Attachment C Third Mailing Materials

Atachment C: Third Mailing Materials

ACS Stateside Outgoing Envelope…………………………………………….. Pages 2 and 3
ACS Follow-up leter…………………………………………………………………Pages 4 and 5
ACS Ques�onnaire, Version SGA (Mark All Version)…………………..Pages 6 through 53
ACS Ques�onnaire, Version SGO (Mark One Version)……………….Pages 54 through 101
ACS Return Envelope………………………………………………………..………Pages 102 and 103

Attachment C: ACS Stateside Outgoing Envelope

DC

PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58

U.S. Census Bureau
National Processing Center
1201 E. 10th St.
Jeffersonville, IN 47132
OFFICIAL BUSINESS
Penalty for Private Use $300

OPEN
IMMEDIATELY

The American Community Survey
Form Enclosed

YOUR RESPONSE IS
REQUIRED BY LAW

ACS-46(2024) (03-22-2023)

Attachment C: ACS Follow-up Letter

DC

U.S. Census Bureau
Washington, DC 20233
Office of the Director

A message from the Director of the U.S. Census Bureau:
The U.S. Census Bureau recently sent you a request to complete the American Community Survey
online. If you have not already responded to this important survey, please do so now.
Complete the survey using ONLY ONE of the following options:
•
•

Respond online at respond.census.gov/acs
If you are unable to respond online, please fill out and mail back
the enclosed questionnaire.

You are required by U.S. law to respond to this survey.
The Census Bureau has randomly selected your address to receive this survey as part of a nationally
representative sample. Because you will be providing important information on behalf of your
community, it is vital that you complete this survey to help meet critical needs in your area – like
deciding where to build new schools, health clinics, and fire stations.
If you do not respond promptly, a Census Bureau interviewer may contact you to complete the survey.
The Census Bureau is required by law to keep your information confidential.
The Census Bureau is not permitted to publicly release your responses in a way that could identify you
or your household.
If you need help completing the survey or have questions, please call 1–888–715–2301.
Thank you for your prompt response.
Sincerely,

Robert L. Santos

Nota: Vea al otro lado para responder en español.

ACS-14(LX)ST (02-16-2024)

census.gov/acs

Will my response be confidential?
Yes. The U.S. Census Bureau is required by law to protect this information. The Census Bureau
is not permitted to publicly release your responses in a way that could identify you. We are
conducting this survey under the authority of Title 13, U.S. Code, Sections 141 and 193.
Federal law protects your privacy and keeps your answers confidential (Title 13, U.S. Code,
Section 9). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected
from cybersecurity risks through screening of the systems that transmit your data.
Am I required to fill out the survey?
Yes. Your response to this survey is required by law (Title 13, U.S. Code, Sections 141, 193,
and 221). Title 13, as changed by Title 18, imposes a penalty for not responding. As a
randomly selected representative of your community, you are the voice of your neighbors and
peers. To create an accurate picture of your community, it is critical that you respond.
How will the Census Bureau use the information I provide?
By law, the Census Bureau can only use your responses to produce statistics. Your information
will be used in combination with information from other households to produce data for your
community. Similar data will be produced for communities across Puerto Rico and the United
States. We may combine your answers with information that you gave to other agencies to
enhance the statistical uses of these data. This information will be given the same protections
as your survey information. Based on the information that you provide, you may be asked to
participate in other Census Bureau surveys that are voluntary.

Para completar la Encuesta sobre la Comunidad Estadounidense en español:
Visite respond.census.gov/acs. Haga clic en "Responder en español". Si necesita ayuda en
español, llame al 1–877–833–5625.

您的地址被美国人口普查局随机选中参与美国社区问卷调查。
如果您对强制性的/必须填写的问卷调查有任何问题，请致电1–800–638–5945。
Địa chỉ của quý vị đã được Cục Thống Kê Dân Số Hoa Kỳ chọn ngẫu nhiên để tham gia vào cuộc Khảo
Sát Cộng Đồng tại Mỹ. Nếu quý vị có thắc mắc về khảo sát bắt buộc này, vui lòng gọi số 1–877–221–9436.

