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DC
The American Community Survey
Start Here
You have two ways to respond:
➜
Respond online today at:
https://respond.census.gov/acs
Please print the name and telephone number of the
person who is filling out this form. We will only
contact you if needed for official Census Bureau business.
Last Name
OR
First Name
Complete this form and mail it
back as soon as possible.
Area Code + Number
Your response is required by law.
The American Community Survey is
conducted by the U.S. Census Bureau.
This survey is one of only a few
surveys for which all recipients are
required by law to respond. The
U.S. Census Bureau is required by
law to protect your information.
MI
—
➜
How many people, including yourself, are living or
staying at this address?
● INCLUDE everyone living or staying here, even if they are
not related to you.
● INCLUDE children, related or unrelated, such as babies,
grandchildren, or foster children.
● INCLUDE anyone else staying here now, such as roommates
and other families who have no other place to stay.
If you need help or have
questions about completing
this form, please call
1-800-354-7271.
● DO NOT INCLUDE anyone who is living somewhere else,
such as a college student living away or someone in the
Armed Forces on deployment.
Number of people
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330.
¿NECESITA AYUDA? Llame sin cargo
alguno al 1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
https://www.census.gov/acs
➜
Fill out pages 2 – 7 for everyone, including yourself,
who is living or staying at this address. Then
complete the rest of the form.
ACS-1(CT)V1
FORM
(05-13-2020) Draft 8
§."53¤
OMB No. 0607-0810
OMB No. 0607-0936
13012026
Person 1
(Person 1 is the person living or staying here in whose
name this house or apartment is owned, being bought,
or rented. If there is no such person, start with the name
of any adult living or staying here.)
➜
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
5
Is Person 1 of Hispanic, Latino, or Spanish origin?
Please print today’s date.
No, not of Hispanic, Latino, or Spanish origin
Month
Yes, Mexican, Mexican Am., Chicano
Day
Year
Yes, Puerto Rican
Yes, Cuban
1
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
What is Person 1’s name?
Last Name (Please print)
First Name
MI
6
What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
2
How is this person related to Person 1?
X
3
Person 1
Male
4
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. C
What is Person 1’s sex? Mark (X) ONE box.
Female
What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
§."5;¤
2
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13012034
Person 2
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 2’s name?
Last Name (Please print)
Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 2’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
§."5C¤
Year of birth
Some other race – Print race or origin. C
3
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13012042
Person 3
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 3’s name?
Last Name (Please print)
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 3’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
§."5K¤
Year of birth
Some other race – Print race or origin. C
4
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13012059
Person 4
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 4’s name?
Last Name (Please print)
Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 4’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
§."5\¤
Year of birth
Some other race – Print race or origin. C
5
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13012067
Person 5
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 5’s name?
Last Name (Please print)
Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
§."5d¤
Year of birth
Some other race – Print race or origin. C
6
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13012075
➜
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. C
Person 6
Last Name (Please print)
Sex
Male
Female
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
Age (in years)
Person 7
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 8
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 9
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 10
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 11
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 12
Last Name (Please print)
Sex
Male
Female
§."5l¤
Age (in years)
7
13012083
Housing
➜
Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
A
Answer questions 4 – 5 if this is a HOUSE OR A
MOBILE HOME; otherwise, SKIP to question 6a.
1
Which best describes this building?
Include all apartments, fiats, etc., even if vacant.
4
How many acres is this house or mobile home on?
A mobile home
Less than 1 acre ➔ SKIP to question 6a
A one-family house detached from any
other house
1 to 9.9 acres
A one-family house attached to one or
more houses
10 or more acres
5
A building with 2 apartments
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
2
About when was this building first built?
6
2000 or later – Specify year
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 fioor to ceiling.
1990 to 1999
● INCLUDE bedrooms, kitchens, etc.
● EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.
1980 to 1989
Number of rooms
1970 to 1979
1960 to 1969
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".
1950 to 1959
1940 to 1949
1939 or earlier
3
Number of bedrooms
When did PERSON 1 (listed on page 2) move into
this house, apartment, or mobile home?
Month
Year
7
Does this house, apartment, or mobile home
have –
Yes
No
a. hot and cold running water?
b. a bathtub or shower?
c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?
§."5t¤
8
13012091
Housing (continued)
8
What is the MAIN type of sewage disposal for
this house, apartment, or mobile home?
13 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?
