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pdfAttachment I - ACS-1PR(2025) (02-28-2024)
13175013
Puerto Rico Community Survey
Please complete this
form and return it as
soon as possible after
receiving it in the mail.
Start Here
➜
Please print today’s date.
Month
➜
This form asks for information
about the people who are living or
staying at the address on the
mailing label and about the house,
apartment, or mobile home located
at the address on the mailing label.
Day
Year
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
MI
First Name
Area Code
+
Number
—
If you need help or have
questions about completing
this form, please call
1–800–717–7381.
➜
How many people, including yourself, live or stay
at this address?
INCLUDE...
✓ anyone not related to you, like roommates and other
families.
✓ babies and children, related or unrelated, including
grandchildren and foster children.
✓ everyone staying here now who has no other place to stay.
¿NECESITA AYUDA? Si usted habla
español y necesita ayuda para completar
su cuestionario, llame sin cargo alguno al
1–800–814–8385.
DO NOT INCLUDE anyone living somewhere else, such as...
✗ a college student living away.
✗ someone in the Armed Forces on deployment.
Number of people
For more information about the
Puerto Rico Community Survey, visit our
website at: census.gov/prcs
➜
Fill out pages 2-7 for everyone, including yourself, who
is living or staying at this address. Then complete the
rest of the form.
ACS-1PR(2025)
FORM
(02-28-2024)
§.2S.¤
OMB No. 0607-0810
OMB No. 0607-0936
13175021
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.)
1
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.
5
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
What is Person 1’s name?
Yes, Mexican, Mexican Am., Chicano
Last Name (Please print)
Yes, Puerto Rican
Yes, Cuban
First Name
2
Person 1
6
What is Person 1’s sex? Mark (X) ONE box.
Male
4
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
X
3
MI
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Female
What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Print numbers in boxes.
Age (in years)
Month
Day
What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
§.2S6¤
2
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13175039
Person 2
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.
1
5
What is Person 2’s name?
Last Name (Please print)
Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 2’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.2SH¤
3
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13175047
Person 3
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.
1
5
What is Person 3’s name?
Last Name (Please print)
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 3’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.2SP¤
4
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13175054
Person 4
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.
1
5
What is Person 4’s name?
Last Name (Please print)
Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 4’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.2SW¤
5
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13175062
Person 5
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race.
For this survey, Hispanic origins are not races.
1
5
What is Person 5’s name?
Last Name (Please print)
Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
American Indian or Alaska Native – Print name of enrolled
or principal tribe(s), for example, Navajo Nation, Blackfeet
Tribe, Mayan, Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, etc. C
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.2S_¤
6
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13175070
➜
If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C
Person 6
Last Name (Please print)
Sex
Male
Female
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
Age (in years)
Person 7
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 8
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 9
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 10
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 11
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 12
Last Name (Please print)
Sex
Male
Female
§.2Sg¤
Age (in years)
7
13175088
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 cuerdas is this house or mobile home
on?
A mobile home
Less than 1 cuerda ➔ SKIP to question 6a
A one-family house detached from any
other house
1 to 9.9 cuerdas
A one-family house attached to one or
more houses
10 or more cuerdas
A building with 2 apartments
A building with 3 or 4 apartments
5
A building with 5 to 9 apartments
IN THE PAST 12 MONTHS, what were the actual
sales of all agricultural products from this
property?
A building with 10 to 19 apartments
None
A building with 20 to 49 apartments
$1 to $999
A building with 50 or more apartments
$1,000 to $2,499
Boat, RV, van, etc.
$2,500 to $4,999
$5,000 to $9,999
2
About when was this building first built?
$10,000 or more
2020 or later – Specify year
6
2010 to 2019
a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend
out at least 6 inches and go from floor to ceiling.
Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.
2000 to 2009
1990 to 1999
Number of rooms
1980 to 1989
1970 to 1979
1960 to 1969
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this
house, apartment, or mobile home were for sale or
rent. If this is an efficiency/studio apartment, print "0".
1950 to 1959
1940 to 1949
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
§.2Sy¤
8
13175096
Housing (continued)
7
Does this house, apartment, or mobile home
have –
Yes
12 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. running water?
b. a water heater?
c. a bathtub or shower?
d. a sink with a faucet?
e. a stove or range?
f. a refrigerator?
8
Is this house, apartment, or mobile home
connected to a public sewer?
Yes
No
Yes, connected to public sewer
No, connected to septic tank
13 How many automobiles, vans, and trucks of
No, use other type of system
9
one-ton capacity or less are kept at home for
use by members of this household?
