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American Community Survey
Start Here
You have two ways to respond:
➜
Respond online today at:
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.
MI
+
Number
—
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.
➜
For more information about the American
Community Survey, visit our website at:
census.gov/acs
§.mI/¤
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.
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.
If you need help or have
questions about completing
this form, please call
1-888-715-2301.
¿NECESITA AYUDA? Llame al
1-877-833-5625.
How many people are living or staying at this address?
Number of people
➜
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)SGA
FORM
(02-26-2024)
OMB No. 0607-0810
OMB No. 0607-0936
13764022
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 6 about
Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.
6
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
7
What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
How is this person related to Person 1?
X
3
MI
Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
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.
Print numbers in boxes.
Age (in years)
4
Day
Year of birth
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
What sex was Person 1 assigned at birth?
Mark (X) ONE box.
Male
5
Month
Female
What is Person 1’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Male
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
Transgender
Nonbinary
This person uses a different term – Specify C
Some other race – Print race or origin. C
§.mI7¤
2
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13764030
Person 2
1
➜ NOTE: Please answer BOTH Question 6 about
What is Person 2’s name?
Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.
Last Name (Please print)
6
First Name
Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2
How is this person related to Person 1?
Mark (X) ONE box.
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
Spouse
Unmarried partner
Biological child
Adopted child
7
Stepchild
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
Sibling
Parent
Grandchild
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
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
Foster child
Other nonrelative
3
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)
4
Day
Year of birth
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
What sex was Person 2 assigned at birth?
Mark (X) ONE box.
Male
5
Month
Chinese
Female
What is Person 2’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Some other race – Print race or origin. C
Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C
§.mI?¤
3
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13764048
Person 3
1
➜ NOTE: Please answer BOTH Question 6 about
What is Person 3’s name?
Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.
Last Name (Please print)
6
First Name
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2
How is this person related to Person 1?
Mark (X) ONE box.
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
Spouse
Unmarried partner
Biological child
Adopted child
7
Stepchild
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
Sibling
Parent
Grandchild
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
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
Foster child
Other nonrelative
3
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)
4
Day
Year of birth
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
What sex was Person 3 assigned at birth?
Mark (X) ONE box.
Male
5
Month
Chinese
Female
What is Person 3’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Some other race – Print race or origin. C
Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C
§.mIQ¤
4
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13764055
Person 4
1
➜ NOTE: Please answer BOTH Question 6 about
What is Person 4’s name?
Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.
Last Name (Please print)
6
First Name
Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2
How is this person related to Person 1?
Mark (X) ONE box.
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
Spouse
Unmarried partner
Biological child
Adopted child
7
Stepchild
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
Sibling
Parent
Grandchild
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
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
Foster child
Other nonrelative
3
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)
4
Day
Year of birth
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
What sex was Person 4 assigned at birth?
Mark (X) ONE box.
Male
5
Month
Chinese
Female
What is Person 4’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Some other race – Print race or origin. C
Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C
§.mIX¤
5
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13764063
Person 5
1
➜ NOTE: Please answer BOTH Question 6 about
What is Person 5’s name?
Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.
Last Name (Please print)
6
First Name
Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2
How is this person related to Person 1?
Mark (X) ONE box.
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
Spouse
Unmarried partner
Biological child
Adopted child
7
Stepchild
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
Sibling
Parent
Grandchild
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
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
Foster child
Other nonrelative
3
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)
4
Day
Year of birth
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
What sex was Person 5 assigned at birth?
Mark (X) ONE box.
Male
5
Month
Chinese
Female
What is Person 5’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Some other race – Print race or origin. C
Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C
§.mI‘¤
6
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13764071
➜
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)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 7
Last Name (Please print)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 8
Last Name (Please print)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 9
Last Name (Please print)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 10
Last Name (Please print)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 11
Last Name (Please print)
First Name
Month
Age (in years)
Day
MI
Year of birth
Related to
Person 1?
Date of birth
Yes
No
Person 12
Last Name (Please print)
First Name
Month
Age (in years)
Day
Year of birth
Related to
Person 1?
Date of birth
§.mIh¤
MI
7
Yes
No
13764089
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
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.
2
$5,000 to $9,999
$10,000 or more
About when was this building first built?
2020 or later – Specify year
IN THE PAST 12 MONTHS, what were the actual
sales of all agricultural products from this
property?
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.
2000 to 2009
Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.