Public sewer
None
Septic system or cesspool
1
Other type of sewage disposal
9
2
Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.
3
4
5
6 or more
Yes
No
14 Are any of the following types of electric
vehicles kept at home for use by members
of this household?
10 At this house, apartment, or mobile home –
do you or any member of this household own
or use any of the following types of computers?
Yes
a. A plug-in electric vehicle?
No
Yes
a. Desktop or laptop
No
b. Smartphone
b. Another type of electric vehicle?
c. Tablet or other portable
wireless computer
Yes
No
d. Some other type of computer
Specify C
15 Which fuel is used MOST for heating this house,
apartment, or mobile home?
Natural gas: from underground pipes serving
the neighborhood
11 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?
Gas: propane, butane, etc.
Electricity
Yes, by paying a cell phone company or
Internet service provider
Fuel oil, kerosene, etc.
Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 13
Coal or coke
No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 13
Wood
Solar energy
12 Do you or any member of this household have
Other fuel
access to the Internet using a –
a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C
§."5|¤
Yes
No
No fuel used
16 Does this house, apartment, or mobile home use
solar panels that generate electricity?
Yes
No
9
13012109
Housing (continued)
17 a. LAST MONTH, what was the cost of electricity 19 Is this house, apartment, or mobile home part of
for this house, apartment, or mobile home?
a condominium?
Last month’s cost – Dollars
$
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.
.00
,
OR
Monthly amount – Dollars
Included in rent or condominium fee
$
No charge or electricity not used
.00
,
OR
b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?
None
No
Last month’s cost – Dollars
$
.00
,
20 Is this house, apartment, or mobile home –
Mark (X) ONE box.
OR
Included in rent or condominium fee
Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.
Included in electricity payment entered above
Owned by you or someone in this household free
and clear (without a mortgage or loan)?
No charge or gas not used
Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page
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
$
B
.00
,
Answer questions 21a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 22.
OR
Included in rent or condominium fee
21 a. What is the monthly rent for this house,
apartment, or mobile home?
No charge
Monthly amount – Dollars
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.
$
Yes
.00
,
No
OR
Included in rent or condominium fee
No charge or these fuels not used
18 In 2019, did you or 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
No
§."6*¤
.00
b. Does the monthly rent include any meals?
Past 12 months’ cost – Dollars
$
,
10
C
13012117
Housing (continued)
C
c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
Answer questions 22 – 26 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required
22 About how much do you think this house and lot,
d. Does the regular monthly mortgage payment
include payments for fire, hazard, or fiood
insurance on THIS property?
apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars
Yes, insurance included in mortgage payment
$
,
.00
,
23 What are the annual real estate taxes on THIS
property?
No, insurance paid separately or no insurance
26 a. Do you or any member of this household have
a second mortgage or a home equity loan on
THIS property?
Annual amount – Dollars
$
Yes, home equity loan
.00
,
Yes, second mortgage
OR
Yes, second mortgage and home equity loan
None
No ➔ SKIP to
24 What is the annual payment for fire, hazard, and
b. How much is the regular monthly payment on
all second or junior mortgages and all home
equity loans on THIS property?
fiood insurance on THIS property?
Annual amount – Dollars
$
Monthly amount – Dollars
.00
,
D
$
OR
.00
,
None
OR
No regular payment required
25 a. Do you or any member of this household have
a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?
Yes, mortgage, deed of trust, or similar debt
D
Answer question 27 if this is a MOBILE HOME.
Otherwise, SKIP to E .
Yes, contract to purchase
No ➔ SKIP to question 26a
27 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.
b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.
Annual costs – Dollars
Monthly amount – Dollars
$
,
$
.00
,
.00
OR
No regular payment required ➔ SKIP to
question 26a
E
§."62¤
11
Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.
13012125
Person 1
➜
Please copy the name of Person 1 from page 2,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
11 What is the highest grade of school or degree this
person has COMPLETED? If currently enrolled, select
the previous grade or highest degree received.
Mark (X) ONE box.
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
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.
12th grade – NO DIPLOMA
Year
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
Doctorate degree (for example: PhD, EdD)
§."6:¤
12
13012133
Person 1 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
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
12 This question focuses on this person’s
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)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. state or
Puerto Rico
ZIP Code
14 a. Does this person speak a language other
than English at home?
Yes
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.
