National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX K
INCOME WORKSHEET

This page has been left blank for double-sided copying.

OMB Control Number: XXXX-XXXX
Expiration Date:

The National Food Study

Income Worksheet
This worksheet will help you to prepare for the final interview at the end of the survey week. To better understand
your household’s food purchases, we will ask you about your household income. This information helps us
understand how much money your household has available to spend on food. Complete this worksheet during the
study week and refer to it during the final interview to make the interview go faster! We will not collect this
worksheet, so feel free to put notes on it.
Remember, your information will be kept private and will not be released in a form that might identify you.
We are required by law to use your information for statistical research only and to keep it confidential. The law
prohibits us from giving anyone any information that may identify you or your family. The information you provide will
not affect any benefits or services received by anyone in your household. Participation is voluntary.

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REVIEW this worksheet with your interviewer during their first visit.

COMPLETE the forms in this worksheet during the study week. If you need
to, check your recent paystubs or statements and ask other household
members for their information.

REPORT this information during the final interview when the interviewer
returns at the end of the study week.

Questions? Call our toll free number: 1-866-275-8659
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is
estimated to average 8 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.

Total Household Gross Income (last month)
INSTRUCTIONS
Use the table below to list the name of each person living in your household who receives income from any source. Next to each person’s
name, list each type of income received last month and how often it was received. List the gross income from work. This is not the
same as take-home pay. See the definitions at the bottom of the page for the items to include in each category.

First Name

Gross income and how often it was received
For example: $100 / month, $100/ twice a month, $100 / every other week, $100 / week
Earnings from Work
(before deductions)

Jane

Unemployment
Compensation

Welfare, Child
Support, Alimony

Retirement and
Disability Income

Investment
Income

All Other Income

200
week $_______/_____
0
150
month $_______/_____
0
0
0
$_______/_____
$_______/______
$_______/_____
$______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____
$_______/______ $_______/_____ $_______/_____ $_______/_____ $_______/_____ $______/_____

Earning from Work (before deductions)
Enter the total amount each household member earns from work before taxes and other deductions (such as union dues, insurance
premiums, and contributions to retirement plans). This amount should be listed on your pay stub. If a household member is paid in cash,
enter that amount. If your income is not always the same, list the amount that you normally get. For example, if you normally get $1000
each month, but you missed some work last month and only got $900, list $1000 per month. If you normally get overtime, include it, but
not if you get it only sometimes.

Welfare, Child Support and Alimony
Most welfare comes from the Temporary Assistance for Needy Families (TANF) program (which may have a different name in your state)
or from General Assistance, General Relief, or the GA program. These programs provide financial assistance to people with little or no
income. In this column also include child support payments that are paid by a former husband, wife, or parent of a child living in your
household; include child support payments paid through a welfare agency or court; and include alimony received by a member of your
household. Alimony is court-ordered support paid by one spouse to another after they are separated.

Retirement and Disability Income
Enter retirement income from pension payments, retirement account withdrawals, and Social Security Retirement Benefit (SSA)
payments. SSA is received by persons who have worked long enough and had enough Social Security deductions taken from their salary
to be entitled to payments (these payments may be made to the spouse or dependent children of a covered worker). Enter disability
income from Social Security Disability Benefit (SSDI) payments which are received by persons who cannot work because of a medical
condition. Also include: (1) black lung benefits; (2) workers compensation; and (3) Supplemental Security Income (SSI).

Investment Income
Include: (1) income from rental properties; (2) interest, dividends and capital gains; and (3) trust fund payments.

All Other Income
Include any other income, such as: (1) strike benefits; (2) fuel assistance; (3) roomers, lodgers or tenants; (4) educational grants, loans or
stipends; (5) insurance settlement payments; (6) Veterans Affairs benefits; (7) lottery winnings; and (8) employment bonuses.

Questions? Call our toll free number: 1-866-275-8659