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pdf2022 Annual Social and Economic Supplement
Items Booklet - Feb/March/April 2022
2022 ANNUAL SOCIAL AND ECONOMIC SUPPLEMENT
CPS FIELD REPRESENTATIVE / CATI INTERVIEWER
ITEMS BOOKLET
This document does not contain any Title 13 data or other Personally Identifiable
Information. All data are fictitious and any resemblance to actual data is coincidental.
Consistent with Field Division Policy, any names referenced in practice interviews or other
exercises are not meant to refer to any actual businesses, schools, group quarters, or
persons, especially any current or former Census Bureau employees.
Table of Contents
1
BASIC CPS ITEMS ........................................................................................................................................ 3
1.1
1.2
1.3
MOVER ITEMS ........................................................................................................................................ 3
FAMILY INCOME ..................................................................................................................................... 3
INCDKR ................................................................................................................................................... 3
2
INTRODUCTION AND WORK EXPERIENCE ................................................................................................... 4
3
EARNED INCOME ...................................................................................................................................... 10
4
INCOME SOURCES ..................................................................................................................................... 23
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
4.17
4.18
4.19
5
UNEMPLOYMENT AND WORKERS COMPENSATION (SOURCE) .............................................................. 25
SOCIAL SECURITY (SOURCE) ................................................................................................................... 27
SOCIAL SECURITY FOR CHILDREN (SOURCE) ........................................................................................... 28
SUPPLEMENTAL SECURITY INCOME (SSI) (SOURCE) ............................................................................... 29
SUPPLEMENTAL SECURITY INCOME FOR CHILDREN (SSI) (SOURCE)....................................................... 30
DISABILITY INCOME (SOURCE) ............................................................................................................... 31
VETERANS PAYMENTS (SOURCE)............................................................................................................ 32
SURVIVOR BENEFITS (SOURCE) .............................................................................................................. 33
PUBLIC ASSISTANCE (SOURCE) ............................................................................................................... 34
FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) (SOURCE) .......................36
PENSIONS (SOURCE) ............................................................................................................................... 37
ANNUITIES (SOURCE) ............................................................................................................................. 38
RETIREMENT ACCOUNTS (SOURCE) ....................................................................................................... 38
INCOME-EARNING ACCOUNTS OUTSIDE OF RETIREMENT (SOURCE) ..................................................... 40
PROPERTY INCOME (SOURCE) ................................................................................................................ 43
EDUCATION ASSISTANCE (SOURCE) ....................................................................................................... 44
CHILD SUPPORT (SOURCE) ..................................................................................................................... 45
REGULAR FINANCIAL ASSISTANCE (SOURCE) ......................................................................................... 45
OTHER MONEY INCOME (SOURCE) ........................................................................................................ 46
INCOME AMOUNTS................................................................................................................................... 46
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
5.21
5.22
UNEMPLOYMENT AND WORKER’S COMPENSATION (AMOUNTS).......................................................... 47
SOCIAL SECURITY (AMOUNTS) ................................................................................................................ 54
SOCIAL SECURITY DISABILITY (AMOUNTS) .............................................................................................. 56
SOCIAL SECURITY FOR CHILDREN (AMOUNTS) ........................................................................................ 58
SUPPLEMENTAL SECURITY INCOME (SSI) (AMOUNTS) ............................................................................ 60
SUPPLEMENTAL SECURITY INCOME FOR CHILDREN (AMOUNTS) ........................................................... 62
DISABILITY INCOME (AMOUNTS) ............................................................................................................ 64
VETERANS PAYMENTS (AMOUNTS) ........................................................................................................ 68
SURVIVOR BENEFITS – AMOUNTS ........................................................................................................... 71
PUBLIC ASSISTANCE (AMOUNTS) ............................................................................................................ 77
FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) (AMOUNTS) ....................79
PENSIONS (AMOUNTS) ........................................................................................................................... 81
ANNUITIES (AMOUNTS) .......................................................................................................................... 84
WITHDRAWALS/DISTRIBUTIONS FROM RETIREMENT PLAN (AMOUNTS) .............................................. 86
INTEREST/DIVIDENDS ON RETIREMENT ACCOUNTS (AMOUNTS) ........................................................... 90
INTEREST/DIVIDENDS ON NON-RETIREMENT ACCOUNTS (AMOUNTS) .................................................. 92
PROPERTY INCOME (AMOUNTS)............................................................................................................. 95
EDUCATIONAL ASSISTANCE (AMOUNTS) ............................................................................................... 97
CHILD SUPPORT (AMOUNTS) ............................................................................................................... 100
REGULAR FINANCIAL ASSISTANCE (AMOUNTS) .................................................................................... 101
OTHER MONEY INCOME (AMOUNTS) ................................................................................................... 103
CONTRIBUTIONS TO RETIREMENT ACCOUNTS (AMOUNTS) ................................................................. 105
1
6
HEALTH INSURANCE ................................................................................................................................ 105
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
INTRODUCTION TO HEALTH INSURANCE SECTION ............................................................................ 105
CURRENT COVERAGE ......................................................................................................................... 106
TYPE OF COVERAGE............................................................................................................................ 107
MONTHS OF COVERAGE..................................................................................................................... 112
OTHER HOUSEHOLD MEMBERS ......................................................................................................... 115
ADDITIONAL PLANS ............................................................................................................................ 117
EMPLOYER-SPONSORED INSURANCE OFFERS AND TAKEUP .............................................................. 117
HEALTH STATUS ................................................................................................................................. 119
MEDICAL EXPENDITURES ................................................................................................................... 119
7
EMPLOYER’S PENSION PLAN ................................................................................................................... 121
8
LOW INCOME ITEMS ............................................................................................................................... 121
8.1
8.2
8.3
8.4
9
MIGRATION ............................................................................................................................................ 124
9.1
10
SCHOOL LUNCHES .............................................................................................................................. 121
PUBLIC HOUSING ............................................................................................................................... 122
WOMEN, INFANTS, AND CHILDREN NUTRITION PROGRAM (WIC)..................................................... 122
ENERGY ASSISTANCE .......................................................................................................................... 123
1-YEAR MIGRATION ........................................................................................................................... 124
SUPPLEMENTAL POVERTY MEASURE ....................................................................................................... 129
10.1
10.2
10.3
10.4
PROPERTY VALUE/PRESENCE OF MORTGAGE.................................................................................... 129
CHILD CARE ........................................................................................................................................ 130
CHILD SUPPORT PAID ......................................................................................................................... 131
STIMULUS/ADVANCE CHILD TAX CREDIT QUESTIONS........................................................................ 133
2
1 BASIC CPS ITEMS
1.1 MOVER ITEMS
HH32b
Did (you/name of reference person) live at this address during the week of
November 19, 2021?
1
2
Yes
No
HH32d
Did any of the following household members live here during the week of
November 19, 2021?
1
2
Yes
No
1.2 FAMILY INCOME
S_FAMINC
Which category represents the total combined income of all members of this
FAMILY during the past 12 months?
This includes money from jobs, net income from business, farm or rent, pensions,
dividends, interest, social security payments and any other money income received
by members of this family who are 15 years of age or older?
1
2
3
4
5
6
7
8
Less than $5,000
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 19,999
20,000 to 24,999
25,000 to 29,999
9
10
11
12
13
14
15
16
30,000 to 34,999
35,000 to 39,999
40,000 to 49,999
50,000 to 59,999
60,000 to 74,999
75,000 to 99,999
100,000 to 149,000
150,000 to more
1.3 INCDKR
Is the combined income of all members of this FAMILY during the past 12 months
above or below $75,000?
1
2
Above
Below
3
2 INTRODUCTION and WORK EXPERIENCE
Pr_incom
?[F1] Importance of responding
Wording of introduction is optional.
The questions you just answered were about your job and economic status last week.
The next set of questions ask about your job and economic status last year.
1
Enter 1 to Continue
Q29a
Did (name/you) work at a job or business at any time during 2021?
1
2
Yes
No
Q29b
Did (you/he/she) do any temporary, part-time, or seasonal work even
for a few days during 2021?
Include any Military Reserves or National Guard work.
1
2
Yes
No
Q30
Even though (name/you) did not work in 2021, did (you/he/she) spend any time
trying to find a job or on layoff?
1
2
Yes
No
Q31
How many different weeks (was/were) (name/you) looking for work or on layoff
from a job?
(01-52) Number of weeks
________________
4
Q32
What was the main reason (you/he/she) did not work in 2021?
Read categories if necessary
1
2
3
4
5
6
Ill, or disabled and unable to work
Retired
Taking care of home or family
Going to school
Could not find work
Doing something else
Q33
During 2021 in how many weeks did (name/you) work even for a few hours?
Include paid vacation and sick leave as work.
(01-52) Number of weeks
Enter 97 if respondent can only answer in months
________________
Q33mon
Enter number of months worked
(1-12)
________________
Q33ver
Then (name/you) worked about (number) weeks. Is that correct?
1
2
Yes
No – back to Q33 and obtain estimate
Q35
Did (name/you) lose any full weeks of work in 2021 because (you/he/she)
(were/was) on layoff from a job or lost a job?
Number of weeks worked in 2021: (number)
1
2
7
Yes
No
Mistake made in number of weeks worked last year - Specify in Q35SP
Q35SP
5
Specify mistake made in number of weeks worked last year
_________________________________________________
Q36
You said (name/you) worked about (number) (week/weeks).
How many OF THE REMAINING (number) WEEKS (was/were)
(you/he/she) looking for work or on layoff from a job?
Enter 0 for none
________________
Q37
Were the (number) weeks (name/you) (was/were) looking for work or on layoff all in
one stretch?
1
2
3
Yes – one stretch
No – two stretches
No – 3 or more stretches
Q38
What was the main reason (name/you) (was/were) not working or looking for work
in the remaining weeks of 2021?
Read list only if respondent is having difficulty answering the question
1
2
3
Ill, or disabled and unable to work
Taking care of home or family
Going to school
4
5
6
Retired
No work available
Other (Specify - Q38sp)
Q38sp
Enter verbatim response
_________________________________________________
Q39
For how many employers did (name/you) work in 2021?
If more than one at the same time, only count it as one employer.
1
2
3
One
Two
Three or more
Q41
6
In the (one week/weeks) that (name/you) worked, how many hours did (you/he/she)
(work that week?/usually work per week?)
Enter number of hours
_______________
Q43
During 2021, were there one or more weeks in which (name/you) worked less than
35 hours?
Exclude time off with pay because of holidays, vacation, days off, or sickness.
1
2
Yes
No
Q44
In the weeks that (name/you) worked, how many weeks did (name/you) work less
than 35 hours in 2021?
Number of weeks worked in 2021: (number)
(Number of weeks was reported in item Q33)
(1-52)
________________
Q45
What was the main reason (name/you) worked less than 35 hours per week?
Read list only if respondent is having difficulty answering the question
1
2
3
4
Could not find a full time job
Wanted to work part time or only able to work part time
Slack work or material shortage
Other reason
Q46
What was (name's/your) longest job during 2021?
Was it:
(IO1NAM:) (name of employer)
(IO1IND:) (kind of business or industry)
(IO1OCC:) (occupation)
(IO1DT:) (duties)
7
CLASS OF WORKER: (PRIVATE/ FEDERAL GOVERNMENT/ STATE
GOVERNMENT/ LOCAL GOVERNMENT/WORKING WITHOUT PAY IN
FAMILY BUS./ SELF EMPLOYED--INCORPORATED/ SELF EMPLOYED-UNINCORPORATED)
1
2
Same as listed
Different job
Q47a
For whom did (name/you) work (?/at) (blank/(your/his/her) (blank/longest job
during 2021?))
Name of Company, business, organization or other employer
(blank/ IO1NAM:) (entry)
The current employer is pre-filled in the Form Pane below. Press ENTER if Same)
(blank/ If longest job last year is military job, enter Armed Forces)
(blank/ Enter N for no work done at all during 2021)
_________________________________________________
Q47b
What kind of business or industry is this?
For example: TV and radio manufacturing, retail shoe store, farm
(blank/ IO1IND:) (entry)
The current business or industry type is pre-filled in the Form Pane below. Press ENTER
if Same)
(blank/ If longest job last year is military job, enter NA)
_________________________________________________
Q47b1
Is this business or organization mainly manufacturing, retail trade, wholesale trade,
or something else?
(blank/ IO1MFG:) (entry)
The current business or organization type is pre-filled in the Form Pane below. Press
ENTER if Same)
(blank/ If longest job last year is military job, enter 4)
1
2
Manufacturing
Retail trade
8
3
4
Wholesale trade
Something else
Q47c
What kind of work (was/were) (you/he/she) doing?
For example: Electrical Engineer, Stock Clerk, Typist
(blank/ IO1OCC:) (entry)
The current occupation is pre-filled in the Form Pane below. Press ENTER if Same)
(blank/ If longest job last year is military job, enter Armed Forces)
_________________________________________________
Q47d1
What were (your/his/her) most important activities or duties?
For example: Types, keeps account books, files, sells cars, operates printing press,
finishes concrete.
(blank/ IO1DT:) (entry)
The current job description is pre-filled in the Form Pane below. Press ENTER if Same)
(blank/ If longest job last year is military job, enter NA)
_________________________________________________
Q47d2
What were (your/his/her) most important activities or duties?
For example: Types, keeps account books, files, sells cars, operates printing press,
finishes concrete.
(blank/ IO1DT:) (entry)
The current job description is pre-filled in the Form Pane below. Press ENTER if Same)
(blank/ If longest job last year is military job, enter NA)
_________________________________________________
Q47E1
Ask Only If Necessary
(Were/Was) (you/he/she) employed by government, by a PRIVATE company, a
nonprofit organization, or (was/were) (you/he/she) self-employed or working in a
family business?
1
2
Government
Private for profit company
9
3
4
5
Non profit organization including tax exempt and charitable organizations
Self employed
Working in family business
Q47E1a
Would that be the federal, state, or local government?
1
2
3
Federal
State
Local (county, city, township)
Q47E1b
Was this business incorporated?
1
2
Yes
No
Q47E1c
(Were/Was) (you/name) the owner of the business?
1
2
Yes
No
Q4788
Counting all locations where (this employer/(name/you)) (operates/operate), what is
the total number of persons who work for ((name's/your) employer)/name/you))?
Read categories if necessary
1
2
3
4
5
6
under 10
10-49
50-99
100-499
500-999
1,000+
3 EARNED INCOME
The Earnings and Income question series include range follow-up questions presented
anytime a respondent doesn’t know or refuses to provide an exact dollar amount for a
source they (or someone in the household) indicates as having received. Follow-up
questions allow respondents that do not feel comfortable giving exact dollar values to
report an income range. There are three sets of categories used for the income range
follow-up questions: high-range, mid-range, and low-range. The income range used in
10
the follow-up range questions depends on the source of the income. See Attachment A to
this items booklet for the three levels of income range follow up questions. See
Attachment B for a table that displays the income source and the range level used for the
follow-up questions.
Q48aa
How much did (name/you) earn from this employer before taxes and other
deductions during 2021?
Enter dollar amount
Enter 0 for none
________________
Q48aarn1 Ask only if the respondent “Doesn’t know” or ‘Refused” Q48aa
Could you tell me if (name/you) earned
less than $45,000
between $45,000 and $60,000
or over $60,000
for the TOTAL yearly amount from this employer before taxes and other
deductions during 2021?
1
2
3
Less than $45,000
Between $45,000 and $60,000
Over $60,000
Q48aarn2
Did (name/you) earn
less than $15,000
between $15,000 and $30,000
or over $30,000
from this employer during 2021?