Ваш адрес был выбран случайным образом Бюро переписи населения США
для участия в Анкетировании населения США по месту жительства. Если у вас есть
вопросы по поводу этого обязательного опроса, позвоните по телефону 1–866–225–2297.
귀하의 주소는 미국 지역사회 조사에 참여할 수 있도록 미국 인구조사국이 무작위로 선택하였습니다.
이 의무적인 설문조사에 대해 질문이 있으시면, 1–800–772–6728로 전화하십시오.

13764014

American Community Survey
Attachment C: ACS Questionnaire Version SGA - Mark All

Start Here
You have two ways to respond:

➜

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

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

OR
First Name

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

Area Code

Your response is required by law.

MI

+

Number

—

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

➜

For more information about the American
Community Survey, visit our website at:
census.gov/acs

§.mI/¤

ჀINCLUDE everyone who is living or staying here for more
than 2 months.
ჀINCLUDE yourself if you are living here for more than 2
months.
ჀINCLUDE anyone else staying here who does not have
another place to stay, even if they are here for 2 months or
less.
ჀDO NOT INCLUDE anyone who is living somewhere else for
more than 2 months, such as a college student living away or
someone in the Armed Forces on deployment.

If you need help or have
questions about completing
this form, please call
1-888-715-2301.
¿NECESITA AYUDA? Llame al
1-877-833-5625.

How many people are living or staying at this address?

Number of people

➜

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

ACS-1(X)SGA

FORM
(02-26-2024)

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

13764022

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

➜

➜ NOTE: Please answer BOTH Question 6 about

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

6

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

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

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

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

First Name

2

7

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

How is this person related to Person 1?
X

3

MI

Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

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

4

Day

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

What sex was Person 1 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Female

What is Person 1’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.
Male

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

Female
Transgender
Nonbinary
This person uses a different term – Specify C

Some other race – Print race or origin. C

§.mI7¤

2

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

13764030

Person 2
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 2’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 2 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 2’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.mI?¤

3

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

13764048

Person 3
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 3’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 3 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 3’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.mIQ¤

4

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

13764055

Person 4
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 4’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 4 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 4’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.mIX¤

5

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

13764063

Person 5
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 5’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 5 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 5’s current gender?
Mark (X) one or more boxes. If this person is less than
15 years old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.mI‘¤

6

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

13764071

➜

If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C

Person 6
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 7
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 8
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 9
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 10
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 11
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 12
Last Name (Please print)

First Name

Month

Age (in years)

Day

Year of birth

Related to
Person 1?

Date of birth

§.mIh¤

MI

7

Yes

No

13764089

Housing
➜

1

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

A

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

4

How many acres is this house or mobile home on?

A mobile home

Less than 1 acre ➔ SKIP to question 6a

A one-family house detached from any
other house

1 to 9.9 acres

A one-family house attached to one or
more houses

10 or more acres

A building with 2 apartments

5

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

None

A building with 10 to 19 apartments

$1 to $999

A building with 20 to 49 apartments

$1,000 to $2,499

A building with 50 or more apartments

$2,500 to $4,999

Boat, RV, van, etc.

2

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

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

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

6

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

2000 to 2009

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

1990 to 1999

Number of rooms

2010 to 2019

1980 to 1989
1970 to 1979

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

1960 to 1969
1950 to 1959
1940 to 1949

Number of bedrooms

1939 or earlier

3

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

Year

§.mIz¤

8

13764097

Housing (continued)
7

Does this house, apartment, or mobile home
have –
Yes

11 Do you or any member of this household have
access to the Internet using a –

No

a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C

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

8

Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.

Yes

No

Yes
No

9

12 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?