No ➔ SKIP to question 15a
b. What is this language?
a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
b. Medicare, for people 65 and older,
or people with certain disabilities
Very well
c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability
Well
Not well
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace, HealthCare.gov,
or a similar website (by this person or
another family member)
Not at all
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C
§."6B¤
13
Yes
No
13012141
Person 1 (continued)
G
b. Does this person have difficulty remembering
or concentrating?
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
No difficulty
Some difficulty
17 a. Is there a premium for this plan? A premium
A lot of difficulty
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Cannot do at all
c. Does this person have difficulty bathing or
dressing?
Yes
No difficulty
No ➔ SKIP to question 18a
Some difficulty
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
A lot of difficulty
Cannot do at all
Yes
d. Using his or her usual language, does this
person have difficulty communicating, for
example, understanding or being understood?
No
18 a. Does this person have difficulty seeing, even
No difficulty
if wearing glasses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
Cannot do at all
I
b. Does this person have difficulty hearing, even
if using a hearing aid?
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
No difficulty
Some difficulty
20 Does this person have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
A lot of difficulty
No difficulty
Cannot do at all
Some difficulty
H
A lot of difficulty
Answer question 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
19 a. Does this person have difficulty walking or
Cannot do at all
21 What is this person’s marital status?
climbing stairs?
Now married
No difficulty
Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to
§."6J¤
14
J on the next page
13012158
Person 1 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
No
a. Married?
Never served in the military ➔ SKIP to question 30a
b. Widowed?
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
c. Divorced?
Now on active duty
23 How many times has this person been married?
On active duty in the past, but not now
Once
Two times
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Three or more times
September 2001 or later
24 In what year did this person last get married?
August 1990 to August 2001 (including
Persian Gulf War)
Year
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
J
February 1955 to July 1964
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
25 In the PAST 12 MONTHS, has this person given
World War II (December 1941 to December 1946)
birth to any children?
November 1941 or earlier
Yes
No
29 a. Does this person have a VA service-connected
disability rating?
26 a. Does this person have any of his/her own
Yes (such as 0%, 10%, 20%, ... , 100%)
grandchildren under the age of 18 living in
this house or apartment?
No ➔ SKIP to question 30a
Yes
b. What is this person’s service-connected
disability rating?
No ➔ SKIP to question 27
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
50 or 60 percent
No ➔ SKIP to question 27
70 percent or higher
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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
§."6[¤
15
13012166
Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 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)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
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.
:
a.m.
p.m.
35 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
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 39b.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 39b
Ferryboat
Other method
§.4"]¤
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?
Yes ➔ SKIP to question 38
No
16
13012174
Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 a. When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
For-profit company or organization
1 to 5 years ago
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
b. In 2019, did this person work at a job or
business at any time, even for a few days?
Local government (for example: city or
county school district)
Yes
State government (including state
colleges/universities)
No ➔ SKIP to question 42
Active duty U.S. Armed Forces or
Commissioned Corps
40 During the weeks that this person WORKED in
2019, how many HOURS did this person usually
work each WEEK?
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Usual hours worked each WEEK
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
41 a. In 2019, did this person work EVERY week?
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
Include all jobs and count paid vacation, paid sick
leave, and military service as work.
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Yes ➔ SKIP to question 42
No
b. Of the 52 weeks in 2019, how many WEEKS
did this person work for at least one day?
Include all jobs, paid time off, and weeks when this
person only worked for a few hours.
c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)
Weeks
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§."6k¤
17
13012182
Person 1 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
,
TOTAL AMOUNT for 2019
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for 2019
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN 2019
Yes ➔
Report all types of income received, taxable and
non-taxable, from January 1, 2019 to December 31,
2019.
No
Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.
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.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
No
,
,
Yes ➔
TOTAL AMOUNT for 2019
$
No
,
,
Loss
No
,
,
TOTAL AMOUNT for 2019
.00
,
Yes ➔
$
No
TOTAL AMOUNT for 2019
.00
,
$
,
,
TOTAL AMOUNT for 2019
.00
Loss
.00
TOTAL AMOUNT for 2019
§."6s¤
No
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
If net income was a loss, mark (X) the “Loss” box
next to the dollar amount.
$
$
Add entries in questions 43a to 43h; subtract any losses.
If net income was a loss, enter the amount and mark (X)
the "Loss" box next to the dollar amount.
None
Yes ➔
Yes ➔
44 What was this person’s total income in 2019?
.00
TOTAL AMOUNT for 2019
TOTAL AMOUNT for 2019
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
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses. If net income was
a loss, mark (X) the “Loss” box next to the dollar
amount.