1
2
3
Less than $15,000
Between $15,000 and $30,000
Over $30,000
Q48aap
Read if necessary
Is this a weekly, every other week, twice a month, monthly, or yearly amount?
11
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q48a1
For how many (weekly/every other week/twice a month/monthly) pay periods did
(name/you) earn (fill from Q48aa) from this employer in 2021?
(1-12/1-24/1-26/1-52)
________________
Q48aC2
Q48aV
Do not read to the respondent.
The annual rate appears out of range. The total annual earnings entered is (amount). Is
this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.
According to my calculations (name/you) earned (total) altogether from this
employer in 2021 before deductions. Does that sound about right?
Q48a2
1
2
Yes
No
What is your best estimate of (name's/your) correct total amount of earnings from
this employer during 2021 before deductions?
PREVIOUS ENTRIES:
Q48aa: (amount)
Q48aap: (periodicity)
Q48a1: (number of pay periods)
Enter dollar amount
________________
Q48a3
Does this amount include all tips, bonuses, overtime pay, or commissions
(name/you) may have received from this employer in 2021?
1
2
Yes
No
Q48aad
12
How much did (name/you) earn in tips, bonuses, overtime pay, or commissions from
this employer in 2021?
Enter dollar amount
________________
Q48aadrn1 Ask only if the respondent “Doesn’t know” or “Refused” Q48aad
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $3,000
or over $3,000
in tips, bonuses, overtime pay, or commissions from this employer during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q48aadrn2
Did (name/you) earn
less than $100
between $100 and $500
or over $500
in tips, bonuses, overtime pay, or commissions from this employer during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q48b
What were (name's/your) net earnings from this business/farm after expenses
during 2021?
If response is "Broke Even" then enter 1
If response is “none” or if respondent does not own a business or farm, then enter "0"
If response is "Lost Money" press Enter
Enter dollar amount
________________
Q48b_char
13
Enter “L” for Lost Money
________________
Q48BL
Enter amount of money lost in 2021
Enter annual amount only
________________
Q48brn1 Ask only if the respondent “Doesn’t know” or “Refused” Q48b.
Could you please tell me if (name/you) earned
less than $45,000
between $45,000 and $60,000
or over $60,000
for the TOTAL yearly amount from this business/farm after expenses during 2021?
1
2
3
Less than $45,000
Between $45,000 and $60,000
Over $60,000
Q48brn2
Did (name/you) earn
less than $15,000
between $15,000 and $30,000
or over $30,000
from this business/farm after expenses during 2021?
1
2
3
Less than $15,000
Between $15,000 and $30,000
Over $30,000
Q48bp
Is this a weekly, every other week, twice a month, monthly, quarterly, or yearly
amount?
1
2
3
4
5
7
Weekly
Every other week
Twice a month
Monthly
Quarterly
Yearly
14
Q48B1A
Do not read to the respondent.
The annual rate appears out of range. The total annual business loss entered is (amount).
Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.
Q48B1B
Do not read to the respondent.
The annual rate appears out of range. The total annual business income entered is
(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and
correct entry.
Q48b2
What is your best estimate of (name's/your) ANNUAL net earnings from this
business/farm after expenses in 2021?
PREVIOUS ENTRIES: Q48b : (amount)
Q48bp: (periodicity)
Enter dollar amount
Q48b2L
What is your best estimate of (name's/your) ANNUAL net LOSS from this
business/farm after expenses in 2021?
PREVIOUS ENTRIES: Q48bL: (amount)
Q48bp: (periodicity)
Enter dollar amount
________________
Q48b3
What were (name's/your) net earnings from this business/farm during the FIRST
quarter of 2021?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is “Lost Money” press enter
Enter dollar amount
________________
Q48b3_char
15
Enter "L" for Lost Money
________________
Q48B3L
Enter amount of money lost in the first quarter of 2021.
________________
Q48b4
What were (name's/your) net earnings from this business/farm during the SECOND
quarter of 2021?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is "Lost Money" press enter
Enter dollar amount
________________
Q48b4_char
Enter "L" for Lost Money
________________
Q48B4L
Enter amount of money lost in the second quarter of 2021.
________________
Q48b5
What were (name's/your) net earnings from this business/farm during the THIRD
quarter of 2021?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is "Lost Money" press enter
Enter dollar amount
________________
Q48b5_char
Enter "L" for Lost Money
________________
Q48B5L
Enter amount of money lost in the third quarter of 2021.
16
________________
Q48b6
What were (name's/your) net earnings from this business/farm during the FOURTH
quarter of 2021?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is "Lost Money" press enter
Enter dollar amount
________________
Q48b6_char
Enter "L" for Lost Money
________________
Q48B6L
Enter amount of money lost in the fourth quarter of 2021.
________________
Q48b7
Does this amount include all tips, bonuses, overtime pay, or commissions
(name/you) may have received from this business in 2021?
1
2
Yes
No
Q48bad
How much did (name/you) earn in tips, bonuses, overtime pay, or commissions
in 2021?
Enter dollar amount
________________
Q48badrn1 Ask only if the respondent “Doesn’t know” or “Refused” Q48bad.
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $3,000
or over $3,000
in tips, bonuses, overtime pay, or commissions from this business during 2021?
17
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q48badrn2
Did (name/you) earn
less than $100
between $100 and $500
or over $500
in tips, bonuses, overtime pay, or commissions during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q49a
Did (name/you) earn money from any other work (you/he/she) did during 2021?
1
2
Yes
No
Q49b1d
How much did (name/you) earn from all other employers before taxes and other
deductions during 2021?
Enter dollar amount
Enter “0” for None
________________
Q49b1drn1 Ask only if the respondent “Doesn’t know” or “Refused” Q48b1d.
Could you please tell me if (name/you) earned
less than $10,000
between $10,000 and $20,000
or over $20,000
from all other employers before taxes and other deductions during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
18
Q49b1drn2
Did (name/you) earn
less than $1,000
between $1,000 and $5,000
or over $5,000
from all other employers before taxes and other deductions during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q49b1p
Read if necessary
Is this a weekly, every other week, twice a month, monthly, or yearly amount?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q49B11
For how many (weekly/every other week/twice a month/monthly) pay periods did
(name/you) earn (fill from Q49b1d) from all other employers in 2021?
(1-12/1-24/1-26/1-52)
________________
Q49B1C
Do not read to the respondent.
The total annual earnings entered from all other employers is (amount). Is this a correct
entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.
Q49B1V
According to my calculations (name/you) earned (total) altogether from all other
employers in 2021. Does that sound about right?
1
2
Yes
No
19
Q49B12
What is your best estimate of (name's/your) correct total amount of earnings from
all other employers during 2021?
PREVIOUS ENTRIES:
Q49b1d: (amount)
Q49b1p: (periodicity)
Q49b11: (number of pay periods)
Enter dollar amount
________________
Q49b13
Does this amount include all tips, bonuses, overtime pay, or commissions
(name/you) may have received from all other employers in 2021?
1
2
Yes
No
Q49B1A
How much did (name/you) earn in tips, bonuses, overtime pay, or commissions from
all other employers in 2021?
Enter dollar amount
________________
Q49B1ARN1 Ask only if the respondent “Doesn’t know” or “Refused” Q49B1A.
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $3,000
or over $3,000
in tips, bonuses, overtime pay, or commissions from all other employers in 2021?
1
2
3
Less than $1,000 (proceed to Q49B1ARN2)
Between $1,000 and $3,000
Over $3,000
Q49B1ARN2
Did (name/you) earn
20
less than $100
between $100 and $500
or over $500
in tips, bonuses, overtime pay, or commissions from all other employers in 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q49b2
How much did (name/you) earn from (blank/any other businesses of) (your/his/her)
(own/own business) after expenses?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is "Lost Money" press enter
Enter annual amount only
________________
Q49b2rn1 Ask only if the respondent “Doesn’t know” or “Refused” Q49b2
Could you tell me if (name/you) earned
less than $10,000
between $10,000 and $20,000
or over $20,000
from (blank/any other businesses of) (your/his/her) (own/own business) after
expenses?
1
2
3
Less than $10,000 (proceed to Q49b2rn2)
Between $10,000 and $20,000
Over $20,000
Q49b2rn2
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $5,000
or over $5,000
from (blank/any other businesses of) (your/his/her) (own/own business) after
expenses?
1
Less than $1,000
21
2
3
Between $1,000 and $5,000
Over $5,000
Q49b2_char
Enter "L" for Lost Money
________________
Q49b3
Enter annual amount lost only
____________
Q49b4
How much did (name/you) earn from (your/his/her) farm after expenses?
If response is "Broke Even" then enter 1
Enter "0" for None
If response is "Lost money" press enter
Enter annual amount only
_______________
Q49b4rn1 Ask only if the respondent “Doesn’t know” or “Refused” Q49b4.
Could you tell me if (name/you) earned
less than $10,000
between $10,000 and $20,000
or over $20,000
from (your/his/her) farm after expenses?
1
2
3
Less than $10,000 (proceed to Q49b4rn2)
Between $10,000 and $20,000
Over $20,000
Q49b4rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
from (your/his/her) farm after expenses?
1
Less than $1,000
22
2
3
Between $1,000 and $5,000
Over $5,000
Q49b4_char
Enter "L" for Lost Money
________________
Q49b5
Enter annual amount lost only
________________
4 INCOME SOURCES
In the ASEC income section, the order of the questions changes based on the household
composition (Low-income, Householder or Spouse Aged 62 or Older, or Default); see chart on
the following page. All low-income transfer program questions are asked in each interview
regardless of household family income.
23
Householder or Spouse
62 Years +
Default
Low Income
Earnings- Person Level
Unemployment/Workers
1
Compensation
Social Security/SS for
2
Children
Supplemental Security
3
Income (SSI)/SSI Children
Earnings- Person Level
Unemployment/Workers
1
Compensation
4
Disability
2
5
Veterans
6
7
Public Assistance / TANF
8
3
Food Stamps (SNAP)
Social Security/SS for
Children
Supplemental Security
Income (SSI)/SSI Children
Survivor Benefits
4
7
Public Assistance / TANF
8
Earnings- Person Level
Unemployment/Workers
1
Compensation
Social Security/SS for
2
Children
Supplemental Security
3
Income (SSI)/SSI Children
4
Disability
5
Veterans
Disability
6
Survivor Benefits
5
Veterans
9
Pensions
Food Stamps (SNAP)
6
Survivor Benefits
10
9
Pensions
9
Pensions
11
10
10
13
Property Income
12
Annuities
Retirement Accounts (within)
– Withdrawals or
distributions
Other Income Earning Assets
(outside of retirement)
12
12
Annuities
Retirement Accounts (within)
– Withdrawals or
distributions
Other Income Earning Assets
(outside of retirement)
Annuities
Retirement Accounts
(within) –Withdrawals or
distributions
Other Income Earning Assets
(outside of retirement)
7
Public Assistance / TANF
13
Property Income
13
Property Income
8
Food Stamps (SNAP)
14
Education Assistance
14
Education Assistance
14
Education Assistance
15
15
16
Child Support
Financial Assistance from
friends or relatives
15
16
Child Support
Financial Assistance from
friends or relatives
16
Child Support
Financial Assistance from
friends or relatives
17
Other Income
17
Other Income
17
Other Income
*
Health Insurance
18
Employers Pension Plan
19
School Lunches- no amount collection
20
Public Housing- no amount collection
21
WIC- no amount collection
22
Energy Assistance
11
11
24
4.1 UNEMPLOYMENT AND WORKERS COMPENSATION (Source)
Q51A1
At any time during 2021 did (you/anyone in the household) receive any State or
Federal unemployment compensation?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1 Yes
2 No
Q51A1b
Read only if necessary
Who received State or Federal unemployment compensation?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q51A2
At any time during 2021 did (you/anyone in the household) receive any
Supplemental Unemployment Benefits (SUB)?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1 Yes
2 No
Q51A2b
Read only if necessary
Who received Supplemental Unemployment Benefits?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q51A3
At any time during 2021 did (you/anyone in the household) receive any Union
Unemployment or Strike Benefits?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1 Yes
25
2 No
Q51A3b
Read only if necessary
Who received Union Unemployment or Strike Benefits?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q52A
During 2021 did (you/anyone in the household) receive any Worker’s Compensation
payments or other payments as a result of a job related injury or illness?
Exclude sick pay and/or disability retirement.
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1 Yes
2 No
Q52Ab
Read only if necessary
Who received Worker’s Compensation or payments as a result of a job related
injury or illness?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Exclude those who received sick pay and/or disability retirement.
Q52b
What was the source of (your/name’s) payments?
1 State Worker's Compensation
2 Employer or employer's insurance worker’s compensation
3 Own insurance worker’s compensation
4 Other
Q52Cs1
Specify other source from workers compensation/insurance
Enter "Worker’s Compensation" if the answer is "Don't Know"
________________________________________________
26
4.2 SOCIAL SECURITY (Source)
Q56a
During 2021 did (you/ anyone in this household) receive any Social Security
payments from the U.S. Government?
1 Yes
2 No
Q56b
Read only if necessary
Who received Social Security payments either for themselves or as combined
payments with other family members?
Enter Line Number Of Parent Or Guardian For Payments Made To Children Under
Age 15
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone else?
SSR
What were the reasons (name/you) (was/were) getting Social Security in 2021?
Mark all that apply, separate using the space bar or a comma.
Probe: Any Other Reason?
1
2
3
4
5
6
7
8
Retired
Disabled
Widowed
Spouse
Surviving child
Dependent child
On behalf of surviving, dependent, or disabled children
Other
SSRs
Specify other reason
________________________________________________
27
SSC
Which children under age 19 were receiving Social Security in 2021?
Probe: Anyone Else?
Enter all that apply, separate by commas.
Enter 96 for All People Enter 0 for None
SSCR
What were the reasons (Child’s name/the children) (was/were) getting Social
Security in 2021?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Reason?
1 Disabled child/children
2 Surviving child/children
3 Dependent child/children
4 Other
SSDIa1
Did (name/you) receive (your/his/her) first Social Security Disability payment in
2021?
1
2
Yes
No
4.3 SOCIAL SECURITY FOR CHILDREN (Source)
Q56f
Did anyone in this household receive any Social Security income in 2021 that we
have not already counted on behalf of children in this household?
Includes all children under 19 years of age
1
2
Yes
No
Q56g
Read only if necessary
Who received these Social Security payments?
28
Enter line number of parent or guardian
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
CSS
Which children under age 19 were receiving Social Security in 2021?
Probe: Anyone Else?
Enter all that apply, separate using the space bar or a comma.
Enter 0 if none listed
Enter 96 for all persons
CRSS
What were the reasons (Child's name/the children) (was/were) getting Social
Security in 2021?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Reason?
1
2
3
4
Disabled child/children
Surviving child/children
Dependent child/children
Other
4.4 SUPPLEMENTAL SECURITY INCOME (SSI) (Source)
Q57a
During 2021 did (you/ anyone in this household) receive:
any SSI payments, that is, Supplemental Security Income?
Note: SSI are assistance payments to low-income aged, blind and disabled persons,
and come from state or local welfare offices, the Federal government, or both.
1
2
Yes
No
Q57b
Read only if necessary
Who received SSI?
Supplemental Security Income
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
29
SSIR
What were the reasons (name/you) (was/were) getting Supplemental Security
Income in 2021?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Reason?
1
2
3
4
5
Disabled
Blind
On behalf of a disabled child
On behalf of a blind child
Other ________________
4.5 SUPPLEMENTAL SECURITY INCOME FOR CHILDREN (SSI)
(Source)
Q57d
Did anyone in this household receive any Supplemental Security Income in 2021
that we have not already counted on behalf of children in this household?
