ACS-1(2025) American Community Survey

The American Community Survey and the Puerto Rico Community Survey

Attachment D - ACS-1(2025) (02-28-2024)

OMB: 0607-0810

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Attachment D - ACS-1(2025) (02-28-2024)

13195011

American Community Survey

Start Here
You have two ways to respond:

➜

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

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

OR
First Name

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

Area Code

Your response is required by law.

MI

+

Number

—

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

➜

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.
DO NOT INCLUDE anyone living somewhere else, such as...
✗ a college student living away.
✗ someone in the Armed Forces on deployment.

If you need help or have
questions about completing
this form, please call
1-800-354-7271.
¿NECESITA AYUDA? Llame al
1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
census.gov/acs

§.4S,¤

How many people, including yourself, live or stay
at this address?

Number of people

➜

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

ACS-1(2025)

FORM
(02-28-2024)

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

13195029

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

➜

➜ NOTE: Please answer BOTH Question 5 about

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

5

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

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

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

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

First Name

2

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

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

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

4

6

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

X

3

MI

Female

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

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

Print numbers in boxes.
Age (in years)

Month

Day

Year of birth

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

Some other race – Print race or origin. C

§.4S>¤

2

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

13195037

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

§.4SF¤

3

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

13195045

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

§.4SN¤

4

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

13195052

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

§.4SU¤

5

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

13195060

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

§.4S]¤

6

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

13195078

➜

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

§.4So¤

Age (in years)

7

13195086

Housing
➜

1

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

A

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

4

How many acres is this house or mobile home on?

A mobile home

Less than 1 acre ➔ SKIP to question 6a

A one-family house detached from any
other house

1 to 9.9 acres

A one-family house attached to one or
more houses

10 or more acres

A building with 2 apartments

5

A building with 3 or 4 apartments
A building with 5 to 9 apartments

None

A building with 10 to 19 apartments

$1 to $999

A building with 20 to 49 apartments

$1,000 to $2,499

A building with 50 or more apartments

$2,500 to $4,999

Boat, RV, van, etc.

2

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

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

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

6

a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend
out at least 6 inches and go from floor to ceiling.

2000 to 2009

Ⴠ INCLUDE bedrooms, kitchens, etc.
Ⴠ EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.

1990 to 1999

Number of rooms

2010 to 2019

1980 to 1989
1970 to 1979

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

1960 to 1969
1950 to 1959
1940 to 1949

Number of bedrooms

1939 or earlier

3

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

Year

§.4Sw¤

8

13195094

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

8

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

Yes

No

No, connected to septic tank
No, use other type of system

13 How many automobiles, vans, and trucks of
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

Yes

2

No

3
4

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

5
6 or more

No

a. Desktop or laptop

14 Do you or any member of this household own or

b. Smartphone

lease an electric vehicle? Include both all-electric
and plug-in hybrid electric vehicles.

c. Tablet or other portable
wireless computer

Yes

d. Some other type of computer
Specify C

No

15 Which FUEL is used MOST for heating this
house, apartment, or mobile home?
Mark (X) one box for the fuel used most.

11 At this house, apartment, or mobile home –

Gas: Natural gas from underground pipes serving
the neighborhood

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

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

Fuel oil, kerosene, etc.

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

Coal or coke
Wood
Solar energy
Other fuel
No fuel used

§.4S¡¤

9

13195102

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 Food
Stamp Program or SNAP (the Supplemental
Nutrition Assistance Program)? Do NOT include
WIC, the School Lunch Program, or assistance from
food banks.

Yes
No

Yes

17 a. LAST MONTH, what was the cost of electricity
for this house, apartment, or mobile home?

No

Last month’s cost – Dollars

$

.00



19 Is this house, apartment, or mobile home part of a
homeowners association or condominium?

OR

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

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?
Last month’s cost – Dollars

$

$

.00



OR
None

OR
No

Included in rent or condominium fee
Included in electricity payment entered above

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

No charge or gas not used

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

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.

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

Past 12 months’ cost – Dollars

$

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

.00



.00



OR
Included in rent or condominium fee

B

No charge

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.

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

Past 12 months’ cost – Dollars

$

$

.00



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

OR



b. Does the monthly rent include any meals?

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

§.4T#¤

.00

No

10

C

13195110

Housing (continued)

C

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

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

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

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

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

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

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

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

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

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

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 26a

§.4T+¤

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.

13195128

Person 1
➜

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

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

Last Name

First Name

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

MI

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

7

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

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

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

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

College undergraduate years (freshman to senior)

8

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

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

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

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA

Year

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

§.4T=¤

12

13195136

Person 1 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

12 This question focuses on this person’s

Name of city, town, or post office

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 U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.

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

YES, INSURED
Mark (X) for all that apply.
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

14 a. Does this person speak a language other
than English at home?
Yes

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

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

15 a. Did this person live in this house or apartment
1 year ago?
NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.4TE¤

13

13195144

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

§.4TM¤

14

13195151

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

§.4TT¤

15

13195169

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

K

Yes ➔ SKIP to question 31

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

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 36a

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

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

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

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

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

f. ZIP Code

No ➔ SKIP to question 37

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.4Tf¤

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

16

13195177

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 or
county school district)

this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work 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.)?