.00
,
g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do NOT include Social Security.
Mark (X) the “No” box for each type of income NOT
received.
Yes ➔
$
Loss
➜
18
Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.
13012190
Person 2
➜
Please copy the name of Person 2 from page 3,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
11 What is the highest grade of school or degree this
person has COMPLETED? If currently enrolled, select
the previous grade or highest degree received.
Mark (X) ONE box.
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
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.
12th grade – NO DIPLOMA
Year
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
Doctorate degree (for example: PhD, EdD)
§."6{¤
19
13012208
Person 2 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
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
12 This question focuses on this person’s
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)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. state or
Puerto Rico
ZIP Code
14 a. Does this person speak a language other
than English at home?
Yes
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.
No ➔ SKIP to question 15a
b. What is this language?
a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
b. Medicare, for people 65 and older,
or people with certain disabilities
Very well
c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability
Well
Not well
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace, HealthCare.gov,
or a similar website (by this person or
another family member)
Not at all
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C
§."7)¤
20
Yes
No
13012216
Person 2 (continued)
G
b. Does this person have difficulty remembering
or concentrating?
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
No difficulty
Some difficulty
17 a. Is there a premium for this plan? A premium
A lot of difficulty
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Cannot do at all
c. Does this person have difficulty bathing or
dressing?
Yes
No difficulty
No ➔ SKIP to question 18a
Some difficulty
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
A lot of difficulty
Cannot do at all
Yes
d. Using his or her usual language, does this
person have difficulty communicating, for
example, understanding or being understood?
No
18 a. Does this person have difficulty seeing, even
No difficulty
if wearing glasses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
Cannot do at all
I
b. Does this person have difficulty hearing, even
if using a hearing aid?
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
No difficulty
Some difficulty
20 Does this person have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
A lot of difficulty
No difficulty
Cannot do at all
Some difficulty
H
A lot of difficulty
Answer question 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
19 a. Does this person have difficulty walking or
Cannot do at all
21 What is this person’s marital status?
climbing stairs?
Now married
No difficulty
Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to
§."71¤
21
J on the next page
13012224
Person 2 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
No
a. Married?
Never served in the military ➔ SKIP to question 30a
b. Widowed?
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
c. Divorced?
Now on active duty
23 How many times has this person been married?
On active duty in the past, but not now
Once
Two times
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Three or more times
September 2001 or later
24 In what year did this person last get married?
August 1990 to August 2001 (including
Persian Gulf War)
Year
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
J
February 1955 to July 1964
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
25 In the PAST 12 MONTHS, has this person given
World War II (December 1941 to December 1946)
birth to any children?
November 1941 or earlier
Yes
No
29 a. Does this person have a VA service-connected
disability rating?
26 a. Does this person have any of his/her own
Yes (such as 0%, 10%, 20%, ... , 100%)
grandchildren under the age of 18 living in
this house or apartment?
No ➔ SKIP to question 30a
Yes
b. What is this person’s service-connected
disability rating?
No ➔ SKIP to question 27
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
50 or 60 percent
No ➔ SKIP to question 27
70 percent or higher
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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
§."79¤
22
13012232
Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 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)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
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.
:
a.m.
p.m.
35 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
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 39b.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 39b
Ferryboat
Other method
§."7A¤
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?
Yes ➔ SKIP to question 38
No
23
13012240
Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 a. When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
For-profit company or organization
1 to 5 years ago
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
b. In 2019, did this person work at a job or
business at any time, even for a few days?
Local government (for example: city or
county school district)
Yes
State government (including state
colleges/universities)
No ➔ SKIP to question 42
Active duty U.S. Armed Forces or
Commissioned Corps
40 During the weeks that this person WORKED in
2019, how many HOURS did this person usually
work each WEEK?
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Usual hours worked each WEEK
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
41 a. In 2019, did this person work EVERY week?
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
Include all jobs and count paid vacation, paid sick
leave, and military service as work.
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Yes ➔ SKIP to question 42
No
b. Of the 52 weeks in 2019, how many WEEKS
did this person work for at least one day?
Include all jobs, paid time off, and weeks when this
person only worked for a few hours.
c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)
Weeks
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§."7I¤
24
13012257
Person 2 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
,
TOTAL AMOUNT for 2019
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for 2019
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN 2019
Yes ➔
Report all types of income received, taxable and
non-taxable, from January 1, 2019 to December 31,
2019.