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

None
1

No

a. Desktop or laptop

2

b. Smartphone

3

c. Tablet or other portable
wireless computer

4
5

d. Some other type of computer
Specify C

6 or more

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

10 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?

Gas: Natural gas from underground pipes serving
the neighborhood

Yes, by paying a cell phone company or
Internet service provider

Gas: Bottled or tank (propane, butane, etc.)
Electricity

Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 12

Fuel oil, kerosene, etc.

No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 12

Coal or coke
Wood
Solar energy
Other fuel
No fuel used

§.mI¿¤

9

13764105

Housing (continued)
14 a. LAST MONTH, what was the cost of electricity 16 Is this house, apartment, or mobile home part of a
for this house, apartment, or mobile home?

homeowners association or condominium?

Last month’s cost – Dollars

$

Yes ➔ What is the required monthly
homeowners association fee
and/or condominium fee? For
renters, answer only if you pay
the fee in addition to your rent;
otherwise, mark the "None" box.
Monthly amount – Dollars

.00


OR

Included in rent or condominium fee
No charge or electricity not used

$

.00



b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?

OR
None

Last month’s cost – Dollars
No

$

.00



17 Is this house, apartment, or mobile home –

OR

Mark (X) ONE box.

Included in rent or condominium fee

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

Included in electricity payment entered above

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

No charge or gas not used

Rented?

c. IN THE PAST 12 MONTHS, what was the cost
of water and sewer for this house, apartment,
or mobile home? If you have lived here less than
12 months, estimate the cost.

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

Past 12 months’ cost – Dollars

$

.00



B

OR

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

Included in rent or condominium fee

18 a. What is the monthly rent for this house,

No charge

apartment, or mobile home?
Monthly amount – Dollars

d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.

$

Past 12 months’ cost – Dollars

$

Yes
No

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

15 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits
from the Food Stamp Program or SNAP (the
Supplemental Nutrition Assistance Program)?
Do NOT include WIC, the School Lunch Program, or
assistance from food banks.
Yes
No

§.mJ&¤

.00

b. Does the monthly rent include any meals?

.00





10

C

13764113

Housing (continued)

C

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

Answer questions 19 – 23 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .

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

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

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

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

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

Answer question 24 if this is a MOBILE HOME.
Otherwise, SKIP to E .

Yes, contract to purchase
No ➔ SKIP to question 23a

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

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 23a

§.mJ.¤

E

11

Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.

13764121

Person 1
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.mJ6¤

12

13764139

Person 1 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.mJH¤

13

Yes

No

13764147

Person 1 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.mJP¤

14

C

13764154

Person 1 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.mJW¤

15

13764162

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.mJ_¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

16

13764170

Person 1 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.mJg¤

17

13764188

Person 1 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.mJy¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

18

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.

13764196

Person 2
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.mJ£¤

19

13764204

Person 2 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.mK%¤

20

Yes

No

13764212

Person 2 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.mK-¤

21

C

13764220

Person 2 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.mK5¤

22

13764238

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.mKG¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

23

13764246

Person 2 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.mKO¤

24

13764253

Person 2 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.mKV¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

25

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.

13764261

Person 3
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.mK^¤

26

13764279

Person 3 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.mKp¤

27

Yes

No

13764287

Person 3 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.mKx¤

28

C

13764295

Person 3 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.mK¢¤

29

13764303

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.mL$¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

30

13764311

Person 3 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.mL,¤

31

13764329

Person 3 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.mL>¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

32

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.

13764337

Person 4
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.mLF¤

33

13764345

Person 4 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.mLN¤

34

Yes

No

13764352

Person 4 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.mLU¤

35

C

13764360

Person 4 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.mL]¤

36

13764378

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.mLo¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

37

13764386

Person 4 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.mLw¤

38

13764394

Person 4 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.mL¡¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

39

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.