Includes all children under 18 years of age
SSI previously reported will appear here
LN Name
1
2
Q57e
Amount for Q57C amount
Yes
No
Read only if necessary
Who received these Supplemental Security Income payments?
Enter line number of parent or guardian
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
RSSI
What were the reasons (name/you) (was/were) getting Supplemental Security
Income on behalf of children in 2021?
Enter all that apply, separate using the space bar or a comma.
30
Probe: Any Other Reason?
1
2
3
On behalf of a disabled child/children
On behalf of a blind child/children
Other ________________
CSSI
Which children under age 18 were receiving Supplemental Security Income
in 2021?
Probe: Anyone Else?
Enter all that apply, separate using the space bar or a comma.
Enter 0 if none listed
Enter 96 for all persons
4.6 DISABILITY INCOME (Source)
Q59AR
At any time in 2021 (did you/did anyone in the household) have a disability or health
problem which prevented (you/them) from working, even for a short time, or which
limited the work (you/they) could do?
1
2
Q59b
Yes
No
Read only if necessary
Who is that?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q60a
(Did you/Is there anyone in this household who) ever (retire or leave/ retired or left)
a job for health reasons?
1
2
Q60b
Yes
No
Read only if necessary
Who is that?
31
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q61b
Did (you/name) receive any income in 2021 as a result of (your/his/her) health
problem (other than Social Security Disability/other than VA benefits/ other than
Social Security Disability or VA Benefits)?
( If amount was reported previously as compensation from a job related injury or
illness, then enter <2>. Amount previously reported in Q52CT was (amount).)
Do not include Veterans’ payments.
1
2
Yes
No
Q61C
What was the source of this income?
Asking About: (name) (blank/- -CURRENT RESPONDENT)
Enter all that apply, separate using the space bar or a comma.
Probe: Any other income related to this health condition or disability?
2
3
4
5
6
7
8
9
10
11
Worker’s compensation
Company or union disability
Federal Government (CIVIL SERVICE) disability
U.S. Military retirement disability
State or Local government employee disability
U.S. Railroad retirement disability
Accident or disability insurance
Black Lung miner’s disability
State temporary sickness
Other or don’t know – Specify – Enter last
Q61Cs1
Specify other source from health problem or disability
Enter "Other Health Problem/Disability" if the answer is "Don't Know"
_____________________________________________
4.7 VETERANS PAYMENTS (Source)
Q60A88
At any time during 2021 did (you/anyone in this household) receive:
32
Any Veterans’ (VA) payments?
Include assistance received by children of veterans
1
2
Yes
No
Q60b_88
Read only if necessary
Who received Veterans’ (VA) payments either for themselves or as combined
payments with other family members?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q60C8
What type of Veterans' payment did (name/you) receive?
Read list only if respondent is having difficulty answering the question.
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Payments?
1 Service-connected disability compensation
2 Survivor Benefits
3 Veterans’ Pension
4 Educational assistance (including assistance received by children of veterans)
5 Other Veterans’ payments ________________
Q60D88
(Are/Is) (name/you) required to fill out an annual income questionnaire for the
Department of Veterans' Affairs?
1
2
Yes
No
4.8 SURVIVOR BENEFITS (Source)
Q58a
Did (you/ anyone in this household) receive any survivor benefits in 2021 such as
widow’s pensions, estates, trusts, insurance annuities, or any other survivor benefits
(other than Social Security/ other than VA benefits/ other than Social Security or
VA benefits)?
33
1
2
Q58b
Yes
No
Read only if necessary
Who received this income?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q58C
What was the source of this income?
Asking About: (name/name- -CURRENT RESPONDENT)
Read list if respondent is having difficulty answering the question
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Source?
2
3
4
5
6
7
8
9
10
11
Company or union survivor pension (INCLUDE PROFIT SHARING)
Federal Government survivor (CIVIL SERVICE) pension
U.S. Military retirement survivor pension
State or Local government survivor pension
U.S. Railroad retirement survivor pension
Worker's compensation survivor pension
Black Lung survivor pension
Regular payments from estates or trusts
Regular payments from annuities or paid-up insurance policies
Other or don't know (SPECIFY) - ENTER LAST
Q58Cs1
Specify other source of income as survivor or widow
Enter "Survivor Benefits" if the answer is "Don't Know"
________________________________________________
4.9 PUBLIC ASSISTANCE (Source)
Q59A88
At any time during 2021, even for one month, did (you/ anyone in this household)
receive any CASH assistance from a state or county welfare program such as
(State Program Name)?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
34
Include cash from:
Welfare or welfare to work
TANF
AFDC/Aid to Families
General Assistance
Diversion payments
Refugee Cash
Gen Assist Indian Affairs
1
2
Don’t include:
Food stamps (SNAP)
SSI
Energy assistance
WIC
School meals
Childcare
Education Assistance
Yes
No
Q59A89
Just to be sure, in 2021, did anyone receive CASH assistance from a state or county
welfare program, on behalf of CHILDREN in the household?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1
2
Yes
No
Q59b_88
Who received this CASH assistance?
Enter line number
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q59C8r
From what type of program did (name/you) receive the CASH assistance? Was it a
welfare or welfare to-work program such as (STATE PROGRAM NAME), General
Assistance, Emergency Assistance, Diversion payments or some other program?
Enter all that apply, separate using the space bar or a comma.
Probe: Any Other Program?
If respondent mentions any of the following categories:
Food Stamps
SSI
Energy Assistance
School Meals
Transportation
Child Care
Rental
Educational Assistance
35
Note this, but explain: “Right now we are interested in CASH assistance”. Seek
answers using the accepted categories
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1
2
3
4
5
6
7
(State Program Name)/Temporary Assistance to Needy Families (TANF)/
welfare/AFDC
General Assistance
Emergency Assistance/short-term cash assistance
Diversion Payments
Refugee Cash and Medical Assistance program
General Assistance from Bureau of Indian Affairs, or Tribal Administered General
Assistance
Some other program (specify)
Q59C8s
What was the name of the other program?
Specify other source of cash assistance
Enter "Cash" if the answer is "Don't Know"
_________________________________________________
4.10 FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) (Source)
Q87r
At any time during 2021, did (you/ anyone in this household) receive benefits from
SNAP (the Supplemental Nutritional Assistance Program) or the Food Stamp
program, or use a SNAP or food stamp benefit card?
Do not include WIC benefits.
1 Yes
2 No
Q87ar
At any time during 2021, even for one month, did (you/ anyone in this household)
receive any food assistance from (State Program name)?
Do not include WIC benefits.
Include SNAP (Supplemental Nutrition Assistance Program)
1 Yes
2 No
36
Q88
Which of the people now living here were covered by that food assistance
during 2021?
List all household members covered by food assistance regardless of age
Enter all that apply, separate using the space bar or a comma.
Enter 96 for All
Enter 0 for None
Probe: Anyone else?
4.11 PENSIONS (Source)
Q62Ar
During 2021 did (you/ anyone in this household) receive any pension income from a
previous employer or union, (other than Social Security/ other VA benefits/ other
than Social Security or VA benefits)?
PLEASE DO NOT INCLUDE DISTRIBUTIONS OR WITHDRAWALS FROM
IRAs, 401(k)s, OR SIMILAR ACCOUNTS!
1 Yes
2 No
Q62b
Read only if necessary
Who received pension income?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Enter persons line number (1-16)
Q62Cr
What was the source of (your/ NAME’s) pension income? Did (you/he/she) have a
pension from a:
READ EACH CATEGORY.
Enter all that apply, separate using the space bar or a comma.
1
2
Company
Union
37
3
4
5
6
7
Federal Government
State Government
Local Government
U.S. Military
Some other source
Q62DR
What was the source of (name's/your) other pension income?
Enter all that apply
Probe as needed: Who received this source?
Probe: Any Other pension income?
1 U.S. Railroad Retirement pension
2 Other source (specify) or “don’t know”
Q62Cs1
Specify other source of pension income
Enter "Other Pension" if the answer is "Don't Know"
4.12 ANNUITIES (Source)
Q96Ar
During 2021 did (you/ anyone in this household) receive any income from an
annuity?
1 Yes
2 No
Q96Br
Read only if necessary
Who received annuity income?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
4.13 RETIREMENT ACCOUNTS (Source)
Q97Ar
38
At any time during 2021 did (you/ anyone in this household) have any retirement
accounts such as a 401(k), 403(b), IRA, or other account designed specifically for
retirement savings?
1 Yes
2 No
Q97Br
Read only if necessary
Who had such a retirement account?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q97Cr
What type of retirement account did (you/ NAME) have? Did (you/he/she) have…
READ EACH CATEGORY
Enter all that apply, separate using the space bar or a comma.
1
2
3
4
401(k)
403(b)
Roth IRA
Regular IRA
5. KEOGH plan (“KEE-OH”)
6. SEP plan (Simplified Employee Pension)
7. another type of retirement account
Q97Dr
What was the source of (name's/your) retirement income?
Enter other source of retirement income
Enter “Other Retirement” if the answer is “Don’t Know”
Q98Ar(1-7)
Did (you/NAME) withdraw any money or receive a distribution from (your/his/her)
[ACCOUNT TYPE_ FILL IN FROM Q97CR or Q97DR] in 2021 (, including any
distributions (you/he/she) may have been required to take)?
1 Yes
2 No
39
4.14 INCOME-EARNING ACCOUNTS OUTSIDE OF RETIREMENT
(Source)
Q99ARa
Now I will ask about assets that may have paid interest or dividends in 2021 outside
of the retirement accounts.
At any time during 2021, did (you/anyone in this household):
Have money in an interest-earning checking account?
1 Yes
2 No
Q99Ba
Ask only if necessary
Which members of this household ages 15 and over had an interest-earning checking
account?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARb
At any time during 2021, did (you/anyone in this household):
Have money in a savings account?
1 Yes
2 No
Q99Bb
Ask only if necessary
Which members of this household ages 15 and over had savings accounts?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARc
40
At any time during 2021, did (you/anyone in this household):
Have money in a money market fund?
1 Yes
2 No
Q99Bc
Ask only if necessary
Which members of this household ages 15 and over had a money market fund?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARd
At any time during 2021, did (you/anyone in this household):
Have money in CDs (certificates of deposit)?
1 Yes
2 No
Q99Bd
Ask only if necessary
Which members of this household ages 15 and over had CDs (certificates of deposit)?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARe
At any time during 2021, did (you/anyone in this household):
Have money in savings bonds?
1 Yes
2 No
41
Q99Be
Ask only if necessary
Which members of this household ages 15 and over had savings bonds?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARf
At any time during 2021, did (you/anyone in this household):
Have money in shares of stock in corporations or mutual funds?
1 Yes
2 No
Q99Bf
Ask only if necessary
Which members of this household ages 15 and over had shares of stock in corporations or
mutual funds?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
Probe: Anyone else?
Q99ARg
At any time during 2021, did (you/anyone in this household):
Have money in any other savings or investments that pay interest or dividends?
1 Yes
2 No
Q99Bg
Ask only if necessary
Which members of this household ages 15 and over had any other savings or investments
that paid interest or dividends?
Include each person in cases of joint accounts or ownership
Enter all that apply, separate using the space bar or a comma
42
Probe: Anyone else?
CAPGDIS
Did (you/NAME) receive any capital gains from (your/his/her) shares of stocks or
mutual funds in 2021?
1 Yes
2 No
Q99BR
What was the source of (name's/your) savings or investments that pay interest or
dividends?
Enter other source of interest or dividend income
4.15 PROPERTY INCOME (Source)
Q65A1
During 2021 did (you/ anyone in this household):
Own any land, business property, apartments, or houses which were rented to
others?
1
2
Yes
No
Q65A2
At any time during 2021 did (you/ anyone in this household):
Receive income from royalties or from roomers or boarders?
(exclude amounts paid by relatives)
1
2
Yes
No
Q65A3
At any time during 2021 did (you/ anyone in this household):
Receive income from estates or trusts?
(exclude estates or trusts already reported)
1
2
Yes
No
43
Q65b
Ask only if necessary
Who received this (income/rent) ?
(Amount previously reported in Q48b was (amount))
Include each in cases of joint ownership. For self-employed persons, determine if
income was already included
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
4.16 EDUCATION ASSISTANCE (Source)
Q66a
During 2021 did (you/anyone in this household) attend school beyond the high school
level including a college, university, or other schools?
(include vocational, business, or trade schools)
1
2
Yes
No
Q66b
Did (you/ anyone in this household) receive any educational assistance for tuition,
fees, books, or living expenses during 2021?
Exclude loans, assistance from household members, and VA educational
benefits
1
2
Yes
No
Q66c
Ask only if necessary
Which member received assistance?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q66d
What type of assistance did (name/you) receive?
Exclude assistance from household members
44
Enter all that apply, separate using the space bar or a comma.
Probe: Any other assistance?
2
3
4
5
6
Pell Grant
Assistance from a welfare or social service office
Some other government assistance
Scholarships, grants, etc.
Other assistance (employers, friends, etc.)
4.17 CHILD SUPPORT (Source)
Q70a
During 2021 did (you/anyone in this household) receive:
Any child support payments?
1
2
Yes
No
Q70b
Read only if necessary
Who received these payments?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
4.18 REGULAR FINANCIAL ASSISTANCE (Source)
Q72a
(Any other/Any) regular financial assistance from friends or relatives not living in this
household?
Do not include loans
1
2
Yes
No
Q72b
Read only if necessary
Who received this assistance?
Enter all that apply, separate using the space bar or a comma.
45
Probe: Anyone Else?
4.19 OTHER MONEY INCOME (Source)
Q73A1R
During 2021 did (you/ anyone in this household) receive cash income not already
covered such as income from:
foster child care, alimony, jury duty, armed forces reserves, severance pay, hobbies,
or any other source?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
1
2
Yes
No
Q73A1b
Ask only if necessary
Who received this income?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone Else?
Q73A1Rc1
What was the source of this income?
Asking about: (name/you – Current respondent)
Do not read answer list to respondent
1 Alaska Permanent Fund Dividend
2 Other sources or don’t know – Specify
Q73A1Rc
Specify other source of income
Asking about: (name/you – Current respondent)
5 INCOME AMOUNTS
AMTINTRO
Now I will ask you about the amount of income you (and others in this household)
received from various sources in 2021.
46
5.1 UNEMPLOYMENT AND WORKER’S COMPENSATION (Amounts)
Q51A1p
What is the easiest way for you to tell us (name's/your) State or Federal
unemployment compensation; weekly, every other week, twice a month, monthly, or
yearly?
1 Weekly
2 Every other week (bi-weekly)
3 Twice a month
4 Monthly
7 Yearly
Q51A11
How much did (name/you) receive (weekly/every other week/ twice a
month/monthly) in State or Federal unemployment compensation during 2021?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
Enter dollar amount
________________
Q51A11r1
Could you please tell me if (name/you) received:
less than $10,000
between $10,000 and $20,000
or over $20,000
in State or Federal unemployment compensation during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q51A11r2
Did (name/you) receive:
less than $1,000
between $1,000 and $5,000
or over $5,000
in State or Federal unemployment compensation during 2021?
47
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q51A1C
Do not read to the respondent.
The annual rate appears out of range. The total State or Federal unemployment
compensation received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to
Suppress. If No, press enter and correct entry.
Q51A12
How many (weekly/every other week/ twice a month/monthly) payments did
(name/you) receive from State or Federal unemployment compensation during
2021?
(1-12/1-24/1-26/1-52)
________________
Q51A13
According to my calculations (name/you) received (total) altogether from State or
Federal unemployment compensation during 2021. Does that sound about right?