No
Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.
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.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
No
,
,
Yes ➔
TOTAL AMOUNT for 2019
$
No
,
,
Loss
No
,
,
TOTAL AMOUNT for 2019
.00
,
Yes ➔
$
No
TOTAL AMOUNT for 2019
.00
,
$
,
,
TOTAL AMOUNT for 2019
.00
Loss
.00
TOTAL AMOUNT for 2019
§."7Z¤
No
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
If net income was a loss, mark (X) the “Loss” box
next to the dollar amount.
$
$
Add entries in questions 43a to 43h; subtract any losses.
If net income was a loss, enter the amount and mark (X)
the "Loss" box next to the dollar amount.
None
Yes ➔
Yes ➔
44 What was this person’s total income in 2019?
.00
TOTAL AMOUNT for 2019
TOTAL AMOUNT for 2019
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
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses. If net income was
a loss, mark (X) the “Loss” box next to the dollar
amount.
.00
,
g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do NOT include Social Security.
Mark (X) the “No” box for each type of income NOT
received.
Yes ➔
$
Loss
➜
25
Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.
13012265
Person 3
➜
Please copy the name of Person 3 from page 4,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
11 What is the highest grade of school or degree this
person has COMPLETED? If currently enrolled, select
the previous grade or highest degree received.
Mark (X) ONE box.
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
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.
12th grade – NO DIPLOMA
Year
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
Doctorate degree (for example: PhD, EdD)
§."7b¤
26
13012273
Person 3 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
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
12 This question focuses on this person’s
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)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. state or
Puerto Rico
ZIP Code
14 a. Does this person speak a language other
than English at home?
Yes
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.
No ➔ SKIP to question 15a
b. What is this language?
a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
b. Medicare, for people 65 and older,
or people with certain disabilities
Very well
c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability
Well
Not well
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace, HealthCare.gov,
or a similar website (by this person or
another family member)
Not at all
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C
§."7j¤
27
Yes
No
13012281
Person 3 (continued)
G
b. Does this person have difficulty remembering
or concentrating?
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
No difficulty
Some difficulty
17 a. Is there a premium for this plan? A premium
A lot of difficulty
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Cannot do at all
c. Does this person have difficulty bathing or
dressing?
Yes
No difficulty
No ➔ SKIP to question 18a
Some difficulty
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
A lot of difficulty
Cannot do at all
Yes
d. Using his or her usual language, does this
person have difficulty communicating, for
example, understanding or being understood?
No
18 a. Does this person have difficulty seeing, even
No difficulty
if wearing glasses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
Cannot do at all
I
b. Does this person have difficulty hearing, even
if using a hearing aid?
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
No difficulty
Some difficulty
20 Does this person have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
A lot of difficulty
No difficulty
Cannot do at all
Some difficulty
H
A lot of difficulty
Answer question 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
19 a. Does this person have difficulty walking or
Cannot do at all
21 What is this person’s marital status?
climbing stairs?
Now married
No difficulty
Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to
§."7r¤
28
J on the next page
13012299
Person 3 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
No
a. Married?
Never served in the military ➔ SKIP to question 30a
b. Widowed?
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
c. Divorced?
Now on active duty
23 How many times has this person been married?
On active duty in the past, but not now
Once
Two times
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Three or more times
September 2001 or later
24 In what year did this person last get married?
August 1990 to August 2001 (including
Persian Gulf War)
Year
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
J
February 1955 to July 1964
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
25 In the PAST 12 MONTHS, has this person given
World War II (December 1941 to December 1946)
birth to any children?
November 1941 or earlier
Yes
No
29 a. Does this person have a VA service-connected
disability rating?
26 a. Does this person have any of his/her own
Yes (such as 0%, 10%, 20%, ... , 100%)
grandchildren under the age of 18 living in
this house or apartment?
No ➔ SKIP to question 30a
Yes
b. What is this person’s service-connected
disability rating?
No ➔ SKIP to question 27
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
50 or 60 percent
No ➔ SKIP to question 27
70 percent or higher
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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
§."7ƒ¤
29
13012307
Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 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)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
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.
:
a.m.
p.m.
35 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
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 39b.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 39b
Ferryboat
Other method
§."8(¤
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?
