ACS Methods Panel Test

Attachment B

2022 ACS Content Test
Field Test

Paper Questionnaires

Control Treatment

13192018

DC

The American Community Survey

Start Here
You have two ways to respond:

➜

Respond online today at:
https://respond.census.gov/acs

Please print the name and telephone number of the
person who is filling out this form. We will only
contact you if needed for official Census Bureau business.
Last Name

OR
First Name

Complete this form and mail it
back as soon as possible.

Area Code

Your response is required by law.
The American Community Survey is
conducted by the U.S. Census Bureau.
This survey is one of only a few
surveys for which all recipients are
required by law to respond. The
U.S. Census Bureau is required by
law to protect your information.

MI

+

Number

—

➜

How many people are living or staying at this address?
ჀINCLUDE everyone who is living or staying here for more
than 2 months.
ჀINCLUDE yourself if you are living here for more than 2
months.
ჀINCLUDE anyone else staying here who does not have
another place to stay, even if they are here for 2 months or
less.

If you need help or have
questions about completing
this form, please call
1-800-354-7271.

ჀDO NOT INCLUDE anyone who is living somewhere else for
more than 2 months, such as a college student living away or
someone in the Armed Forces on deployment.

Number of people

Text Telephone (TTY):
Call 1–800–582–8330.
¿NECESITA AYUDA? Llame sin cargo
alguno al 1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
https://www.census.gov/acs

➜

Fill out pages 2 – 7 for everyone, including yourself,
who is living or staying at this address for more
than 2 months. Then complete the rest of the form.

ACS-1(X)CT-C

FORM
(02-11-2022) D3

§.453¤

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

13192026

Person 1
(Person 1 is the person living or staying here in whose
name this house or apartment is owned, being bought,
or rented. If there is no such person, start with the name
of any adult living or staying here.)

➜

➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

5

Is Person 1 of Hispanic, Latino, or Spanish origin?

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

What is Person 1’s name?
Last Name (Please print)

First Name

2

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.

How is this person related to Person 1?
Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

What is Person 1’s sex? Mark (X) ONE box.
Male

4

6

White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

X

3

MI

Female

What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Print numbers in boxes.
Age (in years)

Month

Day

Year of birth

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Some other race – Print race or origin. C

§.45;¤

2

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

13192034

Person 2
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 2’s name?
Last Name (Please print)

Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 2’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.45C¤

3

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

13192042

Person 3
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 3’s name?
Last Name (Please print)

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 3’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.45K¤

4

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

13192059

Person 4
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 4’s name?
Last Name (Please print)

Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 4’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.45\¤

5

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

13192067

Person 5
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 5’s name?
Last Name (Please print)

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 5’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.45d¤

6

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

13192075

➜

If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C

Person 6
Last Name (Please print)

Sex

Male

Female

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

Age (in years)

Person 7
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 8
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 10
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 11
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 12
Last Name (Please print)

Sex

Male

Female

§.45l¤

Age (in years)

7

13192083

Housing
➜

1

Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.

A

Answer questions 4 – 5 if this is a HOUSE OR A
MOBILE HOME; otherwise, SKIP to question 6a.

4

How many acres is this house or mobile home on?

A mobile home

Less than 1 acre ➔ SKIP to question 6a

A one-family house detached from any
other house

1 to 9.9 acres

A one-family house attached to one or
more houses

10 or more acres

A building with 2 apartments

5

A building with 3 or 4 apartments

2

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

A building with 5 to 9 apartments

None

A building with 10 to 19 apartments

$1 to $999

A building with 20 to 49 apartments

$1,000 to $2,499

A building with 50 or more apartments

$2,500 to $4,999

Boat, RV, van, etc.

$5,000 to $9,999
$10,000 or more

About when was this building first built?
2020 or later – Specify year

6

a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend
out at least 6 inches and go from floor to ceiling.
Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.

2010 to 2019
2000 to 2009

Number of rooms

1990 to 1999
1980 to 1989
1970 to 1979

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this
house, apartment, or mobile home were for sale or
rent. If this is an efficiency/studio apartment, print "0".

1960 to 1969
1950 to 1959

Number of bedrooms

1940 to 1949
1939 or earlier

3

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

7

Does this house, apartment, or mobile home
have –
Yes

Year

a. hot and cold running water?
b. a bathtub or shower?
c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?

§.45t¤

8

No

13192091

Housing (continued)
8

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

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

Yes, connected to public sewer

None ➔ SKIP to question 15

No, connected to septic tank

1

No, use other type of system

2

9

Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.

3
4
5

Yes

6 or more

No

14 Are any of the following types of electric
vehicles kept at home for use by members
of this household?

10 At this house, apartment, or mobile home –
do you or any member of this household own
or use any of the following types of computers?
Yes

a. A plug-in electric vehicle?

No

Yes

a. Desktop or laptop

No

b. Smartphone

b. A hybrid electric vehicle?

c. Tablet or other portable
wireless computer

Yes

d. Some other type of computer
Specify C

No

15 Which FUEL is used MOST for heating this
house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood

11 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?

Gas: bottled, tank, or LP

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

Electricity
Fuel oil, kerosene, etc.

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

Coal or coke

No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 13

Wood
Solar energy

12 Do you or any member of this household have
access to the Internet using a –
a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C

§.45|¤

Other fuel
Yes

No

No fuel used

16 Does this house, apartment, or mobile home use
solar panels that generate electricity?
Yes
No

9

13192109

Housing (continued)
17 a. LAST MONTH, what was the cost of electricity 19 Is this house, apartment, or mobile home part of
for this house, apartment, or mobile home?

a condominium?

Last month’s cost – Dollars

$

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

.00


OR

Monthly amount – Dollars

Included in rent or condominium fee

$

No charge or electricity not used

.00


OR

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

None
No

Last month’s cost – Dollars

$

.00



20 Is this house, apartment, or mobile home –
Mark (X) ONE box.

OR
Included in rent or condominium fee

Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.

Included in electricity payment entered above

Owned by you or someone in this household free
and clear (without a mortgage or loan)?

No charge or gas not used

Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page

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

$

B

.00



Answer questions 21a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 22.

OR
Included in rent or condominium fee

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

No charge

Monthly amount – Dollars

d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.

$



b. Does the monthly rent include any meals?

Past 12 months’ cost – Dollars
Yes

$

.00



No

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

18 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits
from the Food Stamp Program or SNAP (the
Supplemental Nutrition Assistance Program)?
Do NOT include WIC, the School Lunch Program, or
assistance from food banks.
Yes
No

§.46*¤

.00

10

C

13192117

Housing (continued)

C

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

Answer questions 22 – 26 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .

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

22 About how much do you think this house and lot,

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

apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

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

Yes, contract to purchase
No ➔ SKIP to question 26a

27 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 26a

§.462¤

E

11

Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.

13192125

Person 1
➜

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest degree or level of school this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.46:¤

12

13192133

Person 1 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

14 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 15a

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

c. Medicare, for people 65 and older,
or people with certain disabilities

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.46B¤

13

Yes

No

13192141

Person 1 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.46J¤

14

13192158

Person 1 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.46[¤

15

13192166

Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.46c¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

16

13192174

Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.

Yes
No ➔ SKIP to question 39

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 43

GOVERNMENT EMPLOYEE

40 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.46k¤

17

13192182

Person 1 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





TOTAL AMOUNT for past
12 months

$

No





Loss

No



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



$





TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.46s¤

TOTAL AMOUNT for past
12 months

OR

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.



No

.00



PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

.00

TOTAL AMOUNT for past
12 months

$

$

44 What was this person’s total income during the

None

Yes ➔

Yes ➔

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

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

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

18

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.

13192190

Person 2
➜

Please copy the name of Person 2 from page 3,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest degree or level of school this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.46{¤

19

13192208

Person 2 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

14 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 15a

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

c. Medicare, for people 65 and older,
or people with certain disabilities

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.47)¤

20

Yes

No

13192216

Person 2 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.471¤

21

13192224

Person 2 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.479¤

22

13192232

Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.47A¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

23

13192240

Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.

Yes
No ➔ SKIP to question 39

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 43

GOVERNMENT EMPLOYEE

40 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.47I¤

24

13192257

Person 2 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





TOTAL AMOUNT for past
12 months

$

No





Loss

No



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



$





TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.47Z¤

TOTAL AMOUNT for past
12 months

OR

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.



No

.00



PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

.00

TOTAL AMOUNT for past
12 months

$

$

44 What was this person’s total income during the

None

Yes ➔

Yes ➔

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

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

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

25

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.

13192265

Person 3
➜

Please copy the name of Person 3 from page 4,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest degree or level of school this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.47b¤

26

13192273

Person 3 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

14 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 15a

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

c. Medicare, for people 65 and older,
or people with certain disabilities

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.47j¤

27

Yes

No

13192281

Person 3 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.47r¤

28

13192299

Person 3 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.47ƒ¤

29

13192307

Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.48(¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

30

13192315

Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.

Yes
No ➔ SKIP to question 39

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 43

GOVERNMENT EMPLOYEE

40 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.480¤

31

13192323

Person 3 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





TOTAL AMOUNT for past
12 months

$

No





Loss

No



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



$





TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.488¤

TOTAL AMOUNT for past
12 months

OR

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.



No

.00



PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

.00

TOTAL AMOUNT for past
12 months

$

$

44 What was this person’s total income during the

None

Yes ➔

Yes ➔

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

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

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

32

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.

13192331

Person 4
➜

Please copy the name of Person 4 from page 5,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest degree or level of school this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.48@¤

33

13192349

Person 4 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

14 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 15a

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

c. Medicare, for people 65 and older,
or people with certain disabilities

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.48R¤

34

Yes

No

13192356

Person 4 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.48Y¤

35

13192364

Person 4 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.48a¤

36

13192372

Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.48i¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

37

13192380

Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.

Yes
No ➔ SKIP to question 39

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 43

GOVERNMENT EMPLOYEE

40 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.48q¤

38

13192398

Person 4 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





TOTAL AMOUNT for past
12 months

$

No





Loss

No



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



$





TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.48¥¤

TOTAL AMOUNT for past
12 months

OR

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.



No

.00



PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

.00

TOTAL AMOUNT for past
12 months

$

$

44 What was this person’s total income during the

None

Yes ➔

Yes ➔

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

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

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

39

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.

13192406

Person 5
➜

Please copy the name of Person 5 from page 6,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest degree or level of school this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.49’¤

40

13192414

Person 5 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

14 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 15a

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

c. Medicare, for people 65 and older,
or people with certain disabilities

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.49/¤

41

Yes

No

13192422

Person 5 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.497¤

42

13192430

Person 5 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.49?¤

43

13192448

Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.49Q¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

44

13192455

Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.

Yes
No ➔ SKIP to question 39

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 43

GOVERNMENT EMPLOYEE

40 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.49X¤

45

13192463

Person 5 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





TOTAL AMOUNT for past
12 months

$

No





Loss

No



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



$





TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.49‘¤

TOTAL AMOUNT for past
12 months

OR

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.



No

.00



PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

.00

TOTAL AMOUNT for past
12 months

$

$

44 What was this person’s total income during the

None

Yes ➔

Yes ➔

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

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

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

46

Now continue with the mailing instructions
on page 48.

13192471

Page 47 is intentionally
left blank

§.49h¤

47

13192489

Mailing
Instructions
➜ Please make sure you have...

Ⴠ listed all names and answered the
questions on pages 2 – 7
Ⴠ answered all Housing questions
Ⴠ answered all Person questions for each
person
➜ Then...

Ⴠput the completed questionnaire into the
postage-paid return envelope. If the
envelope has been misplaced, please
mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
Ⴠmake sure the barcode above your
address shows in the window of the
return envelope
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" as the
subject. Please DO NOT RETURN your questionnaire
to this address. Use the enclosed preaddressed
envelope to return your completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management
and Budget. This 8-digit number appears in the
bottom right on the front cover of this form.

Form ACS-1(X)CT-C (02-11-2022)

§.49z¤

48

Test Treatment

13212014

DC

The American Community Survey

Start Here
You have two ways to respond:

➜

Respond online today at:
https://respond.census.gov/acs

Please print the name and telephone number of the
person who is filling out this form. We will only
contact you if needed for official Census Bureau business.
Last Name

OR
First Name

Complete this form and mail it
back as soon as possible.

Area Code

Your response is required by law.
The American Community Survey is
conducted by the U.S. Census Bureau.
This survey is one of only a few
surveys for which all recipients are
required by law to respond. The
U.S. Census Bureau is required by
law to protect your information.

MI

+

Number

—

➜

How many people are living or staying at this address?
ჀINCLUDE everyone who is living or staying here for more
than 2 months.
ჀINCLUDE yourself if you are living here for more than 2
months.
ჀINCLUDE anyone else staying here who does not have
another place to stay, even if they are here for 2 months or
less.