1
2
Yes
No
Q51A14
What is your best estimate of the correct total amount (name/you) received from
State or Federal unemployment compensation during 2021?
PREVIOUS ENTRIES: Q51A11: (amount)
Q51A1p: (periodicity)
Q51A12: (number of pay periods)
Enter dollar amount
________________
Q51A2p
What is the easiest way for you to tell us (name's/your) Supplemental
Unemployment Benefits; weekly, every other week, twice a month, monthly, or
yearly?
1
2
Weekly
Every other week (bi-weekly)
48
3
4
7
Twice a month
Monthly
Yearly
Q51A21
How much did (name/you) receive (weekly/every other week/twice a
month/monthly) in Supplemental Unemployment Benefits during 2021?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
Enter dollar amount
_____________
Q51A21r1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
in Supplemental Unemployment Benefits during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q51A21r2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Supplemental Unemployment Benefits during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q51A2C
Do not read to the respondent.
The annual rate appears out of range. The total Supplemental Unemployment Benefits
received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If
No, press enter and correct entry.
49
Q51A22
How many (weekly/every other week/twice a month/ monthly) payments did
(name/you) receive from Supplemental Unemployment Benefits during 2021?
(1-12/1-24/1-26/1-52)
________________
Q51A23
According to my calculations (name/you) received (total) altogether from
Supplemental Unemployment Benefits during 2021. Does that sound about right?
1
2
Yes
No
Q51A24
What is your best estimate of the correct total amount (name/you) received from
Supplemental Unemployment Benefits during 2021?
PREVIOUS ENTRIES: Q51A21: (amount)
Q51A2p: (periodicity)
Q51A22: (number of pay periods)
Enter dollar amount
________________
Q51A3p
What is the easiest way for you to tell us (name's/your) Union Unemployment or
Strike Benefits; weekly, every other week, twice a month, monthly, or yearly?
1 Weekly
2 Every other week (bi-weekly)
3 Twice a month
4 Monthly
7 Yearly
Q51A31
How much did (name/you) receive (weekly/every other week/ twice a
month/monthly) in Union Unemployment or Strike Benefits during 2021?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
Enter dollar amount
50
________________
Q51A31r1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
in Union Unemployment or Strike Benefits during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q51A31r2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Union Unemployment or Strike Benefits during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
C251A3
Do not read to the respondent.
The annual rate appears out of range. The total Union Unemployment or Strike Benefits
received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If
No, press enter and correct entry.
Q51A32
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive from Union Unemployment or Strike Benefits during 2021?
(1-12/1-24/1-26/1-52)
________________
Q51A33
51
According to my calculations (name/you) received (total) altogether from Union
Unemployment or Strike Benefits during 2021. Does that sound about right?
1
2
Yes
No
Q51A34
What is your best estimate of the correct total amount (name/you) received from
Union Unemployment or Strike Benefits during 2021?
PREVIOUS ENTRIES: Q51A31: (amount)
Q51A3p: (periodicity)
Q51A32: (number of pay periods)
Enter dollar amount
________________
Q52cp
What is the easiest way for you to tell us (your/name’s) Worker’s Compensation:
weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q52c1
How much did (name/you) receive (weekly/every other week/twice a
month/monthly) in Worker’s Compensation during 2021?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
Enter dollar amount
________________
Q52cr1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
52
in Worker’s Compensation during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q52cr2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Worker’s Compensation during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q52cC2
Do not read to the respondent.
The annual rate appears out of range. The total worker's compensation received in 2021
was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and
correct entry.
Q52c2
How many (weekly/every other week/twice a month/monthly) payments did
(name/you) receive from Worker’s Compensation during 2021?
(1-12/1-24/1-26/1-52)
________________
Q52c3
Then (name/you) received (total) altogether from Worker’s Compensation during
2021. Does that sound about right?
1
2
Yes
No
Q52c4
What is your best estimate of the correct total amount (name/you)
received from Worker’s Compensation during 2021?
53
PREVIOUS ENTRIES: Q52c1: (amount)
Q52cp: (periodicity)
Q52c2: (number of pay periods)
Enter dollar amount
________________
5.2 SOCIAL SECURITY (Amounts)
Q56dp
What is the easiest way for you to tell us (name's/your) Social Security payment;
monthly, quarterly, or yearly?
4
5
7
Monthly
Quarterly
Yearly
Q56d
How much did (name/you) receive (monthly/quarterly) in Social Security payments
in 2021?
Enter dollar amount
(If already included in amount reported for another household member, press Enter)
________________
Q56d_Char
Enter for Already included
________________
Q56drn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (you/name) received in Social Security payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q56drn2
54
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Social Security payments in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q56d2
For how many (months/quarters) did (name/you) receive Social Security in 2021?
(1-4; 1-12)
________________
Q56d3
Is this $(amount from Q56d/amount from Q56d1) before or after any monthly
Medicare deduction?
1
2
After Deduction
Before Deduction
Q56md
If Q56d3 = 1 then ask:
How much were (name’s/your) monthly Medicare deductions?
If Q56d3 = 2 then ask:
How much were (name’s/your) monthly payments for Medicare?
Include Medicare Advantage, Part B, and Part D premiums.
________________
Q56dC2
Do not read to the respondent.
The annual rate appears out of range. The total Social Security received in 2021 was
(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and
correct entry.
Q56d5
55
According to my calculations (name/you) received $(total) altogether from Social
Security in 2021. Does that sound about right?
1
2
Yes
No
Q56d6
What is your best estimate of the correct amount (name/you) received in Social
Security during 2021?
PREVIOUS ENTRIES:
Q56d: (amount)
Q56dp: (periodicity)
Q56d2: (number of pay periods)
Enter dollar amount
________________
5.3 SOCIAL SECURITY DISABILITY (Amounts)
Q562dp
What is the easiest way for you to tell us (name's/your) Social Security Disability
payment; monthly, quarterly, or yearly?
4
5
7
Monthly
Quarterly
Yearly
Q562d
How much did (name/you) receive (monthly/quarterly) in Social Security Disability
payments in 2021?
Enter dollar amount
(If already included in amount reported for another household member, press Enter)
________________
Q562d_Char
Enter for Already included
________________
Q562d2
For how many (months/quarters) did (name/you) receive Social Security Disability
in 2021?
56
(1-4; 1-12)
________________
Q562drn1
Could you tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
in Social Security Disability payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q562drn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Social Security Disability payments in 2021?
4
5
6
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q562d3
Is this $(amount from Q562d) before or after any monthly Medicare deductions?
1 After Deduction
2 Before Deduction
Q562md
If Q562d3 = 1 then ask:
How much were all of (name’s/your) monthly Medicare deductions?
If Q562d3 = 2 then ask:
How much were (name’s/your) monthly payments for Medicare?
Include Medicare Advantage, Part B, and part D premiums.
57
Q562dC2
Do not read to the respondent.
The annual rate appears out of range. The total Social Security received in 2021 was
(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and
correct entry.
BACKPAY1
During 2021, did (name/you) receive an initial Social Security Disability payment
that was larger than the usual payment that we haven’t accounted for yet?
Sometimes the initial payment from Social Security Disability is larger than the usual
monthly payments to make up for the delay in receiving the first payment.
1
2
Yes
No
BACKPAY2
How much was that initial disability payment?
Q562d5
According to my calculations (name/you) received $(total) altogether from Social
Security Disability in 2021. Does that sound about right?
1
2
Yes
No
Q562d6
What is your best estimate of the correct amount (name/you) received in Social
Security Disability during 2021?
PREVIOUS ENTRIES:
Q562d: (amount)
Q562dp: (periodicity)
Q562d2: (number of pay periods)
BACKPAY2: (amount)
Enter dollar amount
________________
5.4 SOCIAL SECURITY FOR CHILDREN (Amounts)
58
Q56ip
What is the easiest way for you to tell us (name's/your) Social Security payment for
children in this household; monthly, quarterly, or yearly?
4 Monthly
5 Quarterly
7 Yearly
Q56i
How much did (name/you) receive (monthly/quarterly) in Social Security payments
for children in this household in 2021?
Enter dollar amount
(If already included in amount reported for another household member, press Enter)
________________
Q56i_Char
Enter A for Already included
________________
Q56irn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in Social Security payments for
children in this household in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q56irn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Social Security payments for children in this household in 2021?
59
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q56i2
For how many (months/quarters) did (name/you) receive Social Security in 2021?
(1-4; 1-12)
________________
Q56iC2
Do not read to the respondent.
The annual rate appears out of range. The total Social Security received for children in
2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q56i4
According to my calculations (name/you) received $(total) altogether for children in
this household from Social Security in 2021. Does that sound about right?
1
2
Yes
No
Q56i5
What is your best estimate of the correct amount (name/you) received in Social
Security for children in this household during 2021?
Previous entries:
(amount)
Q56ip: (periodicity)
Q56i2: (number of pay periods)
Enter dollar amount
________________
5.5 SUPPLEMENTAL SECURITY INCOME (SSI) (Amounts)
Q57cp
What is the easiest way for you to tell us (name's/your) Supplemental Security
Income payment; monthly, quarterly, or yearly?
4
Monthly
60
5
7
Quarterly
Yearly
Q57c
How much did (name/you) receive (monthly/quarterly) in Supplemental Security
Income payments in 2021?
Enter dollar amount
________________
Q57crn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in Supplemental Security Income
payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q57crn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Supplemental Security Income payments in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q57c2
For how many (months/quarters) did (name/you) receive Supplemental Security
Income in 2021?
(1-4; 1-12)
________________
61
Q57cC2
Do not read to the respondent.
The annual rate appears out of range. The total Supplemental Security Income received
in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q57c4
According to my calculations (name/you) received $(total) altogether from
Supplemental Security Income in 2021. Does that sound about right?
1
2
Yes
No
Q57c5
What is your best estimate of the correct amount (name/you) received in
Supplemental Security Income during 2021?
Previous entries: (amount)
Q57cp: (periodicity)
Q57c2: (number of pay periods)
Enter Dollar Amount
________________
5.6 SUPPLEMENTAL SECURITY INCOME FOR CHILDREN (Amounts)
Q57ip
What is the easiest way for you to tell us the Supplemental Security
Income (name/you) received on behalf of children?
4
5
7
Monthly
Quarterly
Yearly
Q57i
How much did (name/you) receive (monthly/quarterly) in Supplemental Security
Income on behalf of children in 2021?
Enter dollar amount
________________
Q57irn1
62
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in Supplemental Security
Income payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q57irn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in Supplemental Security Income in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q57i2
For how many (months/quarters) did (name/you) receive Supplemental Security
Income on behalf of children in 2021?
(1-4; 1-12)
________________
Q57iC2
Do not read to the respondent.
The annual rate appears out of range. The total Supplemental Security Income received
on behalf of children in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to
Suppress. If No, press enter and correct entry.
Q57i4
According to my calculations (name/you) received $(total) altogether from
Supplemental Security Income on behalf of children in 2021.
Does that sound about right?
63
1
2
Yes
No
Q57i5
What is your best estimate of the correct amount (name/you) received in
Supplemental Security Income on behalf of children during 2021?
PREVIOUS ENTRIES: (amount)
Q57ip: (periodicity)
Q57i2: (number of pay periods)
Enter dollar amount
________________
5.7 DISABILITY INCOME (Amounts)
Q61E1P
What is the easiest way for you to tell us (name's/your) (fill first answer from Q61C
or Q61Cs1) payments; weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q61E1
How much did (name/you) receive (weekly/ every other week/ twice a month/
monthly) before deductions in (fill first answer from Q61C or Q61Cs1) payments in
2021?
Enter dollar amount
Do not include Veterans’ payments.
_______________
Q61e1rn1
Could you please tell me if (name/you) received:
less than $10,000
between $10,000 and $20,000
or over $20,000
64
for the TOTAL amount (name/you) received in (fill first answer from Q61Cr or
Q61Cs1) during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q61e1rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (fill first answer from Q61C or Q61Cs1) during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q61E12
How many (weekly/ every other week/ twice a month/ monthly) payments did
(name/you) receive in (fill first answer from Q61C or Q61Cs1) payments in 2021?
Disability income source #1 (1-12; 1-52)
______________
Q61E1C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from first answer in Q61c or
Q61cs1) payments received in 2021 was (amount). Is this a correct entry? If Yes, enter
"S" to Suppress. If No, press enter and correct entry.
Q61E13
According to my calculations (name/you) received $(total) altogether from
(fill first answer from Q61C or Q61Cs1) payments in 2021. Does that sound about
right?
1
2
Yes
No
Q61E14
65
What is your best estimate of the correct amount (name/you) received from (fill first
answer from Q61C or Q61Cs1) payments during 2021?
PREVIOUS ENTRIES: (amount)
Q61E1P: (periodicity)
Q61E12: (number of pay periods)
Enter dollar amount
_______________
Q61E2P
What is the easiest way for you to tell us (name's/your) (fill second answer from
Q61C or Q61Cs1) payments; weekly, every other week, twice a month, monthly, or
yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q61E2
How much did (name/you) receive (weekly/every other week/ twice a month/
monthly) before deductions in (fill second answer from Q61C or Q61Cs1)
payments in 2021?
Enter dollar amount
_______________
Q61e2rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in (fill second answer from Q61C or
Q61Cs1) during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q61e2rn2
66
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (fill second answer from Q61C or Q61Cs1) during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q61E22
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive in (fill second answer from Q61C or Q61Cs1) payments in 2021?
Disability income payment source #2 (1-12; 1-52)
_______________
Q61E2C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from second answer in Q61c or
Q61cs1) payments received in 2021 was (amount). Is this a correct entry? If Yes, enter
"S" to Suppress. If No, press enter and correct entry.
Q61E23
According to my calculations (name/you) received $(total) altogether
from (fill second answer from Q61C or Q61Cs1) payments in 2021. Does that
sound about right?
1
2
Yes
No
Q61E24
What is your best estimate of the correct amount (name/you) received from (fill
second answer from Q61C or Q61Cs1) payments during 2021?
PREVIOUS ENTRIES:
(amount)
Q61E2P: (periodicity)
Q61E22: (number of pay periods)
Enter dollar amount
_______________
67
5.8 VETERANS PAYMENTS (Amounts)
Q60V1P
What is the easiest way for you to tell us (name's/your) (fill from first answer in
Q60c8); weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q60V1
How much did (name/you) receive (weekly/every other week/ twice a
month/monthly) before deductions in (fill from first answer in Q60c8) in 2021?
Enter dollar amount
_______________
Q60v1rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in (fill from first answer in Q60c8)
during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q60v1rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (fill from first answer in Q60c8) payments during 2021?
68
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q60V12
How many (weekly/every other week/ twice a month/monthly) payments did
(name/you) receive in (fill from first answer in Q60c8) in 2021?
(1-52)
________________
Q60V1C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from first answer in Q60c8) received
in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q60V13
According to my calculations (name/you) received $(total) altogether from (fill from
first answer in Q60c8) in 2021. Does that sound about right?
1
2
Yes
No
Q60V14
What is your best estimate of the correct amount (name/you) received in Veteran's
benefits during 2021?
PREVIOUS ENTRIES:
Enter dollar amount
________________
Q60V1: (amount)
Q60V1P: (periodicity)
Q60V12: (number of pay periods)
Q60V2P
What is the easiest way for you to tell us (name's/your) (fill from second answer in
Q60c8); weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
69
Q60V2
How much did (name/you) receive (weekly/every other week/ twice a
month/monthly) before deductions in (fill from second answer in Q60c8) in 2021?
Enter dollar amount
_______________
Q60v2rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in (fill from second answer in Q60c8)
payments during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q60v2rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (fill from second answer in Q60c8) payments during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q60V22
How many (weekly/every other week/ twice a month/monthly) payments did
(name/you) receive in (fill from second answer in Q60c8) in 2021?