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.
None ➔ SKIP to question 15
1
2
Yes
3
No
4
10 At this house, apartment, or mobile home –
5
do you or any member of this household own
or use any of the following types of computers?
Yes
6 or more
No
a. Desktop or laptop
14 Do you or any member of this household own or
lease an electric vehicle? Include both all-electric
and plug-in hybrid electric vehicles.
b. Smartphone
Yes
c. Tablet or other portable
wireless computer
d. Some other type of computer
Specify C
No
15 To heat this house, apartment, or mobile home,
which fuel do you use MOST?
Mark (X) one box for the fuel used most.
Gas: Natural gas from underground pipes serving
the neighborhood
11 At this house, apartment, or mobile home –
do you or any member of this household
have access to the Internet?
Gas: Bottled or tank (propane, butane, etc.)
Yes, by paying a cell phone company or
Internet service provider
Electricity
Fuel oil, kerosene, etc.
Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 13
Coal or coke
No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 13
Wood
Solar energy
Other fuel
No fuel used
§.2S£¤
9
13175104
Housing (continued)
16 Does this house, apartment, or mobile home
18 IN THE PAST 12 MONTHS, did you or any member
use solar panels that generate electricity?
of this household receive benefits from the
Nutritional Assistance Program? Do NOT include
WIC, the School Lunch Program, or assistance from
food banks.
Yes
No
Yes
17 a. LAST MONTH, what was the cost of electricity
No
for this house, apartment, or mobile home?
Last month’s cost – Dollars
$
19 Is this house, apartment, or mobile home part of a
homeowners association or condominium?
.00
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
OR
Included in rent or condominium fee
No charge or electricity not used
b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?
$
$
OR
.00
None
No
OR
Included in rent or condominium fee
20 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Included in electricity payment entered above
Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.
No charge or gas not used
Owned by you or someone in this household free
and clear (without a mortgage or loan)?
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.
Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page
Past 12 months’ cost – Dollars
$
.00
.00
Last month’s cost – Dollars
OR
B
Included in rent or condominium fee
Answer questions 21a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 22.
No charge
21 a. What is the monthly rent for this house,
apartment, or mobile home?
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.
Monthly amount – Dollars
$
Past 12 months’ cost – Dollars
$
Yes
OR
No
Included in rent or condominium fee
No charge or these fuels not used
§.2T%¤
.00
b. Does the monthly rent include any meals?
.00
10
C
13175112
Housing (continued)
C
c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
Answer questions 22 – 26 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required
22 About how much do you think this house and lot,
d. Does the regular monthly mortgage payment
include payments for fire, hazard, or flood
insurance on THIS property?
apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars
Yes, insurance included in mortgage payment
$
.00
23 What are the annual real estate taxes on THIS
property?
No, insurance paid separately or no insurance
26 a. Do you or any member of this household have
a second mortgage or a home equity loan on
THIS property?
Annual amount – Dollars
$
Yes, home equity loan
.00
Yes, second mortgage
OR
Yes, second mortgage and home equity loan
None
No ➔ SKIP to
24 What is the annual payment for fire, hazard, and
b. How much is the regular monthly payment on
all second or junior mortgages and all home
equity loans on THIS property?
flood insurance on THIS property?
Annual amount – Dollars
$
Monthly amount – Dollars
.00
D
$
OR
.00
OR
None
No regular payment required
25 a. Do you or any member of this household have
a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?
Yes, mortgage, deed of trust, or similar debt
D
Answer question 27 if this is a MOBILE HOME.
Otherwise, SKIP to E .
Yes, contract to purchase
No ➔ SKIP to question 26a
27 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.
b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.
Annual costs – Dollars
Monthly amount – Dollars
$
$
.00
.00
OR
No regular payment required ➔ SKIP to
question 26a
§.2T-¤
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.
13175120
Person 1
➜
Please copy the name of Person 1 from page 2,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in Puerto Rico ➔ SKIP to question 10a
11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.
Yes, born in a U.S. state, District of Columbia, Guam,
the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
When did this person come to live in Puerto Rico?
If this person came to live in Puerto Rico more than
once, print latest year.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Year
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.2T5¤
12
13175138
Person 1 (continued)
b. Where did this person live 1 year ago?
F
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Address
Development or condominium name
Number and street name
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Name of city, town, or post office
Name of municipio in Puerto Rico or U.S. county
Enter Puerto Rico or
name of U.S. state
ZIP Code
13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
YES, INSURED
Mark (X) for all that apply.
14 a. Does this person speak a language other
than English at home?