If you need help or have
questions about completing
this form, please call
1-800-354-7271.

ჀDO NOT INCLUDE anyone who is living somewhere else for
more than 2 months, such as a college student living away or
someone in the Armed Forces on deployment.

Number of people

Text Telephone (TTY):
Call 1–800–582–8330.
¿NECESITA AYUDA? Llame sin cargo
alguno al 1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
https://www.census.gov/acs

➜

Fill out pages 2 – 7 for everyone, including yourself,
who is living or staying at this address for more
than 2 months. Then complete the rest of the form.

ACS-1(X)CT-T

FORM
(02-11-2022) D5

§.65/¤

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

13212022

Person 1
(Person 1 is the person living or staying here in whose
name this house or apartment is owned, being bought,
or rented. If there is no such person, start with the name
of any adult living or staying here.)

➜

➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

5

Is Person 1 of Hispanic, Latino, or Spanish origin?

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

What is Person 1’s name?
Last Name (Please print)

First Name

2

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.

How is this person related to Person 1?
Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

What is Person 1’s sex? Mark (X) ONE box.
Male

4

6

White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

X

3

MI

Female

What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Print numbers in boxes.
Age (in years)

Month

Day

Year of birth

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Some other race – Print race or origin. C

§.657¤

2

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

13212030

Person 2
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 2’s name?
Last Name (Please print)

Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 2’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.65?¤

3

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

13212048

Person 3
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 3’s name?
Last Name (Please print)

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 3’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.65Q¤

4

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

13212055

Person 4
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 4’s name?
Last Name (Please print)

Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 4’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.65X¤

5

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

13212063

Person 5
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 5’s name?
Last Name (Please print)

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 5’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.65‘¤

6

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

13212071

➜

If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C

Person 6
Last Name (Please print)

Sex

Male

Female

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

Age (in years)

Person 7
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 8
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 10
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 11
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 12
Last Name (Please print)

Sex

Male

Female

§.65h¤

Age (in years)

7

13212089

Housing
➜

1

Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.

A

Answer questions 4 – 5 if this is a HOUSE OR A
MOBILE HOME; otherwise, SKIP to question 6a.

4

How many acres is this house or mobile home on?

A mobile home

Less than 1 acre ➔ SKIP to question 6a

A one-family house detached from any
other house

1 to 9.9 acres

A one-family house attached to one or
more houses

10 or more acres

A building with 2 apartments

5

A building with 3 or 4 apartments

2

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

A building with 5 to 9 apartments

None

A building with 10 to 19 apartments

$1 to $999

A building with 20 to 49 apartments

$1,000 to $2,499

A building with 50 or more apartments

$2,500 to $4,999

Boat, RV, van, etc.

$5,000 to $9,999
$10,000 or more

About when was this building first built?
2020 or later – Specify year

6

a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend
out at least 6 inches and go from floor to ceiling.
Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.

2010 to 2019
2000 to 2009

Number of rooms

1990 to 1999
1980 to 1989
1970 to 1979

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this
house, apartment, or mobile home were for sale or
rent. If this is an efficiency/studio apartment, print "0".

1960 to 1969
1950 to 1959

Number of bedrooms

1940 to 1949
1939 or earlier

3

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

7

Does this house, apartment, or mobile home
have –
Yes

Year

a. hot and cold running water?
b. a bathtub or shower?
c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?

§.65z¤

8

No

13212097

Housing (continued)
8

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

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

Yes, connected to public sewer

None ➔ SKIP to question 15

No, connected to septic tank

1

No, use other type of system

2

9

Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.

3
4
5

Yes

6 or more

No

14 Do you or any member of this household own or
lease an electric vehicle? Include both all-electric
and plug-in hybrid electric vehicles.

10 At this house, apartment, or mobile home –
do you or any member of this household own
or use any of the following types of computers?
Yes

Yes

No

No

a. Desktop or laptop
b. Smartphone

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

c. Tablet or other portable
wireless computer

Gas: from underground pipes serving the
neighborhood

d. Some other type of computer
Specify C

Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.

11 At this house, apartment, or mobile home –

Coal or coke

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

Wood

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

Solar energy
Other fuel

Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 13
No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 13

No fuel used

16 Does this house, apartment, or mobile home use
solar panels that generate electricity?

12 Do you or any member of this household have
access to the Internet using a –
a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C

§.65¿¤

Yes
Yes

No

No

9

13212105

Housing (continued)
17 a. LAST MONTH, what was the cost of electricity 19 Is this house, apartment, or mobile home part of
for this house, apartment, or mobile home?

a condominium?

Last month’s cost – Dollars

$

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

.00


OR

Monthly amount – Dollars

Included in rent or condominium fee

$

No charge or electricity not used

.00


OR

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

None
No

Last month’s cost – Dollars

$

.00



20 Is this house, apartment, or mobile home –
Mark (X) ONE box.

OR
Included in rent or condominium fee

Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.

Included in electricity payment entered above

Owned by you or someone in this household free
and clear (without a mortgage or loan)?

No charge or gas not used

Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page

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

$

B

.00



Answer questions 21a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 22.

OR
Included in rent or condominium fee

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

No charge

Monthly amount – Dollars

d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.

$



b. Does the monthly rent include any meals?

Past 12 months’ cost – Dollars
Yes

$

.00



No

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

18 In 2021, did you or any member of this
household receive benefits from the Food
Stamp Program or SNAP (the Supplemental
Nutrition Assistance Program)? Do NOT include
WIC, the School Lunch Program, or assistance from
food banks.
Yes
No

§.66&¤

.00

10

C

13212113

Housing (continued)

C

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

Answer questions 22 – 26 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .

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

22 About how much do you think this house and lot,

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

apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

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

Yes, contract to purchase
No ➔ SKIP to question 26a

27 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 26a

§.66.¤

E

11

Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.

13212121

Person 1
➜

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.666¤

12

13212139

Person 1 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

ZIP Code

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

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

b. Medicare, for people 65 and older, or
people with certain disabilities

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.66H¤

13

Yes

No

13212147

Person 1 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

No difficulty
Some difficulty

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

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

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.66P¤

14

J on the next page

13212154

Person 1 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.66W¤

15

13212162

Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.66_¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

16

13212170

Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.66g¤

17

13212188

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

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔

$

No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)



.00



Loss

TOTAL AMOUNT for 2021

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Supplemental Security Income (SSI).
Yes ➔

44 INCOME IN 2021

No

Report ALL types of income received, TAXABLE AND
NONTAXABLE, from January 1, 2021 to December 31,
2021.