(1-52)
________________
70
Q60V2C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from second answer in Q60c8)
received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If
No, press enter and correct entry.
Q60V23
According to my calculations (name/you) received $(total) altogether from
(fill from second answer in Q60c8) in 2021. Does that sound about right?
1
2
Yes
No
Q60V24
What is your best estimate of the correct amount (name/you) received in
(fill from second answer in Q60c8) during 2021?
PREVIOUS ENTRIES:
Q60V2: (amount)
Q60V2P: (periodicity)
Q60V22: (number of pay periods)
Enter dollar amount
________________
5.9 SURVIVOR BENEFITS – Amounts
Q58E1P
What is the easiest way for you to tell us (name's/your) (fill from first answer
in Q58C or Q58Cs1) payments?
Weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q58E1
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) from (your/his/her) (fill from first answer in Q58C or Q58Cs1) in 2021?
71
Enter dollar amount
_______________
Q58e1rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received from (your/his/her) (fill from first
answer in Q58C or Q58Cs1) payments during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q58e1rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
from (you/his/her) (fill from first answer in Q58C or Q58Cs1) payments during
2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q58E12
How many (weekly/every other week/twice a month/monthly) payments did
(name/you) receive in (fill from first answer in Q58C or Q58Cs1) in 2021?
(1-52)
________________
Q58E1C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from first answer in Q58C or
Q58Cs1) received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to
72
Suppress. If No, press enter and correct entry.
Q58E13
According to my calculations (name/you) received $(total) altogether from
(fill from first answer in Q58C or Q58Cs1) in 2021. Does that sound about right?
1
2
Yes
No
Q58E14
What is your best estimate of the correct amount (name/you) received from
(your/his/her) (fill from first answer in Q58C or Q58Cs1) payments during 2021?
PREVIOUS ENTRIES:
Enter dollar amount
________________
Q58E1: (amount)
Q58E1P: (periodicity)
Q58E12: (number of pay periods)
Q58E2P
What is the easiest way for you to tell us (name's/your) (fill from second answer in
Q58C or Q58Cs1) payments?
Weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q58E2
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) in (fill from second answer in Q58C or Q58Cs1) in 2021?
Enter dollar amount
________________
Q58e2rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
73
or over $20,000
for the TOTAL amount (name/you) received from (your/his/her) (fill from second
answer in Q58C or Q58Cs1) payments during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q58e2rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
from (your/his/her) (fill from second answer in Q58C or Q58Cs1) payments during
2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q58E22
How many (weekly/every other week/twice a month/monthly) payments did
(name/you) receive from (your/his/her) (fill from second answer in Q58C or Q58Cs1)
in 2021?
(1-52)
________________
Q58E2C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from second answer in Q58C or
Q58Cs1) received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to
Suppress. If No, press enter and correct entry.
Q58E23
According to my calculations (name/you) received $(total) altogether from
(your/his/her) (fill from second answer in Q58C or Q58Cs1) payments in 2021.
Does that sound about right?
1
Yes
74
2
No
Q58E24
What is your best estimate of the correct amount (name/you) received from
(your/his/her) (fill from second answer in Q58C or Q58Cs1) payments during 2021?
PREVIOUS ENTRIES:
Q58E2: (amount)
Q58E2P: (periodicity)
Q58E22: (number of pay periods)
Enter dollar amount
________________
Q58E3P
What is the easiest way for you to tell us (name's/your) (fill from third answer in
Q58C or Q58Cs1); weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q58E3
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) in (fill from third answer in Q58C or Q58Cs1) in 2021?
Enter dollar amount
________________
Q58e3rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received from (your/his/her) (fill from third
answer in Q58C or Q58Cs1) payments during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
75
Q58e3rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
from (your/his/her) (fill from third answer in Q58C or Q58Cs1) payments during
2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q58E32
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive from (your/his/her) (fill from third answer in Q58C or Q58Cs1)
in 2021?
(1-52)
________________
Q58E3C
Do not read to the respondent.
The annual rate appears out of range. The total (fill from third answer in Q58C or
Q58Cs1) received in 2021 was (amount). Is this a correct entry? If Yes, enter "S" to
Suppress. If No, press enter and correct entry.
Q58E33
According to my calculations (name/you) received (total) altogether from
(your/his/her) (fill from third answer in Q58C or Q58Cs1) payments in 2021. Does
that sound about right?
1
2
Yes
No
Q58E34
What is your best estimate of the correct amount (name/you) received from
(your/his/her) (fill from third answer in Q58C or Q58Cs1) payments during 2021?
PREVIOUS ENTRIES: Q58E3: (amount)
Q58E3P: (periodicity)
Q58E32: (number of pay periods)
76
Enter dollar amount
_______________
5.10 PUBLIC ASSISTANCE (Amounts)
Q59ep
What is the easiest way for you to tell us (name's/your) TOTAL CASH assistance
payments from (fill from Q59C8r); Is it weekly, every other week, twice a month,
monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q59e
During 2021, how much TOTAL CASH assistance did (name/you) receive (per
week/every other week/twice a month/monthly): (fill from Q59C8r)?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
Enter dollar amount
___________
Q59ern1
Could you tell me if (name/you) received
less than $1,000
between $1,000 and $3,000
or over $3,000
in TOTAL CASH assistance payments in 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3000
Q59ern2
Did (name/you) receive
less than $100
77
between $100 and $500
or over $500
in TOTAL CASH assistance payments in 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q59e2
How many (weekly/every other week/ twice a month/ monthly) cash assistance
payments did (name/you) receive in 2021?
(1-12/1-24/1-26/1-52)
________________
Q59eC2
Do not read to the respondent.
The annual rate appears out of range. The total cash assistance received in 2021 was
$(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and
correct entry.
Q59e3
According to my calculations (name/you) received $(total) altogether in cash
assistance from a state or county program in 2021. Does that sound about right?
1
2
Yes
No
Q59e4
What is your best estimate of the correct amount of cash assistance
(name/you) received during 2021?
PREVIOUS ENTRIES:
Enter dollar amount
________________
Q59e: (amount)
Q59ep: (periodicity)
Q59e2: (number of pay periods)
Q59f
Was the cash assistance for adults AND children in the household, or JUST
78
children?
1
2
3
Both adults AND children
Children only
Adults only
Q59g
(Who/Which children) in your household was the cash assistance for?
Probe: Anyone Else?
Enter all that apply, separate using the space bar or a comma.
Enter 0 if none listed
Enter 96 for all persons
5.11 FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) (Amounts)
Q90p
What is the easiest way for you to tell us the value of the food assistance:
monthly or yearly?
1 Monthly
2 Yearly
3 Already included with TANF/AFDC payment
Q90
What is the (monthly) value of the food assistance received in 2021?
Enter dollar amount
________________
Q90rn1
Could you tell me if the value of food assistance received in 2021 was
less than $1,000
between $1,000 and $3,000
or over $3,000
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3000
Q90rn2
79
Was the value
less than $100
between $100 and $500
or over $500
in food assistance in 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q902
How many months was food assistance received in 2021?
(1-12)
________________
Q90C2
Do not read to the respondent.
The annual rate appears out of range. The total food assistance payments received in
2021 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q903
According to my calculations $(total) was received altogether from food assistance
in 2021. Does that sound about right?
1
2
Yes
No
Q904
What is your best estimate of the correct amount of food assistance received
during 2021?
PREVIOUS ENTRIES:
Q90: (amount)
Q90p: (periodicity)
Q902: (number of pay periods)
Enter dollar amount
________________
80
5.12 PENSIONS (Amounts)
Q62E1PR
What is the easiest way for you to tell us (name's/your) (first answer fill-in from
Q62CR/Q62cS1); weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q62E1R
How much did (name/you) receive (weekly/every other week/ twice a month/
monthly) in (first answer fill-in from Q62CR/Q62cS1) in 2021?
Enter dollar amount
______________
Q62E1rn1
Could you tell me if (you/name) received
less than $10,000
between $10,000 and $20,000
or over $20,000
in (first answer fill-in from Q62CR/Q62cS1) in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q62E1rn2
Did (you/name) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (first answer fill-in from Q62CR/Q62cS1) in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
81
Q62E12R
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive in (first answer fill-in from Q62CR/Q62cS1) in 2021?
Pension/Retirement #1 (1-12; 1-52)
_______________
Q62E1CR
Do not read to the respondent.
The annual rate appears out of range. The total (fill from first answer in
Q62CR/Q62cS1) payments received in 2021 was (amount). Is this a correct entry? If
Yes, enter "S" to Suppress. If No, press enter and correct entry.
Q62E13R
According to my calculations (name/you) received (total) dollars altogether from
(first answer fill-in from Q62CR/Q62cS1) in 2021. Does that sound about right?
1
2
Yes
No
Q62E14R
What is your best estimate of the correct amount (name/you) received in (first
answer fill-in from Q62CR/Q62cS1) during 2021?
PREVIOUS ENTRIES: Q62E1: (amount)
Q62E1P: (periodicity)
Q62E12: (number of pay periods)
Enter dollar amount
_______________
Q62E2PR
What is the easiest way for you to tell us (name's/your) (second answer fill-in from
Q62CR/Q62cS1); weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
Q62E2R
82
How much did (name/you) receive (weekly/every other week/ twice a month/
monthly) in (second answer fill-in from Q62CR/Q62cS1) in 2021?
Enter dollar amount
_______________
Q62E2rn1
Could you please tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
or over $20,000
in (second answer fill-in from Q62CR/Q62cS1) payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q62E2rn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in (second answer fill-in from Q62CR/Q62cS1) in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q62E22R
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive in (second answer fill-in from Q62CR/Q62cS1) in 2021?
Pension/Retirement #1 (1-12; 1-52)
_______________
Q62E2CR
Do not read to the respondent.
The annual rate appears out of range. The total (fill from second answer in
Q62CR/Q62cS1) payments received in 2021 was (amount). Is this a correct entry? If
Yes, enter "S" to Suppress. If No, press enter and correct entry.
83
Q62E23R
According to my calculations (name/you) received $(total) dollars altogether from
(second answer fill-in from Q62CR/Q62cS1) in 2021. Does that sound about right?
1
2
Yes
No
Q62E24R
What is your best estimate of the correct amount (name/you) received in (second
answer fill-in from Q62CR/Q62cS1) during 2021?
PREVIOUS ENTRIES: Q62E1: (amount)
Q62E1P: (periodicity)
Q62E12: (number of pay periods)
Enter dollar amount
_______________
5.13 ANNUITIES (Amounts)
ANNNEW1
What is the easiest way for you to tell us (name/your) annuity income; weekly, every
other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week
Twice a month
Monthly
Yearly
ANNNEW2
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) in annuities in 2021?
Enter dollar amount
_______________
ANNNEWrn1
Could you tell me if (name/you) received
less than $10,000
between $10,000 and $20,000
84
or over $20,000
in annuity payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
ANNNEWrn2
Did (name/you) receive
less than $1,000
between $1,000 and $5,000
or over $5,000
in annuity payments in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
ANNNEW3
How many (weekly/every other week/ twice a month/monthly) payments did
(name/you) receive in 2021?
(1-12; 1-52)
_______________
ANNNEW4
According to my calculations (name/you) received $(total) dollars altogether from
annuities in 2021. Does that sound about right?
1
2
Yes
No
ANNNEW5
What is your best estimate of the correct amount (name/you) received in annuities
in 2021?
Enter dollar amount
_______________
85
5.14 WITHDRAWALS/DISTRIBUTIONS FROM RETIREMENT PLAN
(Amounts)
DISTNEW1
What is the easiest way for you to tell us the amount of money withdrawn or
distributed from (name’s/your) (1st account type fill-in from Q97CR or Q97DR) in
2021: monthly, quarterly, every 6 months, or yearly?
4
5
6
7
Monthly
Quarterly
Every 6 months
Yearly
DISTNEW2
How much was (name's/your) withdrawal or distribution (weekly/every other week/
twice a month/ monthly) from (1st account type fill-in from Q97CR or Q97DR) in
2021?
Enter dollar amount
_______________
DISTNEW3
How many (monthly/quarterly) withdrawals did (name/you) make or distributions
did (name/you) receive in 2021 from the (1st account type fill-in from Q97CR or
Q97DR)?
Valid entries are 1-12 if monthly; 1-4 if quarterly; 1-2 if every six months
DISTNEWrn1
Could you please tell me if (name’s/your) withdrawal or distribution was
less than $10,000
between $10,000 and $20,000
or over $20,000
from (your/his/her) (1st account type fill-in from Q97CR or Q97DR) in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
DISTNEWrn2
86
Was (name’s/your) withdrawal or distribution
less than $1,000
between $1,000 and $5,000
or over $5,000
from (your/his/her) (1st account type fill-in from Q97CR or Q97DR) in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
DISTNEW4
According to my calculations (name/you) withdrew or received a distribution of
$(total) altogether from the (1st account type fill-in from Q97CR or Q97DR) in 2021.
Does that sound about right?
1
2
Yes
No
DISTNEW5
What is your best estimate of the correct amount (name/you) withdrew or the
distribution received from the (1st account type fill-in from Q97CR or Q97DR)
during 2021?
Enter dollar amount
_______________
ROLLA
Did (you/name) re-invest or "roll over" any of the money into an IRA or some other
kind of retirement plan?
1 Yes
2 No
ROLLAMTA
How much did (you/name) re-invest or “roll over” into an IRA or some other kind
of retirement plan in 2021?
Enter dollar amount
Dollar amount should not exceed amount of withdrawals reported.
Amount of withdrawals reported: $(amount)
_______________
87
ROLLB
(Do/Does) (you/name) plan to re-invest or roll over any of the money?
1
2
Yes
No
ROLLAMTB
How much (do/does) (you/name) plan to re-invest or “roll over” into an IRA or
some other kind of retirement plan?
Enter dollar amount
Dollar amount should not exceed amount of withdrawals reported.
Amount of withdrawals reported: $(amount)
_______________
DISTNEW6
What is the easiest way for you to tell us the amount of money withdrawn or
distributed from (name’s/your) (2nd account type fill-in from Q97CR or Q97DR) in
2021: monthly, quarterly, every 6 months, or yearly?
4
5
6
7
Monthly
Quarterly
Every 6 months
Yearly
DISTNEW7
How much was (name's/your) withdrawal or distribution (weekly/every other week/
twice a month/ monthly) from (your/his/her) (2nd account type fill-in from Q97CR
or Q97DR) in 2021?
Enter dollar amount
_______________
DISTNEW8
How many (monthly/quarterly) withdrawals did (name/you) make or distributions
did (name/you) receive in 2021 from the (2nd account type fill-in from Q97CR or
Q97DR)?
(1-12), (1-4), (1-2)
88
DISTNEWrn3
Could you please tell me if (name’s/your) withdrawal or distribution was
less than $10,000
between $10,000 and $20,000
or over $20,000
from (your/his/her) (2nd account type fill-in from Q97CR or Q97DR) in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
DISTNEWrn4
Was (name’s/your) withdrawal or distribution
less than $1,000
between $1,000 and $5,000
or over $5,000
from (your/his/her) (2nd account type fill-in from Q97CR or Q97DR) in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
DISTNEW9
According to my calculations (name/you) withdrew or received a distribution of
$(total) altogether from the (2nd account type fill-in from Q97CR or Q97DR) in
2021. Does that sound about right?
1
2
Yes
No
DISTNEW10
What is your best estimate of the correct amount (name/you) withdrew or the
distribution received from the (2nd account type fill-in from Q97CR or Q97DR)
during 2021?