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)
Yes
No ➔ SKIP to question 15a
Medicare, for people 65 and older, or people
with certain disabilities
b. What is this language?
Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability
For example: Korean, Italian, Spanish, Vietnamese
Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov
c. How well does this person speak English?
Very well
Veteran’s health care (enrolled for VA)
Well
TRICARE or other military health care
Not well
Indian Health Service
Not at all
Any other type of health insurance or health
coverage plan – Specify C
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to question 16
NO, UNINSURED
Yes, this house ➔ SKIP to question 16
No health insurance or health coverage plan
No, outside Puerto Rico and the United States –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
No, different house in Puerto Rico or the
United States
§.2TG¤
13
13175146
Person 1 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.2TO¤
14
13175153
Person 1 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 27
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 27
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
29 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 30a
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
§.2TV¤
15
13175161
Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Yes
Person(s)
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
a. Address
Development or condominium name
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.
Hour
Minute
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
No, outside the city/town limits
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
36 a. LAST WEEK, was this person on layoff from
a job?
d. Name of municipio in Puerto Rico or
U.S. county
Yes ➔ SKIP to question 36c
No
e. Enter Puerto Rico or name of U.S. state or
foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
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
Yes ➔ SKIP to question 38
Bus
Motorcycle
No
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Carro público
Worked from
home ➔ SKIP
to question 40a
Ferryboat
§.2T^¤
Other method
16
13175179
Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work for pay, even for
a few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city,
county, or municipio)
this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.
State government (including school
districts and state universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work for at least
one day? Include weeks when this person only
worked for a few hours. Include all jobs for pay.
Count paid vacation, paid sick leave, and military
service as work.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Weeks
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
41 During the PAST 12 MONTHS, for the weeks
worked, how many HOURS did this person
usually work each WEEK? Include all jobs for
pay and military service.
Usual hours worked each WEEK
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.)?
§.2Tp¤
17
13175187
Person 1 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
No
.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
➜
§.2Tx¤
$
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
44 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.
13175195
Person 2
➜
Please copy the name of Person 2 from page 3,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in Puerto Rico ➔ SKIP to question 10a
11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.
Yes, born in a U.S. state, District of Columbia, Guam,
the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
When did this person come to live in Puerto Rico?
If this person came to live in Puerto Rico more than
once, print latest year.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Year
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.2T¢¤
19
13175203
Person 2 (continued)
b. Where did this person live 1 year ago?
F
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Address
Development or condominium name
Number and street name
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Name of city, town, or post office
Name of municipio in Puerto Rico or U.S. county
Enter Puerto Rico or
name of U.S. state
ZIP Code
13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
YES, INSURED
Mark (X) for all that apply.
14 a. Does this person speak a language other
than English at home?
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)
Yes
No ➔ SKIP to question 15a
Medicare, for people 65 and older, or people
with certain disabilities
b. What is this language?
Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability
For example: Korean, Italian, Spanish, Vietnamese
Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov
c. How well does this person speak English?
Very well
Veteran’s health care (enrolled for VA)
Well
TRICARE or other military health care
Not well
Indian Health Service
Not at all
Any other type of health insurance or health
coverage plan – Specify C
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to question 16
NO, UNINSURED
Yes, this house ➔ SKIP to question 16
No health insurance or health coverage plan
No, outside Puerto Rico and the United States –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
No, different house in Puerto Rico or the
United States
§.2U$¤
20
13175211
Person 2 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.2U,¤
21
13175229
Person 2 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 27
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 27
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
29 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 30a
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
§.2U>¤
22
13175237
Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Yes
Person(s)
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
a. Address
Development or condominium name
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.
Hour
Minute
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
No, outside the city/town limits
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
36 a. LAST WEEK, was this person on layoff from
a job?
d. Name of municipio in Puerto Rico or
U.S. county
Yes ➔ SKIP to question 36c
No
e. Enter Puerto Rico or name of U.S. state or
foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
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
Yes ➔ SKIP to question 38
Bus
Motorcycle
No
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Carro público
Worked from
home ➔ SKIP
to question 40a
Ferryboat
§.2UF¤
Other method
23
13175245
Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work for pay, even for
a few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city,
county, or municipio)
this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.
State government (including school
districts and state universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work for at least
one day? Include weeks when this person only
worked for a few hours. Include all jobs for pay.
Count paid vacation, paid sick leave, and military
service as work.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Weeks
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
41 During the PAST 12 MONTHS, for the weeks
worked, how many HOURS did this person
usually work each WEEK? Include all jobs for
pay and military service.