No

BREAK-EVEN NET INCOME: For break-evens, mark (X)
the "Yes" box and write in $0 for the TOTAL AMOUNT.

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

No



TOTAL AMOUNT for 2021

$

No





Loss

No





No

TOTAL AMOUNT for 2021

.00



Yes ➔

$

No

TOTAL AMOUNT for 2021

.00



$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

§.66y¤

$

OR
None

$

Yes ➔

person’s total income in 2021? Add entries in
questions 44a to 44i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

c. Interest, dividends, royalty income, or income
from estates and trusts. Report even small
amounts credited to an account.
Yes ➔

TOTAL AMOUNT for 2021

45 Including all types of income, what was this

.00

TOTAL AMOUNT for 2021

.00



i. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

.00

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), including proprietorships
and partnerships. Report NET income after
business expenses. If net income was a loss, mark
(X) the “Loss” box next to the dollar amount.
Yes ➔

$

h. Retirement income, pensions, survivor, or
disability income. Do NOT include Social Security.
INCLUDE income from a previous employer or union
and any regular withdrawals or distributions from IRA,
Roth IRA, 401(k), 403(b), or other accounts specifically
designed for retirement.

INCOME RECEIVED JOINTLY: Report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
“No” box for the other person.



TOTAL AMOUNT for 2021

Yes ➔

Mark (X) the “No” box for each type of income NOT
received.

$

.00



g. Any financial assistance from the state or local
welfare office. Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash benefits
like energy or housing assistance.

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

Yes ➔

$

➜

18

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.

13212196

Person 2
➜

Please copy the name of Person 2 from page 3,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.66£¤

19

13212204

Person 2 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

ZIP Code

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

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

b. Medicare, for people 65 and older, or
people with certain disabilities

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.67%¤

20

Yes

No

13212212

Person 2 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

No difficulty
Some difficulty

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

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

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.67-¤

21

J on the next page

13212220

Person 2 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.675¤

22

13212238

Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.67G¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

23

13212246

Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.67O¤

24

13212253

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

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔

$

No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)



.00



Loss

TOTAL AMOUNT for 2021

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Supplemental Security Income (SSI).
Yes ➔

44 INCOME IN 2021

No

Report ALL types of income received, TAXABLE AND
NONTAXABLE, from January 1, 2021 to December 31,
2021.

No

BREAK-EVEN NET INCOME: For break-evens, mark (X)
the "Yes" box and write in $0 for the TOTAL AMOUNT.

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

No



TOTAL AMOUNT for 2021

$

No





Loss

No





No

TOTAL AMOUNT for 2021

.00



Yes ➔

$

No

TOTAL AMOUNT for 2021

.00



$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

§.67V¤

$

OR
None

$

Yes ➔

person’s total income in 2021? Add entries in
questions 44a to 44i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

c. Interest, dividends, royalty income, or income
from estates and trusts. Report even small
amounts credited to an account.
Yes ➔

TOTAL AMOUNT for 2021

45 Including all types of income, what was this

.00

TOTAL AMOUNT for 2021

.00



i. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

.00

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), including proprietorships
and partnerships. Report NET income after
business expenses. If net income was a loss, mark
(X) the “Loss” box next to the dollar amount.
Yes ➔

$

h. Retirement income, pensions, survivor, or
disability income. Do NOT include Social Security.
INCLUDE income from a previous employer or union
and any regular withdrawals or distributions from IRA,
Roth IRA, 401(k), 403(b), or other accounts specifically
designed for retirement.

INCOME RECEIVED JOINTLY: Report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
“No” box for the other person.



TOTAL AMOUNT for 2021

Yes ➔

Mark (X) the “No” box for each type of income NOT
received.

$

.00



g. Any financial assistance from the state or local
welfare office. Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash benefits
like energy or housing assistance.

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

Yes ➔

$

➜

25

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.

13212261

Person 3
➜

Please copy the name of Person 3 from page 4,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.67^¤

26

13212279

Person 3 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

ZIP Code

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

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

b. Medicare, for people 65 and older, or
people with certain disabilities

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.67p¤

27

Yes

No

13212287

Person 3 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

No difficulty
Some difficulty

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

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

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.67x¤

28

J on the next page

13212295

Person 3 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.67¢¤

29

13212303

Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.68$¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

30

13212311

Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.68,¤

31

13212329

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

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔

$

No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)



.00



Loss

TOTAL AMOUNT for 2021

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Supplemental Security Income (SSI).
Yes ➔

44 INCOME IN 2021

No

Report ALL types of income received, TAXABLE AND
NONTAXABLE, from January 1, 2021 to December 31,
2021.

No

BREAK-EVEN NET INCOME: For break-evens, mark (X)
the "Yes" box and write in $0 for the TOTAL AMOUNT.

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

No



TOTAL AMOUNT for 2021

$

No





Loss

No





No

TOTAL AMOUNT for 2021

.00



Yes ➔

$

No

TOTAL AMOUNT for 2021

.00



$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

§.68>¤

$

OR
None

$

Yes ➔

person’s total income in 2021? Add entries in
questions 44a to 44i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

c. Interest, dividends, royalty income, or income
from estates and trusts. Report even small
amounts credited to an account.
Yes ➔

TOTAL AMOUNT for 2021

45 Including all types of income, what was this

.00

TOTAL AMOUNT for 2021

.00



i. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

.00

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), including proprietorships
and partnerships. Report NET income after
business expenses. If net income was a loss, mark
(X) the “Loss” box next to the dollar amount.
Yes ➔

$

h. Retirement income, pensions, survivor, or
disability income. Do NOT include Social Security.
INCLUDE income from a previous employer or union
and any regular withdrawals or distributions from IRA,
Roth IRA, 401(k), 403(b), or other accounts specifically
designed for retirement.

INCOME RECEIVED JOINTLY: Report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
“No” box for the other person.



TOTAL AMOUNT for 2021

Yes ➔

Mark (X) the “No” box for each type of income NOT
received.

$

.00



g. Any financial assistance from the state or local
welfare office. Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash benefits
like energy or housing assistance.

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

Yes ➔

$

➜

32

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.

13212337

Person 4
➜

Please copy the name of Person 4 from page 5,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.68F¤

33

13212345

Person 4 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

ZIP Code

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

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

b. Medicare, for people 65 and older, or
people with certain disabilities

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.68N¤

34

Yes

No

13212352

Person 4 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

No difficulty
Some difficulty

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

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

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.68U¤

35

J on the next page

13212360

Person 4 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.68]¤

36

13212378

Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.68o¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

37

13212386

Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.68w¤

38

13212394

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

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔

$

No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)



.00



Loss

TOTAL AMOUNT for 2021

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Supplemental Security Income (SSI).
Yes ➔

44 INCOME IN 2021

No

Report ALL types of income received, TAXABLE AND
NONTAXABLE, from January 1, 2021 to December 31,
2021.