Enter dollar amount
_______________
ROLLC
89
Did (you/name) re-invest or "roll over" any of the money into an IRA or some other
kind of retirement plan?
1
2
Yes
No
ROLLAMTC
How much did (you/name) re-invest or “roll over” into an IRA or some other kind
of retirement plan in 2021?
Enter dollar amount
Dollar amount should not exceed amount of withdrawals reported.
Amount of withdrawals reported: $(amount)
_______________
ROLLD
(Do/Does) (you/name) plan to re-invest or roll over any of the money?
1
2
Yes
No
ROLLAMTD
How much (do/does) (you/name) plan to re-invest or “roll over” into an IRA or
some other kind of retirement plan?
Enter dollar amount
Dollar amount should not exceed amount of withdrawals reported.
Amount of withdrawals reported: $(amount)
_______________
5.15 INTEREST/DIVIDENDS ON RETIREMENT ACCOUNTS (Amounts)
RETIRENEW1
Within the (1st account type fill-in from Q97CR/Q97DR) account, how much did
(name/you) earn in interest or dividends during 2021? Please include small amounts
reinvested or credited to the account.
Enter dollar amount
_____________
RETIRENEWrn1
90
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $3,000
or over $3,000
in interest or dividends from (your/his/her) (1st account type fill-in from
Q97CR/Q97DR) during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
RETIRENEWrn2
Did (name/you) earn
less than $100
between $100 and $500
or over $500
in interest or dividends from (your/his/her) (1st account type fill-in from
Q97CR/Q97DR) during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
RETIRENEW2
The Census Bureau can estimate the amount earned in this account based on the
size of the account. So can you tell me how much money was in (name’s/your) (1st
account type fill-in from Q97CR/Q97DR) account at the end of 2021?
Enter dollar amount
_____________
RETIRENEW3
Within the (2nd account type fill-in from Q97CR/Q97DR) account, how much did
(name/you) earn in interest or dividends during 2021? Please include small amounts
reinvested or credited to the account.
Enter dollar amount
_____________
RETIRENEWrn3
91
Could you tell me if (name/you) earned
less than $1,000
between $1,000 and $3,000
or over $3,000
in interest or dividends from (your/his/her) (2nd account type fill-in from
Q97CR/Q97DR) during 2021?
4
5
6
Less than $1,000
Between $1,000 and $3,000
Over $3,000
RETIRENEWrn4
Did (name/you) earn
less than $100
between $100 and $500
or over $500
in interest or dividends from (your/his/her) (2nd account type fill-in from
Q97CR/Q97DR) during 2021?
4
5
6
Less than $100
Between $100 and $500
Over $500
5.16 INTEREST/DIVIDENDS ON NON-RETIREMENT ACCOUNTS
(Amounts)
NONRETIRENEW(1-7)1
How much did (you/name) receive in (interest/dividends) from [fill-in from Q99AR
or Q99BR] during 2021, including even small amounts reinvested or credited to
accounts?
If a joint account please split interest income in half for each person.
Enter dollar amount
_____________
NONRETIRENEW(1-7)rn1
Could you tell me if (you/name) received:
92
less than $1,000
between $1,000 and $3,000
or over $3,000
in (interest/dividends) from [fill-in from Q99AR or Q99BR] during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
NONRETIRENEW(1-7)rn2
Did (you/name) receive:
less than $100
between $100 and $500
or over $500
in (interest/dividends) from [fill-in from Q99AR or Q99BR] during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
NONRETIRENEW(1-7)2
The Census Bureau can estimate the amount earned in this account based on the
size of the account. How much money did (you/name) have in [fill-in from Q99AR
or Q99BR] at the end of 2021?
Enter dollar amount
_____________
Q63(c-i)p
Read if necessary
Is this a weekly, every other week, twice a month, monthly, quarterly, every 6
months, or yearly amount?
1
2
3
4
5
6
7
Weekly
Every other week
Twice a month
Monthly
Quarterly
Every 6 months
Yearly
93
Q63(c-i)2
How many (weekly/ every other week/ twice a month/ monthly/ quarterly/ every 6
months) payments did (you/name) receive in interest/dividend income in 2021 from
[fill-in from Q99AR or Q99BR]?
_______________
Q63(c-i)3
According to my calculations (you/name) received $(total) from interest/dividend
income from [fill-in from Q99AR or Q99BR] in 2021. Does that sound about right?
1
2
Yes
No
Q63(c-i)4
What is your best estimate of the correct amount (you/NAME) received from
interest payments during 2021?
PREVIOUS ENTRIES: Q63(c-i): (amount)
Q63(c-i)p: (periodicity)
Q63(c-i)2: (number of pay periods)
Enter dollar amount
_______________
CAPGDAMT
How much did (you/name) receive in capital gains in 2021?
Enter dollar amount
_______________
CAPGDAMTrn1
Could you tell me if (name/you) received:
less than $10,000
between $10,000 and $20,000
or over $20,000
in capital gains during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
94
CAPGDAMTrn2
Did (name/you) receive:
less than $1,000
between $1,000 and $5,000
or over $5,000
in capital gains distributions during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
5.17 PROPERTY INCOME (Amounts)
Q65c
How much did (name/you) receive in income from rent (, roomers or boarders,
estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or trusts fill
from Q65A1-3) AFTER EXPENSES during 2021?
Separate amounts for joint ownership
If response is "Broke Even" then enter 1.
Enter dollar amount
If already included in amount reported for another household member, press Enter
If response is "None" or "Lost Money" press key
_______________
Q65c_Char
Enter "A" for Already included
Enter "L" for Lost Money
Enter "X" for None
______________
Q65cL
Enter amount of money lost in 2021.
_______________
Q65crn1
Could you please tell me if (name/you) received:
less than $10,000
between $10,000 and $20,000
95
or over $20,000
for the TOTAL amount (name/you) received in income from rent (roomers or
boarders, estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or
trusts fill from Q65A1-3) AFTER EXPENSES during 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q65crn2
Did (name/you) receive:
less than $1,000
between $1,000 and $5,000
or over $5,000
in income from rent (roomers or boarders, estates, trusts, or royalties/, roomers or
boarders, or royalties/, estates or trusts fill from Q65A1-3) AFTER EXPENSES
during 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q65cp
Is this a weekly, every other week, twice a month, monthly, quarterly, or yearly
amount?
1
2
3
4
5
7
Weekly
Every other week
Twice a month
Monthly
Quarterly
Yearly
Q65c2
What is your best estimate of (name's/your) ANNUAL net income from rent
(roomers or boarders, estates, trusts, or royalties/, roomers or boarders, or
royalties/, estates or trusts) AFTER EXPENSES in 2021?
PREVIOUS ENTRIES:
Q65c: (amount)
Q65cp: (periodicity)
Enter dollar amount
96
_______________
Q65cC2
Do not read to the respondent.
The annual rate appears out of range. The total income received from rent (roomers or
boarders, estates, trusts, or royalties) was (amount) in 2021. Is this a correct entry? If
Yes, enter "S" to Suppress. If No, press enter and correct entry.
Q65c2L
What is your best estimate of (name’s/your) ANNUAL LOSS from rent (roomers or
boarders, estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or
trusts fill from Q65A1-3) AFTER EXPENSES in 2021?
PREVIOUS ENTRIES:
Q65cL: (amount)
Q65cp: (periodicity)
Enter dollar amount
_______________
5.18 EDUCATIONAL ASSISTANCE (Amounts)
Q69F88
How much did (name/you) receive in Pell Grants during 2021?
Enter annual amount only
________________
Q69Frn1
Could you please tell me if (name/you) received:
less than $1,000
between $1,000 and $3,000
or over $3,000
for the TOTAL amount (name/you) received in Pell Grants during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q69Frn2
Did (name/you) receive:
97
less than $100
between $100 and $500
or over $500
in Pell Grants during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q66HP
What is the easiest way for you to tell us (name's/your) (other/blank) educational
assistance during 2021; weekly, every other week, twice a month, monthly, or
yearly?
1
2
3
4
7
Weekly
Every other week (bi-weekly)
Twice a month
Monthly
Yearly
Q66H
(Aside from the Pell Grant assistance, how/How) much did (name/you) receive
(weekly/every other week/ twice a month/ monthly) in educational assistance during
2021?
Enter dollar amount
________________
Q66H2
How many (weekly/every other week/ twice a month/ monthly) payments did
(name/you) receive in educational assistance in 2021?
(1-12/1-24/1-26/1-52)
________________
Q66Hrn1
Could you please tell me if (name/you) received:
less than $1,000
between $1,000 and $3,000
or over $3,000
98
for the TOTAL amount (name/you) received in educational assistance during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q66Hrn2
Did (name/you) receive:
less than $100
between $100 and $500
or over $500
in educational assistance during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q66HC2
Do not read to the respondent.
The annual rate appears out of range. The total educational assistance received in 2021
was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter
and correct entry.
Q66H3
According to my calculations (name/you) received $(total) altogether from
educational assistance in 2021. Does that sound about right?
1
2
Yes
No
Q66H4
What is your best estimate of the correct amount (name/you) received from
educational assistance during 2021?
Previous entries:
Q66h: (amount)
Q66hp: (periodicity)
Q66h2: (number of pay periods)
Enter dollar amount
________________
99
5.19 CHILD SUPPORT (Amounts)
Q70cp
What is the easiest way for you to tell us (name's/your) child support payments;
weekly, every other week, twice a month, monthly, or yearly?
1
2
3
4
7
Weekly
Every other week (bi-weekly)
Twice a month
Monthly
Yearly
Q70c
How much did (name/you) receive (weekly/ every other week/ twice a month/
monthly) in child support payments in 2021?
Enter dollar amount
________________
Q70c2
How many (weekly/every other week/ twice a month/ monthly) child support
payments did (name/you) receive in 2021?
(1-12/1-24/1-26/1-52)
________________
Q70c1rn1
Could you please tell me if (name/you) received:
less than $10,000
between $10,000 and $20,000
or over $20,000
for the TOTAL amount (name/you) received in child support payments in 2021?
1
2
3
Less than $10,000
Between $10,000 and $20,000
Over $20,000
Q70c1rn2
Did (name/you) receive:
less than $1,000
100
between $1,000 and $5,000
or over $5,000
in child support payments in 2021?
1
2
3
Less than $1,000
Between $1,000 and $5,000
Over $5,000
Q70cC2
Do not read to the respondent.
The annual rate appears out of range. The total child support payments received in
2021 was $(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q70c3
According to my calculations (name/you) received $(total) altogether from child
support payments in 2021. Does that sound about right?
1
2
Yes
No
Q70c4
What is your best estimate of the correct amount (name/you) received from child
support payments during 2021?
PREVIOUS ENTRIES:
Q70c: (amount)
Q70cp: (periodicity)
Q70c2: (number of pay periods)
Enter dollar amount
________________
5.20 REGULAR FINANCIAL ASSISTANCE (Amounts)
Q72cp
What is the easiest way for you to tell us (name's/your) regular financial assistance;
weekly, every other week, twice a month, monthly, or yearly?
1 Weekly
2 Every other week (bi-weekly)
3 Twice a month
4 Monthly
101
7
Yearly
Q72c
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) in regular financial assistance in 2021?
Enter dollar amount
________________
Q72c2
How many (weekly/every other week/twice a month/monthly) payments did
(name/you) receive in regular financial assistance in 2021?
(1-12/1-24/1-26/1-52)
_______________
Q72crn1
Could you please tell me if (name/you) received:
less than $1,000
between $1,000 and $3,000
or over $3,000
in regular financial assistance in 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q72crn2
Did (name/you) receive
less than $100
between $100 and $500
or over $500
in regular financial assistance in 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
102
Q72cC2
Do not read to the respondent.
The annual rate appears out of range. The total regular financial assistance payments
received in 2021 was $(amount). Is this a correct entry? If Yes, enter "S" to Suppress.
If No, press enter and correct entry.
Q72c3
According to my calculations (name/you) received $(total) altogether from regular
financial assistance in 2021. Does that sound about right?
1
2
Yes
No
Q72c4
What is your best estimate of the correct amount (name/you) received from regular
financial assistance during 2021?
PREVIOUS ENTRIES:
________________
Q72c: (amount)
Q72cp: (periodicity)
Q72c2: (number of pay periods)
5.21 OTHER MONEY INCOME (Amounts)
Q731P
What is the easiest way for you to tell us (name's/your) income from (fill from
Q73A1Rc);
weekly, every other week, twice a month, monthly, or yearly?
1 Weekly
2 Every other week (bi-weekly)
3 Twice a month
4 Monthly
7 Yearly
Q731
How much did (name/you) receive (weekly/every other week/twice a month/
monthly) in income from (fill from Q73A1Rc) during 2021?
Do NOT include federal stimulus payments due to the Coronavirus pandemic.
103
Enter dollar amount
________________
Q7312
How many (weekly/every other week/twice a month/monthly) payments did
(name/you) receive in income from (fill from Q73A1Rc) during 2021?
(1-12/1-24/1-26/1-52)
________________
Q73rn1
Could you please tell me if (name/you) received:
less than $1,000
between $1,000 and $3,000
or over $3,000
in income from (Alaska Permanent Fund Dividend/fill-in from Q73a1Rc)?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3,000
Q73rn2
Did (name/you) receive:
less than $100
between $100 and $500
or over $500
in income from (Alaska Permanent Fund Dividend/fill-in from Q73a1Rc)?
1
2
3
Less than $100
Between $100 and $500
Over $500
Q731C2
Do not read to the respondent.
The annual rate appears out of range. The total income from (fill from Q73A1Rc) in
2021 was $(amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press
enter and correct entry.
Q7313
104
According to my calculations (name/you) received $(total) altogether from (Alaska
Permanent Fund Dividend/fill-in from Q73a1Rc) in 2021.
Does that sound about right?
1
2
Yes
No
Q7314
What is your best estimate of the correct amount (name/you) received in income
from (Alaska Permanent Fund Dividend/fill-in from Q73a1Rc) in 2021?
PREVIOUS ENTRIES:
Q731: (amount)
Q731P: (periodicity)
Q7312: (number of pay periods)
Enter dollar amount
________________
5.22 CONTRIBUTIONS TO RETIREMENT ACCOUNTS (Amounts)
CONTRIB1
Earlier we recorded that (you/name) (have/has) a retirement account, such as a
401(k), 403(b), IRA, or other account designed specifically for retirement savings.
Did (you/he/she) contribute any money to (your/his/her) plan(s), for example,
through payroll deductions?
(Do not include amounts reinvested or “rolled over” from other retirement
accounts.)
1
2
Yes
No
CONTRIB2
How much did (you/he/she) contribute to (your/his/her) account(s) in 2021?
Total contributions to all accounts.
________________
6 HEALTH INSURANCE
6.1 INTRODUCTION TO HEALTH INSURANCE SECTION
105
HINTRO
These next questions are about health coverage between January 1, 2021 and now.
Press 1 to Continue
1
Enter 1 to Continue
PINTRO
(First/Next) I'm going to ask about (name's/your) health coverage.
Press 1 to Continue
1
Enter 1 to Continue
FHINTRO
Next, I'm going to ask about (name's/your) health coverage.
Press 1 to Continue
6.2 CURRENT COVERAGE
MCARE1
?[F1]
Medicare is health insurance for people 65 years and older and people under 65
with disabilities. (Is/Are) (name/you) NOW covered by Medicare?
Code Medicare Parts A, B, and C and Medicare Advantage as "Yes"
1
2
Yes
No
ANYCOV
(Does/Do) (name/you) NOW have any type of health plan or health coverage?
