No" box.
35c. If the person was informed by his or her employer, either formally
or informally, that they will be recalled within the next 6 months,
mark the "Yes" box. Also mark the "Yes" box if the person has
been given, formally or informally, a specific date to return to
work, even if that date is more than 6 months away.
36. Mark the "Yes" box if the person tried to get a job or start a
business or professional practice at any time in the LAST 4 WEEKS;
for example, registered at a public or private employment office,
went to a job interview, placed or answered employment ads, or did
anything toward starting a business or professional practice.
37. If the person was expecting to report to a job within 30 days,
mark the "Yes, could have gone to work" box.
Mark the "No, because of own temporary illness" box only if the
person expects to be able to work within 30 days.
If the person could not have gone to work because he or she
was going to school, taking care of children, etc., mark the
"No, because of all other reasons (in school, etc.)" box.
38. Refer to the instructions for questions 29a–29b to determine what to
count as work. Mark the "Over 5 years ago or never worked" box
if the person: (1) never worked at any kind of job or business, either
full or part time, (2) never worked, with or without pay, in a family
business or farm, and (3) never served on active duty in the Armed
Forces.
39a–39b.
Refer to the instructions for questions 29a–29b to determine what to
count as work. Include paid vacation, paid sick leave, and military
service. Count every week in which the person worked at all, even for
an hour.
40. If the hours worked each week varied considerably in the PAST 12
MONTHS, give an approximate average of the hours worked each
week.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

Answer person questions 41 through 46 if the person worked
in the past 5 years.
41. If the person worked for a cooperative, credit union, mutual
insurance company, or similar organization mark the "an employee
of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or charitable
organization?" box.
Employees of foreign governments, the United Nations, and other
international organizations should mark the "a Federal
GOVERNMENT employee?" box.
If the person worked at a public school, college or university, mark
the appropriate government category; for example, mark the
"a state GOVERNMENT employee?" box for a state university, or
mark the "a local GOVERNMENT employee (city, county, etc.)?"
box for a county-run community college or a city-run public school.
42. If the person worked for a company, business, or government
agency, print the name of the company, not the name of the
person’s supervisor. If the person worked for an individual or a
business that had no company name, print the name of the
individual this person worked for. If the person worked in his or her
own un-named business, print "self-employed."
43. Describe one or more words to describe the business, industry, or
individual employer named in question 42. If there is more than one
activity, describe only the major activity at the place where the person
worked. Describe what is made, what is sold, or what service is given.
Enter descriptions like the following: newspaper publishing,
mail order house, auto engine manufacturing.
44. Mark one box to indicate the main type of business or industry
where this person works or worked.
45. Describe the kind of work the person did. If the person was a
trainee, apprentice, or helper, include that in the description.
Enter descriptions like the following: registered nurse,
personnel manager, supervisor of order department, high school
teacher.
If possible, avoid single words such as: nurse, manager, and teacher.
46. Describe the most important activities or duties the person performed.
Enter descriptions like the following: patient care, directing
hiring policies, supervising order clerks, typing and filing, reconciling
financial records.
Answer person questions 47 through 48 if this person is 15 years
old or over.
Mark the "Yes" or "No" box for each type of income, and enter the
amount received IN THE PAST 12 MONTHS for each "Yes" response.
If income from any source was received jointly by household members,
report, if possible, the appropriate share for each person; otherwise,
report the whole amount for only one person and mark the "No" box
for the other person.
When reporting income received jointly, DO NOT include the amount for
a person not listed on pages 2, 3, or 4.
DO NOT include the following as income in any item:
•
•
•
•
•
•

Refunds or rebates of any kind
Withdrawals from savings of any kind
Capital gains or losses from the sale of homes, shares of stock, etc.
Inheritances or insurance settlements
Any type of loan
Pay in-kind such as food, free rent