No

BREAK-EVEN NET INCOME: For break-evens, mark (X)
the "Yes" box and write in $0 for the TOTAL AMOUNT.

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

No



TOTAL AMOUNT for 2021

$

No





Loss

No





No

TOTAL AMOUNT for 2021

.00



Yes ➔

$

No

TOTAL AMOUNT for 2021

.00



$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

§.68¡¤

$

OR
None

$

Yes ➔

person’s total income in 2021? Add entries in
questions 44a to 44i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

c. Interest, dividends, royalty income, or income
from estates and trusts. Report even small
amounts credited to an account.
Yes ➔

TOTAL AMOUNT for 2021

45 Including all types of income, what was this

.00

TOTAL AMOUNT for 2021

.00



i. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

.00

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), including proprietorships
and partnerships. Report NET income after
business expenses. If net income was a loss, mark
(X) the “Loss” box next to the dollar amount.
Yes ➔

$

h. Retirement income, pensions, survivor, or
disability income. Do NOT include Social Security.
INCLUDE income from a previous employer or union
and any regular withdrawals or distributions from IRA,
Roth IRA, 401(k), 403(b), or other accounts specifically
designed for retirement.

INCOME RECEIVED JOINTLY: Report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
“No” box for the other person.



TOTAL AMOUNT for 2021

Yes ➔

Mark (X) the “No” box for each type of income NOT
received.

$

.00



g. Any financial assistance from the state or local
welfare office. Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash benefits
like energy or housing assistance.

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

Yes ➔

$

➜

39

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.

13212402

Person 5
➜

Please copy the name of Person 5 from page 6,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

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

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

College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.69#¤

40

13212410

Person 5 (continued)
15 a. Did this person live in this house or apartment

F

1 year ago?

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

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

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

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

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

Name of U.S. state or
Puerto Rico

ZIP Code

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

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

b. Medicare, for people 65 and older, or
people with certain disabilities

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.69+¤

41

Yes

No

13212428

Person 5 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.

No difficulty
Some difficulty

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

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

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.69=¤

42

J on the next page

13212436

Person 5 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.69E¤

43

13212444

Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.69M¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

44

13212451

Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.69T¤

45

13212469

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

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔

$

No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)



.00



Loss

TOTAL AMOUNT for 2021

e. Social Security or Railroad Retirement.
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Supplemental Security Income (SSI).
Yes ➔

44 INCOME IN 2021

No

Report ALL types of income received, TAXABLE AND
NONTAXABLE, from January 1, 2021 to December 31,
2021.

No

BREAK-EVEN NET INCOME: For break-evens, mark (X)
the "Yes" box and write in $0 for the TOTAL AMOUNT.

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

No



TOTAL AMOUNT for 2021

$

No





Loss

No





No

TOTAL AMOUNT for 2021

.00



Yes ➔

$

No

TOTAL AMOUNT for 2021

.00



$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

§.69f¤

$

OR
None

$

Yes ➔

person’s total income in 2021? Add entries in
questions 44a to 44i; subtract any losses. If net income
was a loss, enter the amount and mark (X) the "Loss"
box next to the dollar amount.

c. Interest, dividends, royalty income, or income
from estates and trusts. Report even small
amounts credited to an account.
Yes ➔

TOTAL AMOUNT for 2021

45 Including all types of income, what was this

.00

TOTAL AMOUNT for 2021

.00



i. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support or alimony.
Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.

.00

b. Self-employment income, including work paid
for in cash. Report income from own businesses
(farm or non-farm), including proprietorships
and partnerships. Report NET income after
business expenses. If net income was a loss, mark
(X) the “Loss” box next to the dollar amount.
Yes ➔

$

h. Retirement income, pensions, survivor, or
disability income. Do NOT include Social Security.
INCLUDE income from a previous employer or union
and any regular withdrawals or distributions from IRA,
Roth IRA, 401(k), 403(b), or other accounts specifically
designed for retirement.

INCOME RECEIVED JOINTLY: Report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
“No” box for the other person.



TOTAL AMOUNT for 2021

Yes ➔

Mark (X) the “No” box for each type of income NOT
received.

$

.00



g. Any financial assistance from the state or local
welfare office. Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash benefits
like energy or housing assistance.

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

Yes ➔

$

➜

46

Now continue with the mailing instructions
on page 48.

13212477

Page 47 is intentionally
left blank

§.69n¤

47

13212485

Mailing
Instructions
➜ Please make sure you have...

Ⴠ listed all names and answered the
questions on pages 2 – 7
Ⴠ answered all Housing questions
Ⴠ answered all Person questions for each
person
➜ Then...

Ⴠput the completed questionnaire into the
postage-paid return envelope. If the
envelope has been misplaced, please
mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
Ⴠmake sure the barcode above your
address shows in the window of the
return envelope
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" as the
subject. Please DO NOT RETURN your questionnaire
to this address. Use the enclosed preaddressed
envelope to return your completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management
and Budget. This 8-digit number appears in the
bottom right on the front cover of this form.

Form ACS-1(X)CT-T (02-11-2022)

§.69v¤

48

Roster Treatment

13222013

DC

The American Community Survey

Start Here

➜

You have two ways to respond:

Please print the name and telephone number of the
person who is filling out this form. We will only
contact you if needed for official Census Bureau business.
Last Name

Respond online today at:
https://respond.census.gov/acs
OR

First Name

Complete this form and mail it
back as soon as possible.

MI

Area Code + Number

Your response is required by law.
The American Community Survey is
conducted by the U.S. Census Bureau.
This survey is one of only a few
surveys for which all recipients are
required by law to respond. The
U.S. Census Bureau is required by
law to protect your information.

—

➜

How many people, including yourself, live or stay
at this address?
INCLUDE...
✓ anyone not related to you, like roommates and other
families.
✓ babies and children, related or unrelated, including
grandchildren and foster children.
✓ everyone staying here now who has no other place to stay.

If you need help or have
questions about completing
this form, please call
1-800-354-7271.

DO NOT INCLUDE anyone living somewhere else, such as...
✗ a college student living away.
✗ someone in the Armed Forces on deployment.

