Individuals/Households - Households

APPENDIX B6. (INSTRUMENT E7) HOUSEHOLD SURVEY INCOME WORKSHEET

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Fourth Access, Participation, Eligibility and Certification Study Series (APEC IV)

E7. HOUSEHOLD SURVEY INCOME WORKSHEET

NOTE TO REVIEWER: The Household Survey Income Worksheet may be sent to the respondent up to four times. For the virtual survey, we send it with the Household Survey Appointment Confirmation and Household Survey Appointment Reminder Letter. For the in-person survey, we send it with the Household Survey Appointment Confirmation and Household Survey Appointment Reminder Letter. Our expectation is that the respondent will complete the document once; however, we send it multiple times for convenience. They are not required to return the completed worksheet to us; it is for their own use during the survey administration.

Thank you for participating in the National School Meals Study (NSMS). Your input will be very important and helpful.

This worksheet will help you prepare for the NSMS Household Survey. Completing this worksheet before your interview will help make the interview go more quickly.

You will be asked to show documentation for income reported. The interviewer will be the only person to review the documentation. They will not copy or photograph any information.

A1. Adults Living in your Household

Including yourself, how many adults live in your household? (An adult is any person 18 years of age or older.)

_____________

A2. Including yourself, list the adults in your household who earned income or received benefit payments and shared income and household expenses in <[If sampled from SY 23-24 list, APPLICATION MONTH, YEAR; if sampled from SY 22-23 list, “the month you submitted an application for meal benefits”>.

Name 1: Name 5:

Name 2: Name 6:

Name 3: Name 7:

Name 4: Name 8:

B. Household Benefits

Do any of the adults listed in A2 receive benefits through the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR)?

Yes – Continue to Section D

No – Continue to Section C

C. Household Income and Payments

Think about all the sources of the income or payments received by the adults listed in question A2 in the month you submitted an application for meal benefits. The table below lists many kinds of income and payments that people might receive.

If any of the adults you listed in question A2 received the payment type listed in column B in <If sampled from SY 23-24 list, [APPLICATION MONTH, YEAR]; if sampled from SY 22-23 list, “the month you submitted an application for meal benefits”>, check the box in column A. Next, record the initials of the person or persons receiving that payment in column C. The table continues onto the next 4 pages.

Column A SOURCE #	Column B TYPE OF INCOME OR PAYMENT	Column C Initials of Adult(s) Receiving this Payment or Income
Source 1	Income for paid work Wages and salary (including tips, commissions, bonuses), including from self-employment If you have your own business, this refers to the salary you pay yourself as personal income or regular earnings, not the business profits or losses. For military service members, this includes Military Basic Pay. For deployed service members, this would only include income made available to the household.
Source 2	Unemployment Compensation Payments that substitute for wages or salary, administered by a government or labor union.
Source 3	Workers Compensation Payments made to an employee who is injured or disabled in connection with work.
Source 4	Strike Benefits Payments made to strikers by a union to support them during a strike.
Source 5	Social Security or Railroad Retirement Benefits Social Security benefits are monthly payments to people (or their spouses or dependent children) who are retired or disabled but have worked and paid taxes into the Social Security system. Railroad Retirement benefits are payments to qualified workers who are retired or disabled or to their survivors.
Source 6	Private or Public Pensions, Annuities, or Survivor’s Benefits Pension benefits are regular payments made to an employee after retirement and are based on such factors as years of service and prior compensation. An annuity is a series of payments under a contract made at regular intervals over a period of more than one full year. They can be either fixed (under which you receive a definite amount) or variable (not fixed). Annuities can be purchased by individuals alone or with the help of an employer. Survivor's benefits are for widows and widowers receiving monthly Social Security benefits based on their deceased spouse’s earnings records.
Source 7	Military Cash Subsidies (not combat pay) Payments for housing, food, or clothing allowances, including the Basic Allowance for Housing (BAH). This does not include combat pay, or benefits from the Family Substance Supplemental Allowance (FSSA) or the Military Housing Privatization Initiative (MHPI). For deployed service members, this only includes benefits made available to the household.
Source 8	Veteran’s Benefits Payments to veterans who have a service-connected disability and were not dishonorably discharged.
Source 9	Government Disability Benefits or Supplementary Security Income (SSI) Benefits Payments to qualifying aged, blind, and disabled people who have little or no income.
Source 10	Private Disability Benefits Payments provided to employees who are unable to work due to disability, through an insurance policy provided by an employer or purchased by an individual from an insurance company.
Source 11	Alimony Payments Payments made by a spouse or former spouse divorce or legal separation. Alimony does NOT include child support, noncash property settlements, payments to keep up the payer’s property, or use of the payer’s property.
Source 12	Child Support Payments Payments made by a parent to contribute to the costs of raising a child following the end of a marriage or other relationship.
Source 13	Interest, Dividends, Capital Gains, Trusts, Estates, 401K distributions, or Investment Income Interest income is interest earned on investments. Dividend income is cash payments or shares of stock distributed by a company to its shareholders. Capital gains income is proceeds from the sale of capital assets. Trust income is income from a trust. Estate income is income from an estate. 401K income is money received from a 401K payout or distribution.
Source 14	Income from Others in the Form of Rent Money paid by someone for use of property, minus the expenses of maintaining the property.
Source 15	Profit or Loss from a Nonfarm Business, Partnership, or Professional Practice Profit or loss from a business you own that is not included in the salary you pay yourself as personal income or regular earnings.
Source 16	Profit or Loss from a Farm Business Income gained (profit) or lost from growing crops, raising livestock, breeding fish, or operating a ranch.
Source 17	Financial Aid to College Students (not including tuition, books, & fees) Payments to cover room and board. This does not include money used for tuition, books, and fees, Pell Grants, Supplemental Education Opportunity Grants, State Student Incentive Grants, National Direct Student Loans, PLUS Loans, College Work Study, or Byrd Honor Scholarship Programs.
Source 18	Regular Payments or Withdrawals from Awards or Settlements Regular payments from legal settlements, inheritance, prize winnings, or bonuses.
Source 19	Regular Cash Payments from Persons Outside the Household Cash gifts or other financial assistance from friends or family.
Source 20	Net Royalties or One-Time Prize Winnings. Income from sources such as net royalties or one-time prize winnings.
Source 21	General Assistance Benefits from State or Local Government (not including TANF or SNAP) Cash benefits from State or County programs serving low-income individuals who do not have minor children, are not disabled enough to qualify for (or do not yet receive) Supplemental Security Income (SSI), and are not elderly, such as state disability assistance or general relief programs.
Source 23	Federal Black Lung Benefits Payments received as part of compensation to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment or to survivors of coal miners whose deaths are attributable to the disease.
Source 24	Another Kind of Public Assistance This does not include WIC, SCHIP, TANF or SNAP benefits, FDPIR, Medicaid, or foster care subsidies. Specify: ________________________________________

