2 ACS English Paper Questionnaire V2

13022017

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 people not related to you,
are living or staying at this address?
INCLUDE...
✓ yourself if you live here.
✓ children, related or unrelated, such as babies,
grandchildren, or foster children.
✓ 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.

Telephone Device for the Deaf (TDD):
Call 1–800–582–8330.

Number of people

¿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)V2

FORM
(05-13-2020) Draft 9

§.#52¤

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

13022025

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

13022033

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

§.#5B¤

Year of birth

Some other race – Print race or origin. C

3

Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C

13022041

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

§.#5J¤

Year of birth

Some other race – Print race or origin. C

4

Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C

13022058

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

13022066

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

§.#5c¤

Year of birth

Some other race – Print race or origin. C

6

Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C

13022074

➜

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

§.#5k¤

Age (in years)

7

13022082

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?

§.#5s¤

8

13022090

Housing (continued)
8

Is this house, apartment, or mobile home
connected to a public sewer?

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

Yes, connected to public sewer

None

No, connected to septic system or cesspool

1

No, use other type of system

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 At this house, apartment, or mobile home, do
you or any member of this household own or
lease any of the following types of electric
vehicles?

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. A hybrid electric vehicle?

c. Tablet or other portable
wireless computer

Yes

d. Some other type of computer
Specify C

No

15 Which fuel is used MOST for heating this house,
apartment, or mobile home?

Gas: 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: Bottled or tank (propane, butane, etc.)

Yes, by paying a cell phone company or
Internet service provider

Electricity

Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 13

Fuel oil, kerosene, etc.
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
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

Other fuel

No

No fuel used

16 Does this house, apartment, or mobile home use

solar power or photovoltaic panels that generate
electricity?
Yes
No

9

13022108

Housing (continued)
17 a. LAST MONTH, what was the cost of electricity 18 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

,

19 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 20a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 21.

OR
Included in rent or condominium fee

20 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

§.#6)¤

.00

b. Does the monthly rent include any meals?

Past 12 months’ cost – Dollars

$

,

10

C

13022116

Housing (continued)
C

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

Answer questions 21 – 25 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to question 27.

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

21 About how much do you think this house and lot, 25 a. Do you or any member of this household have
apartment, or mobile home (and lot, if owned)
a second mortgage or a home equity loan on
THIS property?

would sell for if it were for sale?
Amount – Dollars

Yes, home equity loan

$

,

.00

,

Yes, second mortgage
Yes, second mortgage and home equity loan

22 What are the annual real estate taxes on THIS
property?

No ➔ SKIP to

D

Annual amount – Dollars

$

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

.00

,
OR

Monthly amount – Dollars

None

$

OR

fiood insurance on THIS property?

No regular payment required

Annual amount – Dollars

$

.00

,

D

OR

.00

,

23 What is the annual payment for fire, hazard, and

Answer question 26 if this is a MOBILE HOME.
Otherwise, SKIP to to question 27.

None

24 a. Do you or any member of this household have
a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?

26 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.

Yes, mortgage, deed of trust, or similar debt

Annual costs – Dollars

Yes, contract to purchase

$

No ➔ SKIP to question 25a

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

,

.00

27 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.

Monthly amount – Dollars

$

,

.00

Yes

OR

No

No regular payment required ➔ SKIP to
question 25a

c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
Yes, taxes included in mortgage payment

E

No, taxes paid separately or taxes not required

§.#61¤

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.

13022124

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 level 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 1 YEAR OF SCHOOL COMPLETED

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

Less than 1 year of school completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school or preschool
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
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)

§.#69¤

12

13022132

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

§.#6A¤

13

Yes

No

13022140

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 with self care,
such as washing all over 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 Because of a physical, mental, or emotional

condition, does this person have difficulty doing
errands alone, such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

H

No difficulty
Some 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
climbing steps?

A lot of difficulty
Cannot do at all

21 What is this person’s marital status?
Now married

No difficulty

Widowed

Some difficulty

Divorced

A lot of difficulty

Separated

Cannot do at all

Never married ➔ SKIP to

§.#6I¤

14

J on the next page

13022157

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

§.#6Z¤

15

13022165

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

Ride-hailing services
(including taxi)

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

§.#6b¤

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

13022173

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.)?

§.#6j¤

17

13022181

Person 1 (continued)
d. Net rental income. Report income after expenses.
If net rental income was a loss, mark (X) the “Loss”
box next to the dollar amount.

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

,

Loss

TOTAL AMOUNT for 2019

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for 2019

f. Supplemental Security Income (SSI).