1990 to 1999
Number of rooms
2010 to 2019
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
1940 to 1949
Number of bedrooms
1939 or earlier
3
When did PERSON 1 (listed on page 2) move into
this house, apartment, or mobile home?
Month
Year
§.mIz¤
8
13764097
Housing (continued)
7
Does this house, apartment, or mobile home
have –
Yes
11 Do you or any member of this household have
access to the Internet using a –
No
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
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?
8
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.
Yes
No
Yes
No
9
12 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?
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
None
1
No
a. Desktop or laptop
2
b. Smartphone
3
c. Tablet or other portable
wireless computer
4
5
d. Some other type of computer
Specify C
6 or more
13 Which FUEL is used MOST for heating this
house, apartment, or mobile home?
Mark (X) one box for the fuel used most.
10 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?
Gas: Natural gas from underground pipes serving
the neighborhood
Yes, by paying a cell phone company or
Internet service provider
Gas: Bottled or tank (propane, butane, etc.)
Electricity
Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 12
Fuel oil, kerosene, etc.
No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 12
Coal or coke
Wood
Solar energy
Other fuel
No fuel used
§.mI¿¤
9
13764105
Housing (continued)
14 a. LAST MONTH, what was the cost of electricity 16 Is this house, apartment, or mobile home part of a
for this house, apartment, or mobile home?
homeowners association or condominium?
Last month’s cost – Dollars
$
Yes ➔ What is the required monthly
homeowners association fee
and/or condominium fee? For
renters, answer only if you pay
the fee in addition to your rent;
otherwise, mark the "None" box.
Monthly amount – Dollars
.00
OR
Included in rent or condominium fee
No charge or electricity not used
$
.00
b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?
OR
None
Last month’s cost – Dollars
No
$
.00
17 Is this house, apartment, or mobile home –
OR
Mark (X) ONE box.
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?
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.
Occupied without payment of rent? ➔ SKIP to
on the next page
Past 12 months’ cost – Dollars
$
.00
B
OR
Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.
Included in rent or condominium fee
18 a. What is the monthly rent for this house,
No charge
apartment, or mobile home?
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.
$
Past 12 months’ cost – Dollars
$
Yes
No
OR
Included in rent or condominium fee
No charge or these fuels not used
15 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
§.mJ&¤
.00
b. Does the monthly rent include any meals?
.00
10
C
13764113
Housing (continued)
C
c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
Answer questions 19 – 23 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
19 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
20 What are the annual real estate taxes on THIS
property?
No, insurance paid separately or no insurance
23 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
21 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
22 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 24 if this is a MOBILE HOME.
Otherwise, SKIP to E .
Yes, contract to purchase
No ➔ SKIP to question 23a
24 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 23a
§.mJ.¤
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.
13764121
Person 1
➜
Please copy the name of Person 1 from page 2,
then continue answering questions below.
11 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 12
MI
Yes, public school, public college
Yes, private school, private college, home school
8
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)
9
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 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
12 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
Grade 1 through 11 – Specify
grade 1 – 11
10 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)
§.mJ6¤
12
13764139
Person 1 (continued)
16 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.
Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
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 17
13 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)
14 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
15 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 16a
17 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
§.mJH¤
13
Yes
No
13764147
Person 1 (continued)
I
G
Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.
18 a. Is there a premium for this plan? A premium
Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
21 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 19a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
22 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
19 a. Is this person deaf or do they have serious
Never married ➔ SKIP to
difficulty hearing?
Yes
J on the next page
23 In the PAST 12 MONTHS did this person get –
Yes
No
No
a. Married?
b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?
b. Widowed?
Yes
c. Divorced?
No
24 How many times has this person been married?
H
Once
Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
Two times
Three or more times
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
25 In what year did this person last get married?
Year
Yes
No
26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
Gay or lesbian
No
Straight, that is not gay or lesbian
Bisexual
c. Does this person have difficulty dressing or
bathing?
This person uses a different term – Specify
Yes
No
§.mJP¤
14
C
13764154
Person 1 (continued)
J
Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.
29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a
27 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
Yes
On active duty in the past, but not now
No
30 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.
28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 29
June 1975 through 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?
August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964
Yes
June 1950 through January 1955
(including the Korean War)
No ➔ SKIP to question 29
January 1947 through May 1950
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
December 1941 through December 1946
(including World War II)
November 1941 or earlier
31 a. Does this person have a VA service-connected
disability rating?