Usual hours worked each WEEK
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.)?
§.2UN¤
24
13175252
Person 2 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
No
.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
➜
§.2UU¤
$
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
44 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.
13175260
Person 3
➜
Please copy the name of Person 3 from page 4,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in Puerto Rico ➔ SKIP to question 10a
11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.
Yes, born in a U.S. state, District of Columbia, Guam,
the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
When did this person come to live in Puerto Rico?
If this person came to live in Puerto Rico more than
once, print latest year.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Year
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.2U]¤
26
13175278
Person 3 (continued)
b. Where did this person live 1 year ago?
F
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Address
Development or condominium name
Number and street name
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Name of city, town, or post office
Name of municipio in Puerto Rico or U.S. county
Enter Puerto Rico or
name of U.S. state
ZIP Code
13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
YES, INSURED
Mark (X) for all that apply.
14 a. Does this person speak a language other
than English at home?
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)
Yes
No ➔ SKIP to question 15a
Medicare, for people 65 and older, or people
with certain disabilities
b. What is this language?
Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability
For example: Korean, Italian, Spanish, Vietnamese
Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov
c. How well does this person speak English?
Very well
Veteran’s health care (enrolled for VA)
Well
TRICARE or other military health care
Not well
Indian Health Service
Not at all
Any other type of health insurance or health
coverage plan – Specify C
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to question 16
NO, UNINSURED
Yes, this house ➔ SKIP to question 16
No health insurance or health coverage plan
No, outside Puerto Rico and the United States –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
No, different house in Puerto Rico or the
United States
§.2Uo¤
27
13175286
Person 3 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.2Uw¤
28
13175294
Person 3 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 27
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 27
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
29 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 30a
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
§.2U¡¤
29
13175302
Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Yes
Person(s)
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
a. Address
Development or condominium name
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.
Hour
Minute
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
No, outside the city/town limits
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
36 a. LAST WEEK, was this person on layoff from
a job?
d. Name of municipio in Puerto Rico or
U.S. county
Yes ➔ SKIP to question 36c
No
e. Enter Puerto Rico or name of U.S. state or
foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
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
Yes ➔ SKIP to question 38
Bus
Motorcycle
No
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Carro público
Worked from
home ➔ SKIP
to question 40a
Ferryboat
§.2V#¤
Other method
30
13175310
Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work for pay, even for
a few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city,
county, or municipio)
this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.
State government (including school
districts and state universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work for at least
one day? Include weeks when this person only
worked for a few hours. Include all jobs for pay.
Count paid vacation, paid sick leave, and military
service as work.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Weeks
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
41 During the PAST 12 MONTHS, for the weeks
worked, how many HOURS did this person
usually work each WEEK? Include all jobs for
pay and military service.
Usual hours worked each WEEK
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.)?
§.2V+¤
31
13175328
Person 3 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
No
.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
➜
§.2V=¤
$
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
44 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.
13175336
Person 4
➜
Please copy the name of Person 4 from page 5,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in Puerto Rico ➔ SKIP to question 10a
11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.
Yes, born in a U.S. state, District of Columbia, Guam,
the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
When did this person come to live in Puerto Rico?
If this person came to live in Puerto Rico more than
once, print latest year.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Year
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.2VE¤
33
13175344
Person 4 (continued)
b. Where did this person live 1 year ago?
F
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Address
Development or condominium name
Number and street name
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Name of city, town, or post office
Name of municipio in Puerto Rico or U.S. county
Enter Puerto Rico or
name of U.S. state
ZIP Code
13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
YES, INSURED
Mark (X) for all that apply.
14 a. Does this person speak a language other
than English at home?
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)
Yes
No ➔ SKIP to question 15a
Medicare, for people 65 and older, or people
with certain disabilities
b. What is this language?
Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability
For example: Korean, Italian, Spanish, Vietnamese
Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov
c. How well does this person speak English?
Very well
Veteran’s health care (enrolled for VA)
Well
TRICARE or other military health care
Not well
Indian Health Service
Not at all
Any other type of health insurance or health
coverage plan – Specify C
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to question 16
NO, UNINSURED
Yes, this house ➔ SKIP to question 16
No health insurance or health coverage plan
No, outside Puerto Rico and the United States –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
No, different house in Puerto Rico or the
United States
§.2VM¤
34
13175351
Person 4 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.2VT¤
35
13175369
Person 4 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 27
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 27
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
29 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 30a
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
§.2Vf¤
36
13175377
Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Yes
Person(s)
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
a. Address
Development or condominium name
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.