13764402

Person 5
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.mM#¤

40

13764410

Person 5 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.mM+¤

41

Yes

No

13764428

Person 5 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.mM=¤

42

C

13764436

Person 5 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.mME¤

43

13764444

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.mMM¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

44

13764451

Person 5 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.mMT¤

45

13764469

Person 5 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.mMf¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

46

Now continue with the mailing instructions
on page 48.

13764477

Page 47 is intentionally
left blank

§.mMn¤

47

13764485

Mailing
Instructions
➜ Please make sure you have...

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

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

For Census Bureau Use
POP

EDIT CLERK

EDIT

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
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(X)SGA (02-26-2024)

§.mMv¤

48

13754015

American Community Survey
Attachment C: Questionnaire Version SGO: Mark One

Start Here
You have two ways to respond:

➜

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

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

OR
First Name

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

Area Code

Your response is required by law.

MI

+

Number

—

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

➜

For more information about the American
Community Survey, visit our website at:
census.gov/acs

§.lI0¤

ჀINCLUDE everyone who is living or staying here for more
than 2 months.
ჀINCLUDE yourself if you are living here for more than 2
months.
ჀINCLUDE anyone else staying here who does not have
another place to stay, even if they are here for 2 months or
less.
ჀDO NOT INCLUDE anyone who is living somewhere else for
more than 2 months, such as a college student living away or
someone in the Armed Forces on deployment.

If you need help or have
questions about completing
this form, please call
1-888-715-2301.
¿NECESITA AYUDA? Llame al
1-877-833-5625.

How many people are living or staying at this address?

Number of people

➜

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

ACS-1(X)SGO

FORM
(02-26-2024)

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

13754023

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

➜

➜ NOTE: Please answer BOTH Question 6 about

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

6

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

Please print today’s date.

No, not of Hispanic, Latino, or Spanish origin

Month

Yes, Mexican, Mexican Am., Chicano

Day

Year

Yes, Puerto Rican
Yes, Cuban

1

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

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

First Name

2

7

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

How is this person related to Person 1?
X

3

MI

Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

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

4

Day

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

What sex was Person 1 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Female

What is Person 1’s current gender?
Mark (X) ONE box. If this person is less than 15 years
old, SKIP to the next question.
Male

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

Female
Transgender
Nonbinary
This person uses a different term – Specify C

Some other race – Print race or origin. C

§.lI8¤

2

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

13754031

Person 2
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 2’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 2 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 2’s current gender?
Mark (X) ONE box. If this person is less than 15 years
old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.lI@¤

3

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

13754049

Person 3
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 3’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 3 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 3’s current gender?
Mark (X) ONE box. If this person is less than 15 years
old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.lIR¤

4

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

13754056

Person 4
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 4’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 4 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 4’s current gender?
Mark (X) ONE box. If this person is less than 15 years
old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.lIY¤

5

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

13754064

Person 5
1

➜ NOTE: Please answer BOTH Question 6 about

What is Person 5’s name?

Hispanic origin and Question 7 about race.
For this survey, Hispanic origins are not races.

Last Name (Please print)

6
First Name

Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

2

How is this person related to Person 1?
Mark (X) ONE box.

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

Spouse
Unmarried partner
Biological child
Adopted child

7

Stepchild

What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

Sibling
Parent
Grandchild

Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate

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

Foster child
Other nonrelative

3

What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 5 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 5’s current gender?
Mark (X) ONE box. If this person is less than 15 years
old, SKIP to the next question.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term – Specify C

§.lIa¤

6

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

13754072

➜

If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C

Person 6
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 7
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 8
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 9
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 10
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 11
Last Name (Please print)

First Name

Month

Age (in years)

Day

MI

Year of birth

Related to
Person 1?

Date of birth

Yes

No

Person 12
Last Name (Please print)

First Name

Month

Age (in years)

Day

Year of birth

Related to
Person 1?