6 to 11 months
Yes (such as 0%, 10%, 20%, ... , 100%)
1 or 2 years
No ➔ SKIP to question 32a
3 or 4 years
b. What is this person’s service-connected
disability rating?
5 or more years
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.mJW¤
15
13764162
Person 1 (continued)
32 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 33
Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.
No – Did not work (or retired)
35 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 38a
33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.
36 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.
37 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 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.
No, outside the city/town limits
38 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 38c
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 41
f. ZIP Code
No ➔ SKIP to question 39
34 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 42a
Ferryboat
Other method
§.mJ_¤
c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No
16
13764170
Person 1 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.
Yes
No ➔ SKIP to question 41
44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
40 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.
41 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 45
GOVERNMENT EMPLOYEE
42 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 43
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
43 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.)?
§.mJg¤
17
13764188
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.
45 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
.00
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
$
No
No
$
No
TOTAL AMOUNT for past
12 months
.00
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
Loss
OR
None
$
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.mJy¤
$
PAST 12 MONTHS? Add entries in questions 45a to
45h; 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, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
46 What was this person’s total income during the
.00
TOTAL AMOUNT for past
12 months
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.
13764196
Person 2
➜
Please copy the name of Person 2 from page 3,
then continue answering questions below.
11 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 12
MI
Yes, public school, public college
Yes, private school, private college, home school
8
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)
9
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 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
12 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
Grade 1 through 11 – Specify
grade 1 – 11
10 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)
§.mJ£¤
19
13764204
Person 2 (continued)
16 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.
Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
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 17
13 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)
14 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
15 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 16a
17 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
§.mK%¤
20
Yes
No
13764212
Person 2 (continued)
I
G
Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.
18 a. Is there a premium for this plan? A premium
Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
21 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 19a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
22 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
19 a. Is this person deaf or do they have serious
Never married ➔ SKIP to
difficulty hearing?
Yes
J on the next page
23 In the PAST 12 MONTHS did this person get –
Yes
No
No
a. Married?
b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?
b. Widowed?
Yes
c. Divorced?
No
24 How many times has this person been married?
H
Once
Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
Two times
Three or more times
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
25 In what year did this person last get married?
Year
Yes
No
26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
Gay or lesbian
No
Straight, that is not gay or lesbian
Bisexual
c. Does this person have difficulty dressing or
bathing?
This person uses a different term – Specify
Yes
No
§.mK-¤
21
C
13764220
Person 2 (continued)
J
Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.
29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a
27 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
Yes
On active duty in the past, but not now
No
30 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.
28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 29
June 1975 through 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?
August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964
Yes
June 1950 through January 1955
(including the Korean War)
No ➔ SKIP to question 29
January 1947 through May 1950
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
December 1941 through December 1946
(including World War II)
November 1941 or earlier
31 a. Does this person have a VA service-connected
disability rating?
6 to 11 months
Yes (such as 0%, 10%, 20%, ... , 100%)
1 or 2 years
No ➔ SKIP to question 32a
3 or 4 years
b. What is this person’s service-connected
disability rating?
5 or more years
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.mK5¤
22
13764238
Person 2 (continued)
32 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 33
Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.
No – Did not work (or retired)
35 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 38a
33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.
36 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.
37 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 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.
No, outside the city/town limits
38 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 38c
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 41
f. ZIP Code
No ➔ SKIP to question 39
34 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 42a
Ferryboat
Other method
§.mKG¤
c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No
23
13764246
Person 2 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.
Yes
No ➔ SKIP to question 41
44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
40 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.
41 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 45
GOVERNMENT EMPLOYEE
42 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 43
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
43 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.)?
§.mKO¤
24
13764253
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.
45 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
.00
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
$
No
No
$
No
TOTAL AMOUNT for past
12 months
.00
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
Loss
OR
None
$
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.mKV¤
$
PAST 12 MONTHS? Add entries in questions 45a to
45h; 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, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
46 What was this person’s total income during the
.00
TOTAL AMOUNT for past
12 months
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.
13764261
Person 3
➜
Please copy the name of Person 3 from page 4,
then continue answering questions below.
11 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 12
MI
Yes, public school, public college
Yes, private school, private college, home school
8
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)
9
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 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
12 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
Grade 1 through 11 – Specify
grade 1 – 11
10 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)
§.mK^¤
26
13764279
Person 3 (continued)
16 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.
Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
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 17
13 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)
14 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
15 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 16a
17 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
§.mKp¤
27
Yes
No
13764287
Person 3 (continued)
I
G
Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.
18 a. Is there a premium for this plan? A premium
Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
21 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 19a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
22 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
19 a. Is this person deaf or do they have serious
Never married ➔ SKIP to
difficulty hearing?
Yes
J on the next page
23 In the PAST 12 MONTHS did this person get –
Yes
No
No
a. Married?
b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?
b. Widowed?
Yes
c. Divorced?
No
24 How many times has this person been married?
H
Once
Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
Two times
Three or more times
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
25 In what year did this person last get married?
Year
Yes
No
26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
Gay or lesbian
No
Straight, that is not gay or lesbian
Bisexual
c. Does this person have difficulty dressing or
bathing?
This person uses a different term – Specify
Yes
No
§.mKx¤
28
C
13764295
Person 3 (continued)
J
Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.
29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a
27 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
Yes
On active duty in the past, but not now
No
30 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.
28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 29
June 1975 through 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?
August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964
Yes
June 1950 through January 1955
(including the Korean War)
No ➔ SKIP to question 29
January 1947 through May 1950
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
December 1941 through December 1946
(including World War II)
November 1941 or earlier
31 a. Does this person have a VA service-connected
disability rating?
6 to 11 months
Yes (such as 0%, 10%, 20%, ... , 100%)
1 or 2 years
No ➔ SKIP to question 32a
3 or 4 years
b. What is this person’s service-connected
disability rating?
5 or more years
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.mK¢¤
29
13764303
Person 3 (continued)
32 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 33
Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.
No – Did not work (or retired)
35 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 38a
33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.
36 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.
37 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 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.
No, outside the city/town limits
38 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 38c
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 41
f. ZIP Code
No ➔ SKIP to question 39
34 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 42a
Ferryboat
Other method
§.mL$¤
c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No
30
13764311
Person 3 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.
Yes
No ➔ SKIP to question 41
44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
40 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.
41 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 45
GOVERNMENT EMPLOYEE
42 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 43
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
43 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.)?
§.mL,¤
31
13764329
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.
45 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
.00
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
$
No
No
$
No
TOTAL AMOUNT for past
12 months
.00
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
Loss
OR
None
$
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.mL>¤
$
PAST 12 MONTHS? Add entries in questions 45a to
45h; 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, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
46 What was this person’s total income during the
.00
TOTAL AMOUNT for past
12 months
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.
13764337
Person 4
➜
Please copy the name of Person 4 from page 5,
then continue answering questions below.
11 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 12
MI
Yes, public school, public college
Yes, private school, private college, home school
8
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)
9
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 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
12 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
Grade 1 through 11 – Specify
grade 1 – 11
10 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)
§.mLF¤
33
13764345
Person 4 (continued)
16 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.
Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
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 17
13 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)
14 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
15 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 16a
17 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
§.mLN¤
34
Yes
No
13764352
Person 4 (continued)
I
G
Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.
18 a. Is there a premium for this plan? A premium
Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
21 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 19a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
22 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
19 a. Is this person deaf or do they have serious
Never married ➔ SKIP to
difficulty hearing?
Yes
J on the next page
23 In the PAST 12 MONTHS did this person get –
Yes
No
No
a. Married?
b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?
b. Widowed?
Yes
c. Divorced?
No
24 How many times has this person been married?
H
Once
Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
Two times
Three or more times
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
25 In what year did this person last get married?
Year
Yes
No
26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
Gay or lesbian
No
Straight, that is not gay or lesbian
Bisexual
c. Does this person have difficulty dressing or
bathing?
This person uses a different term – Specify
Yes
No
§.mLU¤
35
C
13764360
Person 4 (continued)
J
Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.
29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a
27 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
Yes
On active duty in the past, but not now
No
30 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.
28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 29
June 1975 through 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?
August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964
Yes
June 1950 through January 1955
(including the Korean War)
No ➔ SKIP to question 29
January 1947 through May 1950
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
December 1941 through December 1946
(including World War II)
November 1941 or earlier
31 a. Does this person have a VA service-connected
disability rating?
6 to 11 months
Yes (such as 0%, 10%, 20%, ... , 100%)
1 or 2 years
No ➔ SKIP to question 32a
3 or 4 years
b. What is this person’s service-connected
disability rating?
5 or more years
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.mL]¤
36
13764378
Person 4 (continued)
32 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 33
Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.