Hour
Minute
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
No, outside the city/town limits
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
36 a. LAST WEEK, was this person on layoff from
a job?
d. Name of municipio in Puerto Rico or
U.S. county
Yes ➔ SKIP to question 36c
No
e. Enter Puerto Rico or name of U.S. state or
foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
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
Yes ➔ SKIP to question 38
Bus
Motorcycle
No
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Carro público
Worked from
home ➔ SKIP
to question 40a
Ferryboat
§.2Vn¤
Other method
37
13175385
Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work for pay, even for
a few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city,
county, or municipio)
this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.
State government (including school
districts and state universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work for at least
one day? Include weeks when this person only
worked for a few hours. Include all jobs for pay.
Count paid vacation, paid sick leave, and military
service as work.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Weeks
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
41 During the PAST 12 MONTHS, for the weeks
worked, how many HOURS did this person
usually work each WEEK? Include all jobs for
pay and military service.
Usual hours worked each WEEK
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.)?
§.2Vv¤
38
13175393
Person 4 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
No
.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
➜
§.2V~¤
$
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
44 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.
13175401
Person 5
➜
Please copy the name of Person 5 from page 6,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in Puerto Rico ➔ SKIP to question 10a
11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.
Yes, born in a U.S. state, District of Columbia, Guam,
the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
LESS THAN GRADE 1
Yes, U.S. citizen by naturalization – Print year
of naturalization C
Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11
No, not a U.S. citizen
9
When did this person come to live in Puerto Rico?
If this person came to live in Puerto Rico more than
once, print latest year.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Year
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.2W"¤
40
13175419
Person 5 (continued)
b. Where did this person live 1 year ago?
F
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Address
Development or condominium name
Number and street name
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Name of city, town, or post office
Name of municipio in Puerto Rico or U.S. county
Enter Puerto Rico or
name of U.S. state
ZIP Code
13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
YES, INSURED
Mark (X) for all that apply.
14 a. Does this person speak a language other
than English at home?
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)
Yes
No ➔ SKIP to question 15a
Medicare, for people 65 and older, or people
with certain disabilities
b. What is this language?
Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability
For example: Korean, Italian, Spanish, Vietnamese
Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov
c. How well does this person speak English?
Very well
Veteran’s health care (enrolled for VA)
Well
TRICARE or other military health care
Not well
Indian Health Service
Not at all
Any other type of health insurance or health
coverage plan – Specify C
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to question 16
NO, UNINSURED
Yes, this house ➔ SKIP to question 16
No health insurance or health coverage plan
No, outside Puerto Rico and the United States –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
No, different house in Puerto Rico or the
United States
§.2W4¤
41
13175427
Person 5 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.
20 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer questions 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.2W<¤
42
13175435
Person 5 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later (Post 9/11)
Yes
August 1990 through August 2001
(including the Persian Gulf War)
No ➔ SKIP to question 27
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 27
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
29 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 30a
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
§.2WD¤
43
13175443
Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Yes
Person(s)
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
a. Address
Development or condominium name
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.
Hour
Minute
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
No, outside the city/town limits
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
36 a. LAST WEEK, was this person on layoff from
a job?
d. Name of municipio in Puerto Rico or
U.S. county
Yes ➔ SKIP to question 36c
No
e. Enter Puerto Rico or name of U.S. state or
foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
c. Has this person been informed that he or she
will be recalled to work within the next 6
months OR been given a date to return to work?
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
Yes ➔ SKIP to question 38
Bus
Motorcycle
No
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Carro público
Worked from
home ➔ SKIP
to question 40a
Ferryboat
§.2WL¤
Other method
44
13175450
Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work for pay, even for
a few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city,
county, or municipio)
this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.
State government (including school
districts and state universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work for at least
one day? Include weeks when this person only
worked for a few hours. Include all jobs for pay.
Count paid vacation, paid sick leave, and military
service as work.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Weeks
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
41 During the PAST 12 MONTHS, for the weeks
worked, how many HOURS did this person
usually work each WEEK? Include all jobs for
pay and military service.
Usual hours worked each WEEK
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.)?
§.2WS¤
45
13175468
Person 5 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
No
f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
$
.00
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
No
.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
➜
§.2We¤
$
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
Yes ➔
44 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
§.2Wm¤
47
13175484
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 Puerto Rico 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-1PR(2025) (02-28-2024)
§.2Wu¤
48
| File Type | application/pdf |
| Subject | ACS-1PR(2024) |
| Author | US Census Bureau |
| File Modified | 2024-03-08 |
| File Created | 2024-02-28 |