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 “No” box for each type of income NOT
received.

No

No

,

.00

TOTAL AMOUNT for 2019

$

No

,

,

.00

TOTAL AMOUNT for 2019

.00

,

TOTAL AMOUNT for 2019

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

i. 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.

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), 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.
Yes ➔

$

h. 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.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

,

TOTAL AMOUNT for 2019

Yes ➔

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.

$

.00

,

g. Any financial assistance from the state or local
welfare office. Do NOT include non-cash benefits,
such as energy or housing assistance, the Food Stamp
Program, or SNAP.

Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.

Yes ➔

$

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

Loss

44 Including all types of income, what was this

person’s total income in 2019? Add entries in
questions 43a to 43i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

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

$

,

,

.00

OR
None

TOTAL AMOUNT for 2019

➜

§.#6r¤

18

$

,

,

TOTAL AMOUNT for 2019

.00
Loss

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.

13022199

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 level 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 1 YEAR OF SCHOOL COMPLETED

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

Less than 1 year of school completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school or preschool
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
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)

§.#6ƒ¤

19

13022207

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

13022215

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 with self care,
such as washing all over 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 Because of a physical, mental, or emotional

condition, does this person have difficulty doing
errands alone, such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

H

No difficulty
Some 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
climbing steps?

A lot of difficulty
Cannot do at all

21 What is this person’s marital status?
Now married

No difficulty

Widowed

Some difficulty

Divorced

A lot of difficulty

Separated

Cannot do at all

Never married ➔ SKIP to

§.#70¤

21

J on the next page

13022223

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

§.#78¤

22

13022231

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

Ride-hailing services
(including taxi)

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

§.#7@¤

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

13022249

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.)?

§.#7R¤

24

13022256

Person 2 (continued)
d. Net rental income. Report income after expenses.
If net rental income was a loss, mark (X) the “Loss”
box next to the dollar amount.

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

,

Loss

TOTAL AMOUNT for 2019

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for 2019

f. Supplemental Security Income (SSI).

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 “No” box for each type of income NOT
received.

No

No

,

.00

TOTAL AMOUNT for 2019

$

No

,

,

.00

TOTAL AMOUNT for 2019

.00

,

TOTAL AMOUNT for 2019

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

i. 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.

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), 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.
Yes ➔

$

h. 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.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

,

TOTAL AMOUNT for 2019

Yes ➔

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.

$

.00

,

g. Any financial assistance from the state or local
welfare office. Do NOT include non-cash benefits,
such as energy or housing assistance, the Food Stamp
Program, or SNAP.

Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.

Yes ➔

$

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

Loss

44 Including all types of income, what was this

person’s total income in 2019? Add entries in
questions 43a to 43i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

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

$

,

,

.00

OR
None

TOTAL AMOUNT for 2019

➜

§.#7Y¤

25

$

,

,

TOTAL AMOUNT for 2019

.00
Loss

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.

13022264

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 level 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 1 YEAR OF SCHOOL COMPLETED

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

Less than 1 year of school completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school or preschool
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
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)

§.#7a¤

26

13022272

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

§.#7i¤

27

Yes

No

13022280

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 with self care,
such as washing all over 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 Because of a physical, mental, or emotional

condition, does this person have difficulty doing
errands alone, such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

H

No difficulty
Some 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
climbing steps?

A lot of difficulty
Cannot do at all

21 What is this person’s marital status?
Now married

No difficulty

Widowed

Some difficulty

Divorced

A lot of difficulty

Separated

Cannot do at all

Never married ➔ SKIP to

§.#7q¤

28

J on the next page

13022298

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

§.#7¥¤

29

13022306

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

Ride-hailing services
(including taxi)

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

13022314

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.)?

§.#8/¤

31

13022322

Person 3 (continued)
d. Net rental income. Report income after expenses.
If net rental income was a loss, mark (X) the “Loss”
box next to the dollar amount.

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

,

Loss

TOTAL AMOUNT for 2019

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for 2019

f. Supplemental Security Income (SSI).

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 “No” box for each type of income NOT
received.

No

No

,

.00

TOTAL AMOUNT for 2019

$

No

,

,

.00

TOTAL AMOUNT for 2019

.00

,

TOTAL AMOUNT for 2019

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

i. 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.

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), 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.
Yes ➔

$

h. 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.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

,

TOTAL AMOUNT for 2019

Yes ➔

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.

$

.00

,

g. Any financial assistance from the state or local
welfare office. Do NOT include non-cash benefits,
such as energy or housing assistance, the Food Stamp
Program, or SNAP.

Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.

Yes ➔

$

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

Loss

44 Including all types of income, what was this

person’s total income in 2019? Add entries in
questions 43a to 43i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

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

$

,

,

.00

OR
None

TOTAL AMOUNT for 2019

➜

§.#87¤

32

$

,

,

TOTAL AMOUNT for 2019

.00
Loss

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.

13022330

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 level 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 1 YEAR OF SCHOOL COMPLETED

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

Less than 1 year of school completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school or preschool
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
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

13022348

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

§.#8Q¤

34

Yes

No

13022355

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 with self care,
such as washing all over 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 Because of a physical, mental, or emotional

condition, does this person have difficulty doing
errands alone, such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

H

No difficulty
Some 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
climbing steps?

A lot of difficulty
Cannot do at all

21 What is this person’s marital status?
Now married

No difficulty

Widowed

Some difficulty

Divorced

A lot of difficulty

Separated

Cannot do at all

Never married ➔ SKIP to

§.#8X¤

35

J on the next page

13022363

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

§.#8‘¤

36

13022371

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

Ride-hailing services
(including taxi)

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

§.#8h¤

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

13022389

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.)?

§.#8z¤

38

13022397

Person 4 (continued)
d. Net rental income. Report income after expenses.
If net rental income was a loss, mark (X) the “Loss”
box next to the dollar amount.

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

,

Loss

TOTAL AMOUNT for 2019

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for 2019

f. Supplemental Security Income (SSI).

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 “No” box for each type of income NOT
received.

No

No

,

.00

TOTAL AMOUNT for 2019

$

No

,

,

.00

TOTAL AMOUNT for 2019

.00

,

TOTAL AMOUNT for 2019

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

i. 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.

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), 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.
Yes ➔

$

h. 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.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

,

TOTAL AMOUNT for 2019

Yes ➔

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.

$

.00

,

g. Any financial assistance from the state or local
welfare office. Do NOT include non-cash benefits,
such as energy or housing assistance, the Food Stamp
Program, or SNAP.

Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.

Yes ➔

$

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

Loss

44 Including all types of income, what was this

person’s total income in 2019? Add entries in
questions 43a to 43i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

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

$

,

,

.00

OR
None

TOTAL AMOUNT for 2019

➜

§.#8¿¤

39

$

,

,

TOTAL AMOUNT for 2019

.00
Loss

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.

13022405

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 level 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 1 YEAR OF SCHOOL COMPLETED

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

Less than 1 year of school completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school or preschool
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
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

13022413

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

13022421

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 with self care,
such as washing all over 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 Because of a physical, mental, or emotional

condition, does this person have difficulty doing
errands alone, such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

H

No difficulty
Some 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
climbing steps?

A lot of difficulty
Cannot do at all

21 What is this person’s marital status?
Now married

No difficulty

Widowed

Some difficulty

Divorced

A lot of difficulty

Separated

Cannot do at all

Never married ➔ SKIP to

§.#96¤

42

J on the next page

13022439

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

§.#9H¤

43

13022447

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

Ride-hailing services
(including taxi)

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

§.#9P¤

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

13022454

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.)?

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45

13022462

Person 5 (continued)
d. Net rental income. Report income after expenses.
If net rental income was a loss, mark (X) the “Loss”
box next to the dollar amount.

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

,

Loss

TOTAL AMOUNT for 2019

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for 2019

f. Supplemental Security Income (SSI).

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 “No” box for each type of income NOT
received.

No

No

,

.00

TOTAL AMOUNT for 2019

$

No

,

,

.00

TOTAL AMOUNT for 2019

.00

,

TOTAL AMOUNT for 2019

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

i. 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.

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), 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.
Yes ➔

$

h. 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.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

,

TOTAL AMOUNT for 2019

Yes ➔

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.

$

.00

,

g. Any financial assistance from the state or local
welfare office. Do NOT include non-cash benefits,
such as energy or housing assistance, the Food Stamp
Program, or SNAP.

Mark (X) the “Yes” box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT.

Yes ➔

$

Yes ➔

$

No

TOTAL AMOUNT for 2019

.00

,

Loss

44 Including all types of income, what was this

person’s total income in 2019? Add entries in
questions 43a to 43i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

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

$

,

,

.00

OR
None

TOTAL AMOUNT for 2019

➜

§.#9_¤

46

$

,

,

TOTAL AMOUNT for 2019

.00
Loss

Now continue with the mailing instructions
on page 48.

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left blank

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47

13022488

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)V2 (05-13-2020)

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48