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

47a. Include wages and salaries before deductions from all jobs. Be sure
to include any tips, commissions, or bonuses. Owners of
incorporated businesses should enter their salary here. Military
personnel should include base pay plus cash housing and/or
subsistence allowance, flight pay, uniform allotments, reenlistment
bonuses.
47b. Include nonfarm profit (or loss) from self-employment in sole
proprietorships and partnerships. Mark the "Loss" box if there is
a loss. Exclude profit (or loss) of incorporated businesses the
person owns.
Include farm profit (or loss) from self-employment in sole
proprietorships and partnerships. Mark the "Loss" box if there is a
loss. Exclude profit (or loss) of incorporated farm businesses the
person owns. Also exclude amounts from land rented for cash but
include amounts from land rented for shares.
47c. Include interest received or credited to checking and saving
accounts, money market funds, certificates of deposit (CDs), IRAs,
KEOGHs, and government bonds.
Include dividends received, credited, or reinvested from ownership
of stocks or mutual funds.
Include profit (or loss) from royalties and the rental of land,
buildings or real estate, or from roomers or boarders. Mark the
"Loss" box if there is a loss. Income received by self-employed
persons whose primary source of income is from renting property or
from royalties should be included in 47b. Include regular payments
from an estate or trust fund.
47d. Include amounts, before Medicare deductions, of Social Security
and/or Railroad Retirement payments to retired persons, to
dependents of deceased insured workers, and to disabled workers.
47e. Include Supplemental Security Income (SSI) received by elderly,
blind, or disabled persons.
47f. Include any public assistance or welfare payments received by check
or electronic transfer from the state or local welfare office, even if
received for only one month or less than a year. Include benefits
received on behalf of children. These payments are sometimes
referred to as Temporary Assistance for Needy Families (TANF), Aid
to Families with Dependent Children (AFDC), Aid to Dependent
Children (ADC), Welfare or welfare to work, General Assistance,
General Relief, Emergency Assistance, and Diversion Payments. Do
not include assistance received from private charities.
Do not include Supplemental Security Income (SSI), food assistance
(such as food stamps and benefits from the Supplemental Nutrition
Assistance Program, or SNAP), rental assistance, education
assistance, child care assistance, transportation assistance, or
assistance with heating or cooling costs or any other energy
assistance (such as Low Income Home Energy Assistance Program, or
LIHEAP).
47g. Include retirement, survivor or disability benefits received from
companies and unions, federal, state, and local governments, and
the U.S. military. Include regular income from annuities and IRA or
KEOGH retirement plans.
47h. Include Veterans’ (VA) disability compensation and educational
assistance payments (VEAP); unemployment compensation, worker’s
compensation, child support or alimony; and all other regular
payments such as Armed Forces transfer payments, assistance from
private charities, regular contributions from persons not living in the
household.
48.

Add the total entries (subtracting losses) for 47a through 47h for the
PAST 12 MONTHS and enter that number in the space provided.
Mark the "Loss" box if there is a loss. Print the total amount in
dollars.

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Attachment D6 -- ACS-30(2015)(5-2014), ACS Instruction Guide

What the Survey Is About -Some Questions and Answers
Why are we taking a survey?
The Census Bureau is conducting the American Community Survey to
provide more timely data than data we typically collect only once every
10 years during the decennial census.
What does the Census Bureau do with the information you provide?
The American Community Survey will be the source of summarized data
that we make available to federal, state, and local governments, and
also to the public. The data will enable your community leaders from
government, business, and non-profit organizations to plan more
effectively.
How was this address selected?
Your address was scientifically selected to represent a cross section of
other households in your community. Households in the sample are
required to complete the survey form. Please return it in the
postage-paid envelope as soon as possible.

Why the Census Bureau Asks Certain
Questions -Here are reasons we ask some of the questions on the survey.
Name
Names help make sure that everyone in a household is included, and
that no one is listed twice.
Value or rent
Government and planning agencies use answers to these questions in
combination with other information to develop housing programs to
meet the needs of people at different economic levels.
Plumbing and Kitchen facilities
This question helps provide information on the quality of housing. The
data are used with other statistics to show how the "level of living"
compares in various areas and how it changes over time.
Place of birth
This question provides information used to study long-term trends about
where people move and to study migration patterns and differences in
growth patterns.
Job
Answers to the questions about the jobs people hold provide information
on the extent and types of employment in different areas of the country.
From this information, communities can develop training programs, and
business and local governments can determine the need for new
employment opportunities.
Income
Income helps determine how well families or persons live. Income
information makes it possible to compare the economic levels of different
areas, and how economic levels for a community change over time.
Funding for many government programs is based on the answers to these
questions.
Education
Responses to the education questions in the survey help to determine the
number of new public schools, education programs, and daycare services
required in a community.
Disability
Questions about disability provide the means to allocate federal funding
for healthcare services and new hospitals in many communities.
Journey to work
Answers to these questions help communities plan road improvements,
develop public transportation services, and design programs to ease traffic
problems.

ACS-30(2015) (5-2014)

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Attachment D7 -- ACS-46(2012)(5-2011), ACS Stateside Outgoing Envelope

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville IN 47132-0001
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-46(2012) (5-2011)

The American Community Survey
Form Enclosed

YOUR RESPONSE IS
REQUIRED BY LAW

AN EQUAL OPPORTUNITY EMPLOYER

PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58

Attachment D7 -- ACS-46(2012)(5-2011), ACS Stateside Outgoing Envelope
U.S. DEPARTMENT OF COMMERCE

AN EQUAL OPPORTUNITY EMPLOYER

PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58

Economics and Statistics Administration
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville IN 47132-0001
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-46(2012) (5-2011)

The American Community Survey
Form Enclosed

YOUR RESPONSE IS
REQUIRED BY LAW
2-1/2"

3-3/8"

5"
1-1/2"