D. Provide Documentation for Income and Payments

The interviewer will ask to look at documentation or a statement that shows participation in a benefits program (i.e., SNAP, TANF or FDPIR) or that describes income or payments for each type of income earned by each member of the household. Please have documents available for the interviewer to see during the interview. The interviewer only needs to look at one document for each type of income for each person.

The table below describes acceptable documents to have available for the interview.

Type of Income or Benefits	Personal Documents to Review
SNAP, TANF, or FDPIR	(a) Certification notice or benefits card. (b) Dated and signed letter from SNAP or welfare office stating that these benefits are received.
Wages and Salary (including base and overtime rates, bonuses, and incentives)	(a) Pay stubs. (b) Earnings statement or W-2 form identifying employee and showing amount earned over a specific period. (c) Statement indicating contact with employer by phone or in person specifying amount to be earned per pay period. (d) Income tax return.
Self-employment	(a) Notarized statement or form 1040/1040A showing amount earned (b) Income tax return.
Unemployment or Worker’s Compensation	(a) Copy of check issued by agency. (b) Award letter signed by agency. (c) Signed and dated verification form showing amount and period received. (d) Printout of online statement. (e) 1099-G Tax Form.
Social Security, Pensions, or Retirement	(a) Social Security retirement benefit letter. (b) Statement of benefits received. (c) Pension award notice. (d) Signed and dated verification form from agency or organization paying the pension.
Child Support Payments	(a) Copy of payment records furnished by court, signed and dated, showing amount received. (b) Copy of divorce decree showing amount of support. (c) Copy of check. (d) Written statement from paying parent.
Interest and Dividends	(a) Statement showing interest received and period covered. (b) Income tax return. (c) Dividend statement. (d) Dated and signed verification form completed by savings institution showing amount received and time period covered.
Other Income	(a) Information or statement showing the amount received, how often it is received, and the date it was received. (b) Income tax return.
Public or General Assistance	(a) Copy of check issued by agency. (b) Award letter signed by agency. (c) Signed and dated verification form signed showing amount and period received.

If you have any questions, contact the NSMS team at [INSERT NUMBER] or [INSERT EMAIL].

Thank you,

NSMS Research Team

This information is being collected to provide the Food and Nutrition Service with key information on the annual error rates and improper payments for the school meal programs. This is a voluntary collection and FNS will use the information to examine school meal error rates and inform future APEC studies. This collection requests personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0530. The time required to complete this information collection is estimated to average 0.334 hours (20 minutes) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0530). Do not return the completed form to this address.

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