Yes ➔ SKIP to question 38
No
30
13012315
Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 a. When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
For-profit company or organization
1 to 5 years ago
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
b. In 2019, did this person work at a job or
business at any time, even for a few days?
Local government (for example: city or
county school district)
Yes
State government (including state
colleges/universities)
No ➔ SKIP to question 42
Active duty U.S. Armed Forces or
Commissioned Corps
40 During the weeks that this person WORKED in
2019, how many HOURS did this person usually
work each WEEK?
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Usual hours worked each WEEK
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
41 a. In 2019, did this person work EVERY week?
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
Include all jobs and count paid vacation, paid sick
leave, and military service as work.
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Yes ➔ SKIP to question 42
No
b. Of the 52 weeks in 2019, how many WEEKS
did this person work for at least one day?
Include all jobs, paid time off, and weeks when this
person only worked for a few hours.
c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)
Weeks
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§."80¤
31
13012323
Person 3 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
,
TOTAL AMOUNT for 2019
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for 2019
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN 2019
Yes ➔
Report all types of income received, taxable and
non-taxable, from January 1, 2019 to December 31,
2019.
No
Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.
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.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
No
,
,
Yes ➔
TOTAL AMOUNT for 2019
$
No
,
,
Loss
No
,
,
TOTAL AMOUNT for 2019
.00
,
Yes ➔
$
No
TOTAL AMOUNT for 2019
.00
,
$
,
,
TOTAL AMOUNT for 2019
.00
Loss
.00
TOTAL AMOUNT for 2019
§."88¤
No
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
If net income was a loss, mark (X) the “Loss” box
next to the dollar amount.
$
$
Add entries in questions 43a to 43h; subtract any losses.
If net income was a loss, enter the amount and mark (X)
the "Loss" box next to the dollar amount.
None
Yes ➔
Yes ➔
44 What was this person’s total income in 2019?
.00
TOTAL AMOUNT for 2019
TOTAL AMOUNT for 2019
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
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses. If net income was
a loss, mark (X) the “Loss” box next to the dollar
amount.
.00
,
g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do NOT include Social Security.
Mark (X) the “No” box for each type of income NOT
received.
Yes ➔
$
Loss
➜
32
Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.
13012331
Person 4
➜
Please copy the name of Person 4 from page 5,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
11 What is the highest grade of school or degree this
person has COMPLETED? If currently enrolled, select
the previous grade or highest degree received.
Mark (X) ONE box.
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
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.
12th grade – NO DIPLOMA
Year
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
Doctorate degree (for example: PhD, EdD)
§."8@¤
33
13012349
Person 4 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
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
12 This question focuses on this person’s
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)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. state or
Puerto Rico
ZIP Code
14 a. Does this person speak a language other
than English at home?
Yes
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.
No ➔ SKIP to question 15a
b. What is this language?
a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
b. Medicare, for people 65 and older,
or people with certain disabilities
Very well
c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability
Well
Not well
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace, HealthCare.gov,
or a similar website (by this person or
another family member)
Not at all
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C
§."8R¤
34
Yes
No
13012356
Person 4 (continued)
G
b. Does this person have difficulty remembering
or concentrating?
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
No difficulty
Some difficulty
17 a. Is there a premium for this plan? A premium
A lot of difficulty
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Cannot do at all
c. Does this person have difficulty bathing or
dressing?
Yes
No difficulty
No ➔ SKIP to question 18a
Some difficulty
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
A lot of difficulty
Cannot do at all
Yes
d. Using his or her usual language, does this
person have difficulty communicating, for
example, understanding or being understood?
No
18 a. Does this person have difficulty seeing, even
No difficulty
if wearing glasses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
Cannot do at all
I
b. Does this person have difficulty hearing, even
if using a hearing aid?
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
No difficulty
Some difficulty
20 Does this person have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
A lot of difficulty
No difficulty
Cannot do at all
Some difficulty
H
A lot of difficulty
Answer question 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
19 a. Does this person have difficulty walking or
Cannot do at all
21 What is this person’s marital status?
climbing stairs?
Now married
No difficulty
Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to
§."8Y¤
35
J on the next page
13012364
Person 4 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
No
a. Married?
Never served in the military ➔ SKIP to question 30a
b. Widowed?
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
c. Divorced?
Now on active duty
23 How many times has this person been married?
On active duty in the past, but not now
Once
Two times
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Three or more times
September 2001 or later
24 In what year did this person last get married?
August 1990 to August 2001 (including
Persian Gulf War)
Year
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
J
February 1955 to July 1964
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
25 In the PAST 12 MONTHS, has this person given
World War II (December 1941 to December 1946)
birth to any children?