1
2
Yes
No
MEDI
?[F1]
106
(Are/Is/Was/Were) (name/you) covered by Medicaid, Medical Assistance, or
(CHIP/or Medicare)?
1
2
Yes
No
OTHGOVT
(Is/Are) (name/you) NOW covered by a state or government assistance program
that helps pay for healthcare, such as: State Medicaid, CHIP, Exchange/Portal, or
other State Health program?
Stop reading list if respondent says "YES"
1
2
Yes
No
VET
(Is/Are) (name/you) NOW covered by Veteran's Administration (VA) care?
1
2
Yes
No
VERIFY
I recorded that (name/you) (is/are) not currently covered by a health plan. Is that
correct?
1
2
Yes, is NOT covered
No, is covered
6.3 TYPE OF COVERAGE
SRCEGEN
?[F1]
ASK OR VERIFY
For the coverage (name/you) (has/have/had) NOW, (do/does/did) (he/she/you) get it
through a job, the government or state, or some other way?
1. JOB
Former job/Retiree
2. GOVERNMENT OR
STATE
Medical Assistance
107
3. OTHER WAY
Privately purchased
Union
Spouse/parent's job
Job with the government
COBRA
TRICARE/TRICARE For Life
Medicaid
Medicare (Parts A+B; Part C)
Medicare Advantage
State-provided health coverage
VA Care/CHAMPVA/other
military
Parent or spouse
Medicare Supplements
Exchange plan/Marketplace
Group or association
School
IF RESPONDENT CHOOSES MORE THAN ONE: Let's talk about one plan at a
time. Which would you like to tell me about first?
[
If respondent is not covered, go back to VERIFY and select "Yes"]
1
2
3
Job (current or former)
Government or State
Some other way
SRCEDEPDIR
ASK OR VERIFY
(Does/Do/Did) (name/you) get that coverage through a parent or spouse,
(does/do/did) (he/she/you) buy it (himself/herself/yourself), or (does/did/do)
(he/she/you) get it some other way?
1. PARENT OR SPOUSE
Parent
Spouse
1
2
3
2. BUY IT DIRECTLY
Buy it
Parent or spouse buys it
Medicare Supplement
3. SOME OTHER WAY
Former employer
Group or association
Indian Health Service
School
Parent or spouse
Buy it
Some other way
SRCEOTH
ASK OR VERIFY
(Does/Do/Did) (name/you) get it through a former employer, a union, a group or
association, the Indian Health Service, a school, or some other way?
1
2
3
4
5
6
Former employer
Union
Group or association
Indian Health Service
School
Some other way
108
JOBCOV
(Is/Was) that coverage related to a JOB with the government or state?
READ IF NECESSARY: Include coverage through FORMER employers and unions,
and COBRA plans.
1
2
Yes
No
MILPLAN
ASK OR VERIFY
(Is/Was) that plan related to military service in any way?
Examples of military plans include:
- VA Care
- TRICARE
- TRICARE for Life
- CHAMPVA
- Other military care
1
2
Yes
No
GOVTYPE
?[F1]
ASK OR VERIFY
(Is/Was) that coverage Medicaid, CHIP, Medicare, a plan through the military, or
some other program?
Code Medicare Parts A, B, and C and Medicare Advantage as "Medicare"
IF RESPONDENT CHOOSES MORE THAN ONE: Let's talk about one plan at a
time. Which would you like to tell me about first?
1
2
3
4
5
Medicaid or Medical Assistance
CHIP
Medicare
Military
Other
MILTYPE
109
ASK OR VERIFY
(Is/Was) that plan through TRICARE, TRICARE for Life, CHAMPVA, VA Care,
military health care, or something else?
1 TRICARE
2 TRICARE for Life
3 CHAMPVA
4 Veterans Administration (VA) care
5 Military health care
6 Other
POLHOLDER
ASK OR VERIFY
Whose name (is/was) the policy in? (Who (is/was) the policyholder?)
1-16
17
Name on roster
Someone living outside the household
Enter persons line number (1-16), or 17 for person not in the household
SRCEPTSP
ASK OR VERIFY
(Do/Did) they get that coverage through their job, (do/did) they buy it themselves, or
(do/did) they get it some other way?
1
2
3
Job (current or former)
Buy it
Some other way
GOVPLAN
ASK OR VERIFY
What do you call the program?
IF RESPONDENT ANSWERS WITH INSURANCE COMPANY NAME: OK, so
that would be the plan name. What do you call the program? Some examples of
programs in (state) are [read full list below].
1
2
3
Medicaid
Medical Assistance
Indian Health Service (IHS)
110
4-12
13-15
16
17
18
State Medicaid Programs Names
State Exchange Programs Names
Plan through State Exchange Portal
Other government plan
Other (please specify)
MISCSPEC
Please Specify
Write in plan name
_______________
PORTAL
ASK OR VERIFY
(Is/Was) that coverage through (State Exchange Portal Name), which may also be
known as (State Exchange Program Name 1, Name 2, Name 3)?
1
2
Yes
No
EXCHTYPE
ASK OR VERIFY
What do you call it – State Exchange Program (Portal, Name 1, Name 2, Name 3)?
1-4
State Exchange Programs Names
HIPAID
(Does/Did) (your/policyholder name's/the policyholder’s) employer or union pay for
all, part, or none of the health insurance premium?
Report here employer's contribution to employee's health insurance premiums, not the
employee's medical bills.
1
2
3
All
Part
None
SHOP
Small businesses can offer health coverage to their employees through (State
Exchange SHOP Portal Name). (Is/Was) the coverage at all related to (State
Exchange SHOP Portal Name), (such as State SHOP Name 1, Name 2, Name 3)?
111
1
2
Yes
No
POLHOLDER2
ASK OR VERIFY
Whose name (is/was) the policy in? (Who [is/was] the policyholder?)
1-16
17
Name on roster
Someone living outside the household
Enter persons line number (1-16), or 17 for person not in the household
PREMYN
Is there a monthly premium for this plan?
A monthly premium is a fixed amount of money people pay each month to have
health coverage. It does not include copays or other expenses such as prescription
costs.
1
2
Yes
No
PREMSUBS
Is the cost of the premium subsidized based on (your/family) income?
A monthly premium is a fixed amount of money people pay each month to have
health coverage. It does not include copays or other expenses such as prescription
costs.
Subsidized health coverage is insurance with a reduced premium. Low and middle
income families are eligible to receive tax credits that allow them to pay lower
premiums for insurance bought through healthcare exchanges or marketplaces.
1
2
Yes
No
6.4 MONTHS OF COVERAGE
BEFORAFT
Did (name's/your) coverage from (plan type) start before January 1, 2021?
READ IF NECESSARY: Your best estimate is fine.
112
(READ IF NECESSARY: If (policyholder) switched employers or plans through
(your/their) employer, consider it the same plan.)
(READ IF NECESSARY: If (policyholder) switched plans that (you/he/she)
(buy/buys), consider it the same plan.)
1
2
Yes
No
MNTHBEG1/2
In which month did (that/this) coverage start?
READ IF NECESSARY: Your best estimate is fine.
(READ IF NECESSARY: If (policyholder) switched employers or plans through
(your/their) employer, consider it the same plan.)
(READ IF NECESSARY: If (policyholder) switched plans that (you/he/she)
(buy/buys), consider it the same plan.)
This question refers to (plan type).
1
2
3
4
5
6
7
8
9
10
11
12
January
February
March
April
May
June
July
August
September
October
November
December
YEARBEG
ASK OR VERIFY
Which year was that?
(READ IF NECESSARY: If (policyholder) switched employers or plans through
(your/their) employer, consider it the same plan.)
(READ IF NECESSARY: If (policyholder) switched plans that (you/he/she)
(buy/buys), consider it the same plan.)
113
This question refers to (plan type).
1
2
2021
2022
CNTCOV
Has it been continuous since (beginning month)?
(READ IF NECESSARY: If (policyholder) switched employers or plans through
(your/their) employer, consider it the same plan.)
(READ IF NECESSARY: If (policyholder) switched plans that (you/he/she)
(buy/buys), consider it the same plan.)
READ IF NECESSARY: If the gap in coverage was less than 3 weeks, consider the
coverage "continuous."
This question refers to (plan type).
1
2
Yes
No
SPELLADD
I have recorded that (name/you) (was/were) covered by (plan type) in (months of
coverage). Were there any OTHER months between January 2021 and now that
(name/you) (was/were) also covered by (plan type)?
1
2
Yes
No
ANYTHIS
Which months (was/were) (name/you) covered by (plan type) THIS year -- in 2022?
1
2
3
4
20
21
January 2022
February 2022
March 2022
April 2022
All months of 2022
No months of 2022
ANYLAST
Which months (was/were) (name/you) covered by (plan type) LAST year -- in 2021?
114
1
2
3
4
5
6
7
8
9
10
11
12
20
21
January
February
March
April
May
June
July
August
September
October
November
December
All months from January 2021 until December 2021
No months from January 2021 until December 2021
WMNTHS
Which months between January 2021 and now (was/were) (name/you) covered by
(plan type)?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
20
21
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
July 2021
August 2021
September 2021
October 2021
November 2021
December 2021
January 2022
February 2022
March 2022
April 2022
All months from January 2021 until now
No months from January 2021 until now
6.5 OTHER HOUSEHOLD MEMBERS
OTHMEMB
Between January 1, 2021 and now, was anyone in the household other than
(name/you) ALSO covered by (plan type)?
1
2
Yes
No
115
COVWHO
Who else was covered? Who else was covered by (plan type)?
PROBE: Anyone else?
0
1-16
96
No one listed
Person 1 through 16’s name
All persons listed
SAMEMNTHS
(Was/Were) (name/names) also covered from January 2021 until now?
This question refers to (plan type)
1
2
All also covered from January 2021 until now
None covered from January 2021 until now
MNTHS_P(1-16)M
Which months between January 2021 and now was (NAME) covered? [How about
(NAME)?]
This question refers to (plan type)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
20
21
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
July 2021
August 2021
September 2021
October 2021
November 2021
December 2021
January 2022
February 2022
March 2022
April 2022
All months from January 2021 until now
No months from January 2021 until now
OTHOUT
116
Does that plan cover anyone living outside this household?
This question refers to (plan type)
1
2
Yes
No
OTHWHO
How old are they -- under 19, 19-25, or older than 25?
Mark all that apply
1
2
3
Under 19
19-25 years old
Older than 25
6.6 ADDITIONAL PLANS
ADDGAP
So far, I have recorded that (name/you) (was/were) NOT covered in (months of no
coverage). (Was/Were) (name/you) covered by any type of health plan or health
coverage in (those months/that month)?
READ IF NECESSARY: Do not include plans that cover only one type of care, such
as dental or vision plans.
1
2
Yes
No
ADDOTH
Other than (plan type[s]), (was/were) (name/you) covered by any other type of health
plan or health coverage AT ANY TIME between January 1, 2021 and now?
READ IF NECESSARY: Do not include plans that cover only one type of care, such
as dental or vision plans.
1
2
Yes
No
6.7 EMPLOYER-SPONSORED INSURANCE OFFERS AND TAKEUP
ESIINTRO
117
Earlier I recorded that (name/you) (is/are) employed but (does/do) not have health
coverage through (his/her/your) job.
1
Enter 1 to continue
OFFER
Does (employer name) offer a health insurance plan to any of its employees?
1
2
Yes
No
COULD
Could (name/you) be in this plan if (he/she/you) wanted to?
1
2
Yes
No
WNTAKE
Why (aren't/isn't) (you/he/she) in this plan?
Choose all that apply
1
2
3
4
5
6
7
8
Covered by another plan
Traded health insurance for higher pay
Too expensive
Don't need health insurance
Have a pre-existing condition
Haven't yet worked for this employer long enough to be covered
Contract or temporary employees not allowed in plan
Other/specify
WNTAKESPEC
Please specify other reason why not in the plan
WNELIG
Why not? Why can't (name/you) be in this plan if (he/she/you) wanted to?
Choose all that apply
1
2
3
4
Don't work enough hours per week or weeks per year
Contract or temporary employees not allowed in plan
Haven't yet worked for this employer long enough to be covered
Have a pre-existing condition
118
5
6
Too expensive
Other/specify
WNELIGSPEC
Please specify other reason why not eligible.
________________
6.8 HEALTH STATUS
HealthStatus_Intro
An important factor in evaluating a person's or family's health insurance situation
is their current health status and/or the current health status of other family
members.
Enter 1 to Continue
HealthStatus
Would you say (name's/your) health in general is excellent, very good, good, fair, or
poor?
1
2
3
4
5
Excellent
Very good
Good
Fair
Poor
6.9 MEDICAL EXPENDITURES
MedExp_Intro
Next I would like to ask about out-of-pocket medical expenses during 2021.
Press 1 to Continue
1
Enter 1 to continue
HIPREM
[Earlier I recorded that (your/name’s) employer or union did not pay for
(your/his/her) entire health insurance premium.] Last year, how much did
(you/name) pay out-of-pocket for ALL health insurance premiums [covering
119
(yourself/himself/herself) or others in the household]? Include both comprehensive
and supplemental plans (such as vision and dental insurance).
[What about (you/name)?]
[DO NOT include the $(amount reported) per month from Medicare deductions
from (Social Security/ Social Security Disability/ Social Security and Social Security
Disability) payments mentioned earlier.]
Enter dollar amount
________________
MEDAMT
?[F1]
Last year, how much was paid out-of-pocket for (your/name’s) OWN medical care,
such as copays for doctor and dentist visits, diagnostic tests, prescription medicine,
glasses and contacts, and medical supplies?
[What about (you/name)? Last year, how much was paid out-of-pocket for
(your/name’s) OWN medical care, such as copays for doctor and dentist visits,
diagnostic tests, prescription medicine, glasses and contacts, and medical supplies?]
Include any amount paid out-of-pocket on (your/his/her) behalf by anyone in this
household.
Enter dollar amount
________________
OTCMEDAMT
Last year, how much was paid out-of-pocket for (your/name’s) non-prescription
healthcare products such as vitamins, allergy and cold medicine, pain relievers, quit
smoking aids, AND anything else not yet reported?
[What about (you/name)? Last year, how much was paid out-of-pocket for
(your/name’s) non-prescription healthcare products such as vitamins, allergy and
cold medicine, pain relievers, quit smoking aids, AND anything else not yet
reported?]
Include any amount paid out-of-pocket on (your/his/her) behalf by anyone in this
household.
Enter dollar amount
If unsure of the amount, a best guess is acceptable.
________________
120
7 EMPLOYER’S PENSION PLAN
Q74a
Other than Social Security did (the/any) employer or union that (name/you) worked
for in 2021 have a pension or other type of retirement plan for any of its employees?
1
2
Yes
No
Q74b
(Were/Was) (name/you) included in that plan?
1
2
Yes
No
8 LOW INCOME ITEMS
8.1 SCHOOL LUNCHES
Q80
During 2021 which of the children ages 5 to 18 in this household usually ate a
complete lunch offered at school?
“Usually” refers to days where school was being held in person, such as during the
pre-pandemic period or in areas where schools remained open.
Probe: Anyone else?
Enter all that apply, separate using the space bar or a comma.
Enter 96 for All
Enter 0 for None
Q83
During 2021 which of the children in this household received free or reduced priced
lunches because they qualified for the Federal School Lunch Program or their
school provided free lunches to all students?
Probe: Anyone else?
Enter all that apply, separate using the space bar or a comma.
Enter 96 for All
Enter 0 for None
121
ECVDPEBT
Did any children in this household receive free/reduced price meals through your
school or school district if schools were closed during the or did anyone in your
household receive a school meal/debit card (P-EBT) when schools were disrupted
due to the coronavirus pandemic?