Text Telephone (TTY):
Call 1–800–582–8330.

Number of people

¿NECESITA AYUDA? Llame sin cargo
alguno al 1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
https://www.census.gov/acs

➜

Fill out pages 2 – 7 for everyone, including yourself,
who is living or staying at this address. Then
complete the rest of the form.

ACS-1(X)CT-R

FORM
(02-11-2022) D5

§.75.¤

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

13222021

Person 1
(Person 1 is the person living or staying here in whose
name this house or apartment is owned, being bought,
or rented. If there is no such person, start with the name
of any adult living or staying here.)

➜

➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

5

Is Person 1 of Hispanic, Latino, or Spanish origin?

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

What is Person 1’s name?
Last Name (Please print)

First Name

2

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.

How is this person related to Person 1?
Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

What is Person 1’s sex? Mark (X) ONE box.
Male

4

6

White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

X

3

MI

Female

What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Print numbers in boxes.
Age (in years)

Month

Day

Year of birth

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Some other race – Print race or origin. C

§.756¤

2

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

13222039

Person 2
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 2’s name?
Last Name (Please print)

Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 2’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.75H¤

3

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

13222047

Person 3
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 3’s name?
Last Name (Please print)

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 3’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.75P¤

4

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

13222054

Person 4
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 4’s name?
Last Name (Please print)

Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 4’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.75W¤

5

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

13222062

Person 5
➜ NOTE: Please answer BOTH Question 5 about

Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.

1

5

What is Person 5’s name?
Last Name (Please print)

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

First Name

Yes, Puerto Rican

MI

Yes, Cuban

2

Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C

How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

6

Same-sex husband/wife/spouse

What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

3

Foster child

Chinese

Vietnamese

Native Hawaiian

Other nonrelative

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

What is Person 5’s sex? Mark (X) ONE box.
Male

4

Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C

Female

What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
Some other race – Print race or origin. C

§.75_¤

6

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

13222070

➜

If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C

Person 6
Last Name (Please print)

Sex

Male

Female

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

First Name

MI

Age (in years)

Person 7
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 8
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 10
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 11
Last Name (Please print)

Sex

Male

Female

Age (in years)

Person 12
Last Name (Please print)

Sex

Male

Female

§.75g¤

Age (in years)

7

13222088

Housing
➜

1

Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.

A

Answer questions 4 – 5 if this is a HOUSE OR A
MOBILE HOME; otherwise, SKIP to question 6a.

4

How many acres is this house or mobile home on?

A mobile home

Less than 1 acre ➔ SKIP to question 6a

A one-family house detached from any
other house

1 to 9.9 acres

A one-family house attached to one or
more houses

10 or more acres

A building with 2 apartments

5

A building with 3 or 4 apartments

2

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

A building with 5 to 9 apartments

None

A building with 10 to 19 apartments

$1 to $999

A building with 20 to 49 apartments

$1,000 to $2,499

A building with 50 or more apartments

$2,500 to $4,999

Boat, RV, van, etc.

$5,000 to $9,999
$10,000 or more

About when was this building first built?
2020 or later – Specify year

6

a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend
out at least 6 inches and go from floor to ceiling.
Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.

2010 to 2019
2000 to 2009

Number of rooms

1990 to 1999
1980 to 1989
1970 to 1979

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this
house, apartment, or mobile home were for sale or
rent. If this is an efficiency/studio apartment, print "0".

1960 to 1969
1950 to 1959

Number of bedrooms

1940 to 1949
1939 or earlier

3

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

7

Does this house, apartment, or mobile home
have –
Yes

Year

a. hot and cold running water?
b. a bathtub or shower?
c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?

§.75y¤

8

No

13222096

Housing (continued)
8

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

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

Yes, connected to public sewer

None ➔ SKIP to question 15

No, connected to septic tank

1

No, use other type of system

2

9

Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.

3
4
5

Yes

6 or more

No

14 Are any of the following types of electric
vehicles kept at home for use by members
of this household?

10 At this house, apartment, or mobile home –
do you or any member of this household own
or use any of the following types of computers?
Yes

a. A plug-in electric vehicle?

No

Yes

a. Desktop or laptop

No

b. Smartphone

b. A hybrid electric vehicle?

c. Tablet or other portable
wireless computer

Yes

d. Some other type of computer
Specify C

No

15 Which FUEL is used MOST for heating this
house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood

11 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?

Gas: bottled, tank, or LP

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

Electricity
Fuel oil, kerosene, etc.

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

Coal or coke

No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 13

Wood
Solar energy

12 Do you or any member of this household have
access to the Internet using a –
a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C

§.75£¤

Other fuel
Yes

No

No fuel used

16 Does this house, apartment, or mobile home use
solar panels that generate electricity?
Yes
No

9

13222104

Housing (continued)
17 a. LAST MONTH, what was the cost of electricity 19 Is this house, apartment, or mobile home part of
for this house, apartment, or mobile home?

a condominium?

Last month’s cost – Dollars

$

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

.00


OR

Monthly amount – Dollars

Included in rent or condominium fee

$

No charge or electricity not used

.00


OR

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

None
No

Last month’s cost – Dollars

$

.00



20 Is this house, apartment, or mobile home –
Mark (X) ONE box.

OR
Included in rent or condominium fee

Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.

Included in electricity payment entered above

Owned by you or someone in this household free
and clear (without a mortgage or loan)?

No charge or gas not used

Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page

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

$

B

.00



Answer questions 21a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 22.

OR
Included in rent or condominium fee

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

No charge

Monthly amount – Dollars

d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.

$



b. Does the monthly rent include any meals?

Past 12 months’ cost – Dollars
Yes

$

.00



No

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

18 In 2021, did you or any member of this
household receive benefits from the Food
Stamp Program or SNAP (the Supplemental
Nutrition Assistance Program)? Do NOT include
WIC, the School Lunch Program, or assistance from
food banks.
Yes
No

§.76%¤

.00

10

C

13222112

Housing (continued)

C

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

Answer questions 22 – 26 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .

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

22 About how much do you think this house and lot,

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

apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

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

Yes, contract to purchase
No ➔ SKIP to question 26a

27 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 26a

§.76-¤

E

11

Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.

13222120

Person 1
➜

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

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?

Nursery school, preschool

In the United States – Print name of state.

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

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

11 What is the highest degree or level of school this

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

person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED
No schooling completed

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

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.765¤

12

13222138

Person 1 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

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

Name of city, town, or post office

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

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover
only one type of service, such as dental, drug, or vision
plans.