November 1941 or earlier
Yes
No
29 a. Does this person have a VA service-connected
disability rating?
26 a. Does this person have any of his/her own
Yes (such as 0%, 10%, 20%, ... , 100%)
grandchildren under the age of 18 living in
this house or apartment?
No ➔ SKIP to question 30a
Yes
b. What is this person’s service-connected
disability rating?
No ➔ SKIP to question 27
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
50 or 60 percent
No ➔ SKIP to question 27
70 percent or higher
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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
§."8a¤
36
13012372
Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 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)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
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.
:
a.m.
p.m.
35 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
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 39b.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 39b
Ferryboat
Other method
§."8i¤
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?
Yes ➔ SKIP to question 38
No
37
13012380
Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 a. When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
For-profit company or organization
1 to 5 years ago
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
b. In 2019, did this person work at a job or
business at any time, even for a few days?
Local government (for example: city or
county school district)
Yes
State government (including state
colleges/universities)
No ➔ SKIP to question 42
Active duty U.S. Armed Forces or
Commissioned Corps
40 During the weeks that this person WORKED in
2019, how many HOURS did this person usually
work each WEEK?
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Usual hours worked each WEEK
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
41 a. In 2019, did this person work EVERY week?
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
Include all jobs and count paid vacation, paid sick
leave, and military service as work.
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Yes ➔ SKIP to question 42
No
b. Of the 52 weeks in 2019, how many WEEKS
did this person work for at least one day?
Include all jobs, paid time off, and weeks when this
person only worked for a few hours.
c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)
Weeks
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§."8q¤
38
13012398
Person 4 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
,
TOTAL AMOUNT for 2019
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for 2019
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN 2019
Yes ➔
Report all types of income received, taxable and
non-taxable, from January 1, 2019 to December 31,
2019.
No
Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.
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.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
No
,
,
Yes ➔
TOTAL AMOUNT for 2019
$
No
,
,
Loss
No
,
,
TOTAL AMOUNT for 2019
.00
,
Yes ➔
$
No
TOTAL AMOUNT for 2019
.00
,
$
,
,
TOTAL AMOUNT for 2019
.00
Loss
.00
TOTAL AMOUNT for 2019
§."8¥¤
No
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
If net income was a loss, mark (X) the “Loss” box
next to the dollar amount.
$
$
Add entries in questions 43a to 43h; subtract any losses.
If net income was a loss, enter the amount and mark (X)
the "Loss" box next to the dollar amount.
None
Yes ➔
Yes ➔
44 What was this person’s total income in 2019?
.00
TOTAL AMOUNT for 2019
TOTAL AMOUNT for 2019
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
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses. If net income was
a loss, mark (X) the “Loss” box next to the dollar
amount.
.00
,
g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do NOT include Social Security.
Mark (X) the “No” box for each type of income NOT
received.
Yes ➔
$
Loss
➜
39
Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.
13012406
Person 5
➜
Please copy the name of Person 5 from page 6,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
11 What is the highest grade of school or degree this
person has COMPLETED? If currently enrolled, select
the previous grade or highest degree received.
Mark (X) ONE box.
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
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.
12th grade – NO DIPLOMA
Year
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
Doctorate degree (for example: PhD, EdD)
§."9’¤
40
13012414
Person 5 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
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
12 This question focuses on this person’s
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)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. state or
Puerto Rico
ZIP Code
14 a. Does this person speak a language other
than English at home?
Yes
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.
No ➔ SKIP to question 15a
b. What is this language?
a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
b. Medicare, for people 65 and older,
or people with certain disabilities
Very well
c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability
Well
Not well
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace, HealthCare.gov,
or a similar website (by this person or
another family member)
Not at all
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C
§."9/¤
41
Yes
No
13012422
Person 5 (continued)
G
b. Does this person have difficulty remembering
or concentrating?
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
No difficulty
Some difficulty
17 a. Is there a premium for this plan? A premium
A lot of difficulty
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Cannot do at all
c. Does this person have difficulty bathing or
dressing?
Yes
No difficulty
No ➔ SKIP to question 18a
Some difficulty
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
A lot of difficulty
Cannot do at all
Yes
d. Using his or her usual language, does this
person have difficulty communicating, for
example, understanding or being understood?