§.4Tn¤

17

13195185

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

➜

§.4Tv¤

$

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.

13195193

Person 2
➜

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

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

Last Name

First Name

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

MI

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

7

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

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

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

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

College undergraduate years (freshman to senior)

8

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

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

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

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA

Year

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

§.4T~¤

19

13195201

Person 2 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

12 This question focuses on this person’s

Name of city, town, or post office

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 U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.

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

YES, INSURED
Mark (X) for all that apply.
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

14 a. Does this person speak a language other
than English at home?
Yes

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

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

15 a. Did this person live in this house or apartment
1 year ago?
NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.4U"¤

20

13195219

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

§.4U4¤

21

13195227

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

§.4U<¤

22

13195235

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

K

Yes ➔ SKIP to question 31

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

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 36a

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

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

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

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

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

f. ZIP Code

No ➔ SKIP to question 37

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.4UD¤

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

23

13195243

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 or
county school district)

this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work 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.)?

§.4UL¤

24

13195250

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

➜

§.4US¤

$

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.

13195268

Person 3
➜

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

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

Last Name

First Name

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

MI

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

7

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

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

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

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

College undergraduate years (freshman to senior)

8

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

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

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

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA

Year

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

§.4Ue¤

26

13195276

Person 3 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

12 This question focuses on this person’s

Name of city, town, or post office

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 U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.

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

YES, INSURED
Mark (X) for all that apply.
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

14 a. Does this person speak a language other
than English at home?
Yes

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

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

15 a. Did this person live in this house or apartment
1 year ago?
NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.4Um¤

27

13195284

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

§.4Uu¤

28

13195292

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

§.4U}¤

29

13195300

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

K

Yes ➔ SKIP to question 31

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

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 36a

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

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

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

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

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

f. ZIP Code

No ➔ SKIP to question 37

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.4V!¤

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

30

13195318

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 or
county school district)

this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work 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.)?

§.4V3¤

31

13195326

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

➜

§.4V;¤

$

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.

13195334

Person 4
➜

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

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

Last Name

First Name

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

MI

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

7

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

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

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

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

College undergraduate years (freshman to senior)

8

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

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

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

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA

Year

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

§.4VC¤

33

13195342

Person 4 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

12 This question focuses on this person’s

Name of city, town, or post office

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 U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.

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

YES, INSURED
Mark (X) for all that apply.
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

14 a. Does this person speak a language other
than English at home?
Yes

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

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

15 a. Did this person live in this house or apartment
1 year ago?
NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.4VK¤

34

13195359

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

§.4V\¤

35

13195367

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

§.4Vd¤

36

13195375

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

K

Yes ➔ SKIP to question 31

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

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 36a

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

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

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

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

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

f. ZIP Code

No ➔ SKIP to question 37

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.4Vl¤

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

37

13195383

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 or
county school district)

this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work 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.)?

§.4Vt¤

38

13195391

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

➜

§.4V|¤

$

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.

13195409

Person 5
➜

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

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

Last Name

First Name

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

MI

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

7

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

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

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

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

College undergraduate years (freshman to senior)

8

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

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

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

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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

12th grade – NO DIPLOMA

Year

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

§.4W*¤

40

13195417

Person 5 (continued)
b. Where did this person live 1 year ago?

F

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

Address (Number and street name)

12 This question focuses on this person’s

Name of city, town, or post office

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 U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13 What is this person’s ancestry or ethnic origin?
16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Do NOT include plans that cover only
one type of service, such as dental, drug, or vision plans.

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

YES, INSURED
Mark (X) for all that apply.
Insurance through a current or former employer,
union, or professional association (of this person
or another family member)

14 a. Does this person speak a language other
than English at home?
Yes

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

No ➔ SKIP to question 15a

Medicaid, Children’s Health Insurance Program
(CHIP), or any kind of government-assistance plan
for those with low incomes or a disability

b. What is this language?

Insurance purchased directly from an insurance
company, a broker, or a State or Federal Marketplace,
such as HealthCare.gov

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?

Veteran’s health care (enrolled for VA)

Very well

TRICARE or other military health care

Well

Indian Health Service

Not well

Any other type of health insurance or health
coverage plan – Specify C

Not at all

15 a. Did this person live in this house or apartment
1 year ago?
NO, UNINSURED

Person is under 1 year old ➔ SKIP to question 16

No health insurance or health coverage plan

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

No, different house in the United States or
Puerto Rico

§.4W2¤

41

13195425

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

§.4W:¤

42

13195433

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

§.4WB¤

43

13195441

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

K

Yes ➔ SKIP to question 31

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

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 36a

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

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

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

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 36c
No

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

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

f. ZIP Code

No ➔ SKIP to question 37

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

§.4WJ¤

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

44

13195458

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 or
county school district)

this person work EVERY week? Count paid
vacation, paid sick leave, and military service as
work. Include all jobs for pay.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 41

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work 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.)?

§.4W[¤

45

13195466

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

➜

§.4Wc¤

$

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

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47

13195482

Mailing
Instructions
➜ Please make sure you have...

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

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

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

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

Form ACS-1(2025) (02-28-2024)

§.4Ws¤

48


File Typeapplication/pdf
AuthorOneFormUser
File Modified2024-03-08
File Created2024-02-28

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