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

YES, INSURED
Mark (X) for all that apply.

14 a. Does this person speak a language other

Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

than English at home?
Yes

Medicare, for people 65 and older, or people
with certain disabilities

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as Healthcare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

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

NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.76G¤

13

13222146

Person 1 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.76O¤

14

13222153

Person 1 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.76V¤

15

13222161

Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.76^¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

16

13222179

Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

41 a. In 2021 (52 weeks), did this person work

Federal government civilian employee

EVERY week? Count paid vacation, paid sick leave,
and military service as work. Include all jobs for pay.

SELF-EMPLOYED OR OTHER

Yes ➔ SKIP to question 42

Owner of non-incorporated business,
professional practice, or farm

No

Owner of incorporated business,
professional practice, or farm

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Include all jobs for pay. Count paid vacation, paid
sick leave, and military service as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Weeks

42 In 2021, for the weeks worked, how many HOURS

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.76p¤

17

13222187

Person 1 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for 2021

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Any public assistance or welfare payments
from the state or local welfare office.

44 INCOME IN 2021

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received from January 1, 2021 to December 31,
2021. Give your best estimate of the TOTAL AMOUNT.

No

Mark (X) the "No" box to show types of income NOT
received.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
"No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

No





Yes ➔

TOTAL AMOUNT for 2021

$

No





Yes ➔

$

No

TOTAL AMOUNT for 2021

Yes ➔

$

No

TOTAL AMOUNT for 2021

Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

No

$





None

$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

Loss

➜

§.76x¤

.00



Add entries in questions 44a to 44h; subtract any
losses. If net income was a loss, enter the amount
and mark (X) the "Loss" box next to the dollar amount.

OR

Yes ➔

.00



45 What was this person’s total income in 2021?

.00

TOTAL AMOUNT for 2021

TOTAL AMOUNT for 2021

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

Yes ➔

$

18

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.

13222195

Person 2
➜

Please copy the name of Person 2 from page 3,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?

Nursery school, preschool

In the United States – Print name of state.

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

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

11 What is the highest degree or level of school this

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

person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED
No schooling completed

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

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.76¢¤

19

13222203

Person 2 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

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

Name of city, town, or post office

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

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover
only one type of service, such as dental, drug, or vision
plans.

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

YES, INSURED
Mark (X) for all that apply.

14 a. Does this person speak a language other

Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

than English at home?
Yes

Medicare, for people 65 and older, or people
with certain disabilities

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as Healthcare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

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

NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.77$¤

20

13222211

Person 2 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.77,¤

21

13222229

Person 2 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.77>¤

22

13222237

Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.77F¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

23

13222245

Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

41 a. In 2021 (52 weeks), did this person work

Federal government civilian employee

EVERY week? Count paid vacation, paid sick leave,
and military service as work. Include all jobs for pay.

SELF-EMPLOYED OR OTHER

Yes ➔ SKIP to question 42

Owner of non-incorporated business,
professional practice, or farm

No

Owner of incorporated business,
professional practice, or farm

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Include all jobs for pay. Count paid vacation, paid
sick leave, and military service as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Weeks

42 In 2021, for the weeks worked, how many HOURS

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.77N¤

24

13222252

Person 2 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for 2021

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Any public assistance or welfare payments
from the state or local welfare office.

44 INCOME IN 2021

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received from January 1, 2021 to December 31,
2021. Give your best estimate of the TOTAL AMOUNT.

No

Mark (X) the "No" box to show types of income NOT
received.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
"No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

No





Yes ➔

TOTAL AMOUNT for 2021

$

No





Yes ➔

$

No

TOTAL AMOUNT for 2021

Yes ➔

$

No

TOTAL AMOUNT for 2021

Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

No

$





None

$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

Loss

➜

§.77U¤

.00



Add entries in questions 44a to 44h; subtract any
losses. If net income was a loss, enter the amount
and mark (X) the "Loss" box next to the dollar amount.

OR

Yes ➔

.00



45 What was this person’s total income in 2021?

.00

TOTAL AMOUNT for 2021

TOTAL AMOUNT for 2021

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

Yes ➔

$

25

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.

13222260

Person 3
➜

Please copy the name of Person 3 from page 4,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?

Nursery school, preschool

In the United States – Print name of state.

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

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

11 What is the highest degree or level of school this

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

person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED
No schooling completed

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

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.77]¤

26

13222278

Person 3 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

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

Name of city, town, or post office

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

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover
only one type of service, such as dental, drug, or vision
plans.

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

YES, INSURED
Mark (X) for all that apply.

14 a. Does this person speak a language other

Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

than English at home?
Yes

Medicare, for people 65 and older, or people
with certain disabilities

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as Healthcare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

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

NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.77o¤

27

13222286

Person 3 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.77w¤

28

13222294

Person 3 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.77¡¤

29

13222302

Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.78#¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

30

13222310

Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

41 a. In 2021 (52 weeks), did this person work

Federal government civilian employee

EVERY week? Count paid vacation, paid sick leave,
and military service as work. Include all jobs for pay.

SELF-EMPLOYED OR OTHER

Yes ➔ SKIP to question 42

Owner of non-incorporated business,
professional practice, or farm

No

Owner of incorporated business,
professional practice, or farm

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Include all jobs for pay. Count paid vacation, paid
sick leave, and military service as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Weeks

42 In 2021, for the weeks worked, how many HOURS

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.78+¤

31

13222328

Person 3 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for 2021

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Any public assistance or welfare payments
from the state or local welfare office.

44 INCOME IN 2021

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received from January 1, 2021 to December 31,
2021. Give your best estimate of the TOTAL AMOUNT.

No

Mark (X) the "No" box to show types of income NOT
received.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
"No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

No





Yes ➔

TOTAL AMOUNT for 2021

$

No





Yes ➔

$

No

TOTAL AMOUNT for 2021

Yes ➔

$

No

TOTAL AMOUNT for 2021

Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

No

$





None

$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

Loss

➜

§.78=¤

.00



Add entries in questions 44a to 44h; subtract any
losses. If net income was a loss, enter the amount
and mark (X) the "Loss" box next to the dollar amount.

OR

Yes ➔

.00



45 What was this person’s total income in 2021?

.00

TOTAL AMOUNT for 2021

TOTAL AMOUNT for 2021

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

Yes ➔

$

32

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.

13222336

Person 4
➜

Please copy the name of Person 4 from page 5,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?

Nursery school, preschool

In the United States – Print name of state.