No – Did not work (or retired)
35 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 38a
33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.
36 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.
37 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 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.
No, outside the city/town limits
38 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 38c
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 41
f. ZIP Code
No ➔ SKIP to question 39
34 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 42a
Ferryboat
Other method
§.mLo¤
c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No
37
13764386
Person 4 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.
Yes
No ➔ SKIP to question 41
44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
40 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.
41 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 45
GOVERNMENT EMPLOYEE
42 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 43
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
43 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.)?
§.mLw¤
38
13764394
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.
45 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
.00
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
$
No
No
$
No
TOTAL AMOUNT for past
12 months
.00
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
Loss
OR
None
$
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.mL¡¤
$
PAST 12 MONTHS? Add entries in questions 45a to
45h; 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, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
46 What was this person’s total income during the
.00
TOTAL AMOUNT for past
12 months
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.
13764402
Person 5
➜
Please copy the name of Person 5 from page 6,
then continue answering questions below.
11 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 12
MI
Yes, public school, public college
Yes, private school, private college, home school
8
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)
9
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 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
12 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
Grade 1 through 11 – Specify
grade 1 – 11
10 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)
§.mM#¤
40
13764410
Person 5 (continued)
16 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.
Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
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 17
13 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)
14 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
15 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 16a
17 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
§.mM+¤
41
Yes
No
13764428
Person 5 (continued)
I
G
Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.
18 a. Is there a premium for this plan? A premium
Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.
21 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 19a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
22 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
19 a. Is this person deaf or do they have serious
Never married ➔ SKIP to
difficulty hearing?
Yes
J on the next page
23 In the PAST 12 MONTHS did this person get –
Yes
No
No
a. Married?
b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?
b. Widowed?
Yes
c. Divorced?
No
24 How many times has this person been married?
H
Once
Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.
Two times
Three or more times
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
25 In what year did this person last get married?
Year
Yes
No
26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
Gay or lesbian
No
Straight, that is not gay or lesbian
Bisexual
c. Does this person have difficulty dressing or
bathing?
This person uses a different term – Specify
Yes
No
§.mM=¤
42
C
13764436
Person 5 (continued)
J
Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.
29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a
27 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
Yes
On active duty in the past, but not now
No
30 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.
28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 29
June 1975 through 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?
August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964
Yes
June 1950 through January 1955
(including the Korean War)
No ➔ SKIP to question 29
January 1947 through May 1950
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
December 1941 through December 1946
(including World War II)
November 1941 or earlier
31 a. Does this person have a VA service-connected
disability rating?
6 to 11 months
Yes (such as 0%, 10%, 20%, ... , 100%)
1 or 2 years
No ➔ SKIP to question 32a
3 or 4 years
b. What is this person’s service-connected
disability rating?
5 or more years
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.mME¤
43
13764444
Person 5 (continued)
32 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 33
Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.
No – Did not work (or retired)
35 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 38a
33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.
36 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.
37 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 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.
No, outside the city/town limits
38 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 38c
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 41
f. ZIP Code
No ➔ SKIP to question 39
34 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxi or ride-hailing
services
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 42a
Ferryboat
Other method
§.mMM¤
c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No
44
13764451
Person 5 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.
Yes
No ➔ SKIP to question 41
44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
40 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.
41 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 45
GOVERNMENT EMPLOYEE
42 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 43
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
43 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.)?
§.mMT¤
45
13764469
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.
45 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
.00
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
$
No
No
$
No
TOTAL AMOUNT for past
12 months
.00
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
Loss
OR
None
$
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.mMf¤
$
PAST 12 MONTHS? Add entries in questions 45a to
45h; 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, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
46 What was this person’s total income during the
.00
TOTAL AMOUNT for past
12 months
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.
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left blank
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47
13764485
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...
Ⴠ put the completed questionnaire into the
postage-paid return envelope. If the
envelope has been misplaced, please
mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
Ⴠ make sure the barcode above your
address shows in the window of the
return envelope
Thank you for participating in
the American Community Survey.
For Census Bureau Use
POP
EDIT CLERK
EDIT
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" as the
subject. Please DO NOT RETURN your questionnaire
to this address. Use the enclosed preaddressed
envelope to return your completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management
and Budget. This 8-digit number appears in the
bottom right on the front cover of this form.
Form ACS-1(X)SGA (02-26-2024)
§.mMv¤
48
| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2024-02-26 |
| File Created | 2024-02-26 |