No
18 a. Does this person have difficulty seeing, even
No difficulty
if wearing glasses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
Cannot do at all
I
b. Does this person have difficulty hearing, even
if using a hearing aid?
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.
No difficulty
Some difficulty
20 Does this person have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
A lot of difficulty
No difficulty
Cannot do at all
Some difficulty
H
A lot of difficulty
Answer question 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.
19 a. Does this person have difficulty walking or
Cannot do at all
21 What is this person’s marital status?
climbing stairs?
Now married
No difficulty
Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to
§."97¤
42
J on the next page
13012430
Person 5 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes
27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
No
a. Married?
Never served in the military ➔ SKIP to question 30a
b. Widowed?
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
c. Divorced?
Now on active duty
23 How many times has this person been married?
On active duty in the past, but not now
Once
Two times
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Three or more times
September 2001 or later
24 In what year did this person last get married?
August 1990 to August 2001 (including
Persian Gulf War)
Year
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
J
February 1955 to July 1964
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
25 In the PAST 12 MONTHS, has this person given
World War II (December 1941 to December 1946)
birth to any children?
November 1941 or earlier
Yes
No
29 a. Does this person have a VA service-connected
disability rating?
26 a. Does this person have any of his/her own
Yes (such as 0%, 10%, 20%, ... , 100%)
grandchildren under the age of 18 living in
this house or apartment?
No ➔ SKIP to question 30a
Yes
b. What is this person’s service-connected
disability rating?
No ➔ SKIP to question 27
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
50 or 60 percent
No ➔ SKIP to question 27
70 percent or higher
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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
§."9?¤
43
13012448
Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 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)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
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.
:
a.m.
p.m.
35 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
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 39b.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 39b
Ferryboat
Other method
§."9Q¤
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?
Yes ➔ SKIP to question 38
No
44
13012455
Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 a. When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
For-profit company or organization
1 to 5 years ago
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
b. In 2019, did this person work at a job or
business at any time, even for a few days?
Local government (for example: city or
county school district)
Yes
State government (including state
colleges/universities)
No ➔ SKIP to question 42
Active duty U.S. Armed Forces or
Commissioned Corps
40 During the weeks that this person WORKED in
2019, how many HOURS did this person usually
work each WEEK?
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Usual hours worked each WEEK
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
41 a. In 2019, did this person work EVERY week?
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
Include all jobs and count paid vacation, paid sick
leave, and military service as work.
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Yes ➔ SKIP to question 42
No
b. Of the 52 weeks in 2019, how many WEEKS
did this person work for at least one day?
Include all jobs, paid time off, and weeks when this
person only worked for a few hours.
c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)
Weeks
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§."9X¤
45
13012463
Person 5 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
,
TOTAL AMOUNT for 2019
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for 2019
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN 2019
Yes ➔
Report all types of income received, taxable and
non-taxable, from January 1, 2019 to December 31,
2019.
No
Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.
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.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
No
,
,
Yes ➔
TOTAL AMOUNT for 2019
$
No
,
,
Loss
No
,
,
TOTAL AMOUNT for 2019
.00
,
Yes ➔
$
No
TOTAL AMOUNT for 2019
.00
,
$
,
,
TOTAL AMOUNT for 2019
.00
Loss
.00
TOTAL AMOUNT for 2019
§."9‘¤
No
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
If net income was a loss, mark (X) the “Loss” box
next to the dollar amount.
$
$
Add entries in questions 43a to 43h; subtract any losses.
If net income was a loss, enter the amount and mark (X)
the "Loss" box next to the dollar amount.
None
Yes ➔
Yes ➔
44 What was this person’s total income in 2019?
.00
TOTAL AMOUNT for 2019
TOTAL AMOUNT for 2019
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
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses. If net income was
a loss, mark (X) the “Loss” box next to the dollar
amount.
.00
,
g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do NOT include Social Security.
Mark (X) the “No” box for each type of income NOT
received.
Yes ➔
$
Loss
➜
46
Now continue with the mailing instructions
on page 48.
13012471
Page 47 is intentionally
left blank
§."9h¤
47
13012489
Mailing
Instructions
➜ Please make sure you have...
● listed all names and answered the
questions on pages 2 – 7
● 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 CLERK
EDIT
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, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" 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(CT)V1 (05-13-2020)
§."9z¤
48
| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2020-05-20 |
| File Created | 2020-05-14 |