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

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

11 What is the highest degree or level of school this

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

person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED
No schooling completed

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

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.78E¤

33

13222344

Person 4 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

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

Name of city, town, or post office

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

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover
only one type of service, such as dental, drug, or vision
plans.

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

YES, INSURED
Mark (X) for all that apply.

14 a. Does this person speak a language other

Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

than English at home?
Yes

Medicare, for people 65 and older, or people
with certain disabilities

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as Healthcare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

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

NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.78M¤

34

13222351

Person 4 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.78T¤

35

13222369

Person 4 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.78f¤

36

13222377

Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.78n¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

37

13222385

Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

41 a. In 2021 (52 weeks), did this person work

Federal government civilian employee

EVERY week? Count paid vacation, paid sick leave,
and military service as work. Include all jobs for pay.

SELF-EMPLOYED OR OTHER

Yes ➔ SKIP to question 42

Owner of non-incorporated business,
professional practice, or farm

No

Owner of incorporated business,
professional practice, or farm

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Include all jobs for pay. Count paid vacation, paid
sick leave, and military service as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Weeks

42 In 2021, for the weeks worked, how many HOURS

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.78v¤

38

13222393

Person 4 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for 2021

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Any public assistance or welfare payments
from the state or local welfare office.

44 INCOME IN 2021

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received from January 1, 2021 to December 31,
2021. Give your best estimate of the TOTAL AMOUNT.

No

Mark (X) the "No" box to show types of income NOT
received.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
"No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

No





Yes ➔

TOTAL AMOUNT for 2021

$

No





Yes ➔

$

No

TOTAL AMOUNT for 2021

Yes ➔

$

No

TOTAL AMOUNT for 2021

Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

No

$





None

$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

Loss

➜

§.78~¤

.00



Add entries in questions 44a to 44h; subtract any
losses. If net income was a loss, enter the amount
and mark (X) the "Loss" box next to the dollar amount.

OR

Yes ➔

.00



45 What was this person’s total income in 2021?

.00

TOTAL AMOUNT for 2021

TOTAL AMOUNT for 2021

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

Yes ➔

$

39

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.

13222401

Person 5
➜

Please copy the name of Person 5 from page 6,
then continue answering questions below.

10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 11

MI

Yes, public school, public college
Yes, private school, private college, home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?

Nursery school, preschool

In the United States – Print name of state.

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)

8

Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

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

11 What is the highest degree or level of school this

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

person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.

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

NO SCHOOLING COMPLETED
No schooling completed

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

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.79"¤

40

13222419

Person 5 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

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

Name of city, town, or post office

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

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover
only one type of service, such as dental, drug, or vision
plans.

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

YES, INSURED
Mark (X) for all that apply.

14 a. Does this person speak a language other

Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

than English at home?
Yes

Medicare, for people 65 and older, or people
with certain disabilities

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as Healthcare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

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

NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.794¤

41

13222427

Person 5 (continued)
I
G

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

17 a. Is there a premium for this plan? A premium

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.

20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 18a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

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

Yes

Divorced

No

Separated

18 a. Is this person deaf or does he/she have

Never married ➔ SKIP to

serious difficulty hearing?

J on the next page

Yes
No

22 In the PAST 12 MONTHS did this person get –
Yes

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No

23 How many times has this person been married?

H

Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.

Once
Two times
Three or more times

19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

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

Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

c. Does this person have difficulty dressing or
bathing?
Yes
No

§.79<¤

42

13222435

Person 5 (continued)
27 Has this person ever served on active duty in the

J

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

25 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty
On active duty in the past, but not now

Yes
No

28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later

Yes

August 1990 to August 2001 (including
Persian Gulf War)

No ➔ SKIP to question 27

May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 27

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

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
longest period of time.
disability rating?
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 30a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years

0 percent

5 or more years

10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.79D¤

43

13222443

Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?

K

Yes ➔ SKIP to question 31

Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.

No – Did not work (or retired)

33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?

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

Person(s)

Yes
No ➔ SKIP to question 36a

31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

f. ZIP Code

No ➔ SKIP to question 37

32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40

Ferryboat

Other method

§.79L¤

c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
Yes ➔ SKIP to question 38
No

44

13222450

Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

39 When did this person last work for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

41 a. In 2021 (52 weeks), did this person work

Federal government civilian employee

EVERY week? Count paid vacation, paid sick leave,
and military service as work. Include all jobs for pay.

SELF-EMPLOYED OR OTHER

Yes ➔ SKIP to question 42

Owner of non-incorporated business,
professional practice, or farm

No

Owner of incorporated business,
professional practice, or farm

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Include all jobs for pay. Count paid vacation, paid
sick leave, and military service as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Weeks

42 In 2021, for the weeks worked, how many HOURS

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

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45

13222468

Person 5 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for 2021

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for 2021

f. Any public assistance or welfare payments
from the state or local welfare office.

44 INCOME IN 2021

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received from January 1, 2021 to December 31,
2021. Give your best estimate of the TOTAL AMOUNT.

No

Mark (X) the "No" box to show types of income NOT
received.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible, report
the whole amount for only one person and mark the
"No" box for the other person.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

No





Yes ➔

TOTAL AMOUNT for 2021

$

No





Yes ➔

$

No

TOTAL AMOUNT for 2021

Yes ➔

$

No

TOTAL AMOUNT for 2021

Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.

No

$





None

$





TOTAL AMOUNT for 2021

.00
Loss

.00

TOTAL AMOUNT for 2021

Loss

➜

§.79e¤

.00



Add entries in questions 44a to 44h; subtract any
losses. If net income was a loss, enter the amount
and mark (X) the "Loss" box next to the dollar amount.

OR

Yes ➔

.00



45 What was this person’s total income in 2021?

.00

TOTAL AMOUNT for 2021

TOTAL AMOUNT for 2021

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

Yes ➔

$

46

Now continue with the mailing instructions
on page 48.

13222476

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left blank

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47

13222484

Mailing
Instructions
➜ Please make sure you have...

Ⴠ listed all names and answered the
questions on pages 2 – 7
Ⴠ answered all Housing questions
Ⴠ answered all Person questions for each
person
➜ Then...

Ⴠput the completed questionnaire into the
postage-paid return envelope. If the
envelope has been misplaced, please
mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
Ⴠmake sure the barcode above your
address shows in the window of the
return envelope
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" as the
subject. Please DO NOT RETURN your questionnaire
to this address. Use the enclosed preaddressed
envelope to return your completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management
and Budget. This 8-digit number appears in the
bottom right on the front cover of this form.

Form ACS-1(X)CT-R (02-11-2022)

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48