This includes any food provided by the school, regardless of where and how it is
delivered.
1
2
3
Yes
No
Schools were not closed disrupted
8.2 PUBLIC HOUSING
Q85
Is this public housing, that is, is it owned by a local housing authority or other
public agency?
4
5
Yes
No
Q86
Are you paying lower rent because the Federal, State, or local government is paying
part of the cost?
1
2
Yes
No
SPHS8
Is this through Section 8 or through some other government program?
1
2
3
Section 8
Some other government program
Not sure
8.3 WOMEN, INFANTS, AND CHILDREN NUTRITION PROGRAM
(WIC)
SWRWIC
At any time during 2021, (was/were) (you/ anyone in this household) on WIC, the
Women, Infants, and Children Nutrition Program?
122
1
2
Yes
No
SWRW
Who received WIC for themselves or on behalf of a child?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone else?
8.4 ENERGY ASSISTANCE
Q93
The government has an energy assistance program which helps pay heating and
cooling costs. This assistance can be received directly by the household or it can be
paid directly to the electric company, gas company, or fuel dealer.
In 2021, (did you/did this household) receive assistance of this type from the federal,
state, or local government?
1
2
Yes
No
Q93pr1
Do you remember receiving an additional or unexpected check that was sent during
the year to help pay heating or cooling costs?
1
2
Yes
No
Q93pr2
Was it used to pay heating costs?
1
2
Yes
No
Q94
Altogether, how much energy assistance has been received in 2021?
Enter annual amount only
________________
123
Q94rn1
Could you tell me if you received:
less than $1,000
between $1,000 and $3,000
or over $3,000
in energy assistance during 2021?
1
2
3
Less than $1,000
Between $1,000 and $3,000
Over $3000
Q94rn2
Did you receive:
less than $100
between $100 and $500
or over $500
in energy assistance during 2021?
1
2
3
Less than $100
Between $100 and $500
Over $500
9 MIGRATION
9.1 1-YEAR MIGRATION
MIGSAM
(Were/Was) (you/reference person's name) living in this house (or apartment) one
year ago?
1
2
3
Yes, this house (apt)
No, different house in U.S.
No, outside the U.S.
MIGPLC
Where did (reference person's name/you) live one year ago?
Name of city/town/post office
Current: (city)
124
Enter correct city/town/post office or press ENTER for SAME
_______________
MIGSTA
Where did (reference person's name/you) live one year ago?
Name of State
Current: (state)
Enter W for person living on a ship at sea
Enter correct State or press ENTER for SAME
_______________
MIGZIP
Where did (reference person's name/you) live one year ago?
Zip Code
Current: (zip)
Enter correct Zip Code or press ENTER for SAME
_______________
MIGCLM
Did (reference person's name/you) live inside the city limits of (place name)?
1
2
Yes, inside city limits
No, outside city limits or post office name only
MIGCOU
What (county/parish) is (place name) in?
Enter "IND CITY" if an independent city, not a county
_____________________________________________
S_MIGCN1
What country did (reference person's name/you) live in one year ago?
MI1RES
What was (your/name’s) main reason for moving to this house (apartment)?
The answer categories are separated into the following groups:
FAMILY-RELATED REASONS* 1-3
EMPLOYMENT-RELATED REASONS 5-9
HOUSING-RELATED REASONS 10-15
OTHER REASONS 4, 16-20
125
*Family-related reasons only include family as defined by the Census Bureau. Family
consists of people who are related by birth, marriage, or adoption.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
change in marital status
to establish own household
other family reason (specify)
relationship with unmarried partner (boy/girlfriend, fiancé, etc.)
new job or job transfer
to look for work or lost job
to be closer to work/easier commute
retired
other job-related reason (specify)
wanted to own home, not rent
wanted newer/better/larger house or apartment
wanted better neighborhood/less crime
cheaper housing
foreclosure/eviction
other housing reason (specify)
to attend or leave college
change of climate
health reasons
natural disaster (hurricane, tornado, etc.)
other reason (specify)
MI1s
What was the reason for moving?
_____________________________________________
MIGALL
There are (number) other persons in this household ages 1 year or over.
Did (all of these persons/this person) live with (reference person's name/you) (in this
house/in City, State/outside the U.S.) one year ago?
1
2
Yes, all lived with (reference person's name/you)
No, some or all did not live with (reference person's name/you)
MIGM
Which of the other members of this household did NOT live with (reference
person's name/you) one year ago?
PROBE: Anyone else?
Enter all that apply, separate using the space bar or a comma.
Enter Line Number(s)
126
NXTSAM
Did (name/you) live in this house (apartment) one year ago?
1 Yes , this house
2 No, different house in U.S.
3 No, outside the U.S.
NXTPLC
Where did (name/you) live one year ago?
Name of city/town/post office
Current: (city) Enter correct city/town/post office or
Press ENTER for SAME
_____________________________________________
NXTSTA
Where did (name/you) live one year ago?
Name of State
Current: (state)
Enter correct State or press ENTER for SAME
_____________________________________________
NXTZIP
Where did (name/you) live one year ago?
Zip Code Current: (zip)
Enter correct zip code or
Press ENTER for SAME
_______________
NXTCLM
Did (name/you) live inside the city limits of (place name)?
1
2
Yes, inside city limits
No, outside city limits or post office name only
NXTCOU
What (county/parish) is (place name) in?
127
Enter "IND CITY" if an independent city, not a county
_____________________________________________
S_NXTCN1
What country did (name/you) live in one year ago?
NX1RES
What was (name’s/your) main reason for moving to this house (apartment)?
The answer categories are separated into the following groups:
FAMILY-RELATED REASONS* 1-3
EMPLOYMENT-RELATED REASONS 5-9
HOUSING-RELATED REASONS 10-15
OTHER REASONS 4, 16-20
*Family-related reasons only include family as defined by the Census Bureau. Family are
people who are related by birth, marriage, or adoption.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
change in marital status
to establish own household
other family reason (specify)
relationship with unmarried partner (boy/girlfriend, fiancé, etc.)
new job or job transfer
to look for work or lost job
to be closer to work/easier commute
retired
other job-related reason (specify)
wanted to own home, not rent
wanted newer/better/larger house or apartment
wanted better neighborhood/less crime
cheaper housing
foreclosure/eviction
other housing reason (specify)
to attend or leave college
change of climate
health reasons
natural disaster (hurricane, tornado, etc.)
other reason (specify)
NX1OTH
What was the reason for moving?
_____________________________________________
128
SUNITS
Ask if necessary
How many housing units are in your building?
1
2
3
4
5
Only one
Two
Three or four
Five to nine
Ten or more
10 SUPPLEMENTAL POVERTY MEASURE
10.1 PROPERTY VALUE/PRESENCE OF MORTGAGE
VALPROP
About how much do you think this (house and lot/apartment/mobile home)
would sell for if it were for sale?
Enter dollar amount
________________
VALPROPR
Could you tell me if you think this (house and lot/apartment/mobile home) would
sell for:
less than $100,000
between $100,000 and $250,000
between $250,000 and $500,000
or $500,000 or more?
1
2
3
4
Less than $100,000
Between $100,000 and $250,000
Between $250,000 and $500,000
$500,000 or more
MORTYN
Not counting home equity loans, do you or any other member of this household have
a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?
129
1
2
Yes
No
SMORTYN
Do you or any member of this household have a second mortgage or a home equity
loan on THIS property?
1
2
3
4
Yes, home equity loan.
Yes, second mortgage.
Yes, second mortgage and home equity loan.
No
10.2 CHILD CARE
Q95
Now we want to ask about some of your expenses for children.
Did (you/ anyone in this household) PAY for the care of (your/their) (child/children)
while (you/they) worked in 2021?
Include: All child care expenses including preschool and nursery school expenses,
before and after school care, and summer care.
Do not include: cost of kindergarten or grade/elementary school.
1
2
Yes
No
Q95A
Which children needed care while their parents worked?
Enter all that apply, separate using the space bar or a comma.
Probe: Anyone else?
Enter 96 for All persons
Enter 0 if none
CCFREQ
What is the easiest way for you to tell us how much was paid for child care while
(you/they) worked in 2021: weekly, every other week, twice a month, monthly, or
yearly?
1
2
Weekly
Every other week
130
3
4
7
Twice a month
Monthly
Yearly
CCAMT
How much was paid (weekly/every other week/twice a month/monthly) for child
care?
Include child care payments made for all children in the household.
For example, if there are two adults in the household with childcare
expenses use the total paid by both adults. Do not try to separate
the payments. Record one total for the entire household.
________________
CCNUMPAY
How many (weekly/every other week/twice a month/monthly) payments did
(you/they) make during 2021?
(1-52), (1-26), (1-24), (1-12)
________________
CCTOT
Then (you/they) paid $(amount) altogether in child care while (you/they) worked
during 2021. Does that sound about right?
1
2
Yes
No
CCEST
What is your best estimate of the correct amount (you/they) paid for child care
while (you/they) worked in 2021?
________________
10.3 CHILD SUPPORT PAID
CSPCHILD
(Do you/Does anyone in this household) have any children who lived elsewhere with
their other parent or guardian at anytime during 2021?
1
2
Yes
No
131
CSPWHO
Who had children who lived elsewhere? Anyone else?
Enter line number
Enter all that apply, separate using the space bar or a comma.
________________
CSPREQ
In 2021, did (name/you) pay any child support for children living elsewhere with
their other parent or guardian?
1
2
Yes
No
CSPAMT
How much child support did (name/you) pay in 2021?
Enter dollar amount
COUNT ALL FORMS OF CHILD SUPPORTS PAYMENTS, INCLUDING:
…PAYMENTS MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
…PAYMENTS MADE THROUGH A COURT OR AGENCY; AND
…PAYMENTS WITHHELD FROM THIS PERSON'S PAYCHECK
132
10.4 STIMULUS/ADVANCE CHILD TAX CREDIT QUESTIONS
ECVD_EIP
During 2021, have you or anyone in your household received a “stimulus payment,”
that is the coronavirus (COVID-19) related Economic Impact Payment from the
Federal Government?
During 2020, did you or anyone in your household received any stimulus payment
or payments from the Department of the Treasury due to the coronavirus-Covid-19
pandemic?
Do not include refunds on annual income taxes, unemployment compensation, or
payments from an employer
1
2
Yes
No
ECVD_COV
Who was the stimulus payment for?
Enter line number
Enter all that apply, separate using the space bar or a comma.
________________
ECVD_AMT
What was the amount of the stimulus payment(s) that you received for all the
covered adults and children in 2020?
Enter dollar amount
________________
133
ECTC
In the spring of 2021, as part of the American Rescue Plan, the child tax credit was
expanded and the IRS was instructed to pay out the benefit to parents, monthly,
starting in July 2021. Since July, have you or anyone in your household received an
Advance Child Tax Credit payment from the Federal Government?
Please report “yes” if you received the payment as a paper check or as a direct
deposit.
1
Yes
2
No
________________
134
Attachment A. Income Range Follow-up Questions
The three levels of income range follow-up questions are:
1) High-range income follow-up brackets:
•
•
•
Less than $45,000
Between $45,000 and $60,000
$60,000 or more
If the respondent selects the lowest bracket (Less than $45,000), then the following
ranges will be presented to the respondent:
•
•
•
Less than $15,000
Between $15,000 and $30,000
$30,000 or more
2) Mid-range income follow-up questions:
•
•
•
Less than $10,000
Between $10,000 and $20,000
$20,000 or more
If the respondent selects the lowest bracket (Less than $10,000), then the following
ranges will be presented to the respondent:
•
•
•
Less than $1,000
Between $1,000 and $5,000
$5,000 or more
3) Low-range income follow-up questions:
•
•
•
Less than $1,000
Between $1,000 and $3,000
$3,000 or more
If the respondent selects the lowest bracket (Less than $1,000), then the following
ranges will be presented to the respondent:
•
•
•
Less than $100
Between $100 and $500
$500 or more
135
Attachment B. Income Source and Follow-Up Question Range Level
The following table displays the income source and range level used in the follow-up range
questions.
Source
Screen
Range
Level
Income Source
Range Screen
Earnings from Longest Job
Longest Job: tips, bonuses, etc.
Earnings from Business/ Farm
Business/ Farm: tips, bonuses, etc.
Earnings from All Other Employers
All Other Employers: tips, bonuses, etc.
Earnings from Any Other Business
Earnings from Any Other Farm
State or Federal Unemployment Compensation
Supplemental Unemployment Benefits
Union Unemployment or Strike Benefits
Worker's Compensation
Social Security
Social Security for Children
Supplemental Security Income (SSI)
SSI for Children
Disability Income (source 1)
Disability Income (source 2)
Veteran's Payments (source 1)
Veteran's Payments (source 2)
Survivor Benefits (source 1)
Survivor Benefits (source 2)
Survivor Benefits (source 3)
PUQ48AARN1
PUQ48AADRN1
PUQ48BRN1
PUQ48BADRN1
PUQ49B1DRN1
PUQ49B1ARN1
PUQ49B2RN1
PUQ49B4RN1
PUQ51A11R1
PUQ51A21R1
PUQ51A31R1
PUQ52CR1
PUQ656DRN1
PUQ56IRN1
PUQ57CRN1
PUQ57IRN1C
PUQ61E1RN1
PUQ61E2RN1
PUQ60V1RN1
PUQ60V2RN1
PUQ58E1RN1
PUQ58E2RN1
PUQ58E3RN1
Public Assistance/ TANF
PUQ59ERN1
Low
Food Assistance/ SNAP
HUQ90RN1
Low
Q99ARa
Pensions (source 1)
Pensions (source 2)
Annuities
Retirement Withdrawals/Distributions (source 1)
Retirement Withdrawals/Distributions (source 2)
Retirement Interest (source 1)
Retirement Interest (source 2)
Checking Account Interest
PUQ62E1RN1
PUQ62E2RN1
PUANNEWRN1
PUDSTNEWR1
PUDSTNEWR3
PURETNEWRN1
PURETNEWRN3
PUQ63C1B
Q99ARb
Savings Account Interest
PUQ63D1B
Low
Q99ARc
Money Market Account Interest
PUQ63e1B
Low
Q99ARd
CD Interest
PUQ63f1B
Low
Q99ARe
Saving Bonds Interest
PUQ63g1b
Low
Q99ARe
Stock Dividends
PUQ63h1b
Low
Q99ARg
Any Other Interest
PUQ63i1b
Low
Q48AA
Q48AAD
Q48B
Q48BAD
Q49B1D
Q49B1A
Q49B2
Q49B4
Q51A1
Q51A2
Q51A3
Q52A
Q56A
Q56F
Q57A
Q57D
Q59AR
Q60A88
Q58A
Q59A88,
Q59A89
Q87R,
Q87AR
Q62AR
Q96AR
Q98Ar
Q97Cr
136
High
Low
High
Low
Mid
Low
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Mid
Low
Low
Source
Screen
Income Source
Range Screen
CAPGDIS
Nonretirement Interest
Q65A1,
Q65A2,
Q65A3
PUCAPGDAMTRN
1
Property Income
PUQ65CRN1
Q70A
Pell Grant
Other Education Assistance
Child Support
PUQ69FRN1
PUQ66HRN1
PUQ70C1RN1
Q72A
Regular Financial Assistance
PUQ72CRN1
Low
Q73A1
Other Money Income
PUQ73RN1
Low
Q93
Energy Assistance
HUQ94RN1
Low
Q66B
137
Range
Level
Mid
Mid
Low
Mid
| File Type | application/pdf |
| File Title | 2016 ASEC Items Booklet |
| Author | Lisa Paska |
| File Modified | 2021-11-02 |
| File Created | 2021-08-06 |