Date of birth

§.lIi¤

MI

7

Yes

No

13754080

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

§.lIq¤

8

13754098

Housing (continued)
7

Does this house, apartment, or mobile home
have –
Yes

11 Do you or any member of this household have
access to the Internet using a –

No

a. cellular data plan for a
smartphone or other mobile
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C

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

8

Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.

Yes

No

Yes
No

9

12 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?

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

None
1

No

a. Desktop or laptop

2

b. Smartphone

3

c. Tablet or other portable
wireless computer

4
5

d. Some other type of computer
Specify C

6 or more

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

10 At this house, apartment, or mobile home –
do you or any member of this household have
access to the Internet?

Gas: Natural gas from underground pipes serving
the neighborhood

Yes, by paying a cell phone company or
Internet service provider

Gas: Bottled or tank (propane, butane, etc.)
Electricity

Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 12

Fuel oil, kerosene, etc.

No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 12

Coal or coke
Wood
Solar energy
Other fuel
No fuel used

§.lI¥¤

9

13754106

Housing (continued)
14 a. LAST MONTH, what was the cost of electricity 16 Is this house, apartment, or mobile home part of a
for this house, apartment, or mobile home?

homeowners association or condominium?

Last month’s cost – Dollars

$

Yes ➔ What is the required monthly
homeowners association fee
and/or condominium fee? For
renters, answer only if you pay
the fee in addition to your rent;
otherwise, mark the "None" box.
Monthly amount – Dollars

.00


OR

Included in rent or condominium fee
No charge or electricity not used

$

.00



b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?

OR
None

Last month’s cost – Dollars
No

$

.00



17 Is this house, apartment, or mobile home –

OR

Mark (X) ONE box.

Included in rent or condominium fee

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

Included in electricity payment entered above

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

No charge or gas not used

Rented?

c. IN THE PAST 12 MONTHS, what was the cost
of water and sewer for this house, apartment,
or mobile home? If you have lived here less than
12 months, estimate the cost.

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

Past 12 months’ cost – Dollars

$

.00



B

OR

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

Included in rent or condominium fee

18 a. What is the monthly rent for this house,

No charge

apartment, or mobile home?
Monthly amount – Dollars

d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.

$

Past 12 months’ cost – Dollars

$

Yes
No

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

15 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits
from the Food Stamp Program or SNAP (the
Supplemental Nutrition Assistance Program)?
Do NOT include WIC, the School Lunch Program, or
assistance from food banks.
Yes
No

§.lJ’¤

.00

b. Does the monthly rent include any meals?

.00





10

C

13754114

Housing (continued)

C

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

Answer questions 19 – 23 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .

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

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

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

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

Yes, insurance included in mortgage payment

$



.00



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

No, insurance paid separately or no insurance

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

Annual amount – Dollars

$

Yes, home equity loan

.00



Yes, second mortgage

OR

Yes, second mortgage and home equity loan

None

No ➔ SKIP to

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

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

flood insurance on THIS property?
Annual amount – Dollars

$

Monthly amount – Dollars

.00



D

$

OR

.00



None

OR
No regular payment required

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

D

Answer question 24 if this is a MOBILE HOME.
Otherwise, SKIP to E .

Yes, contract to purchase
No ➔ SKIP to question 23a

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

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

Annual costs – Dollars

Monthly amount – Dollars

$



$

.00



.00

OR
No regular payment required ➔ SKIP to
question 23a

§.lJ/¤

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.

13754122

Person 1
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.lJ7¤

12

13754130

Person 1 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.lJ?¤

13

Yes

No

13754148

Person 1 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.lJQ¤

14

C

13754155

Person 1 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.lJX¤

15

13754163

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.lJ‘¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

16

13754171

Person 1 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.lJh¤

17

13754189

Person 1 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.lJz¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

18

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 3,
SKIP to page 48 for mailing instructions.

13754197

Person 2
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.lJ¿¤

19

13754205

Person 2 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.lK&¤

20

Yes

No

13754213

Person 2 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.lK.¤

21

C

13754221

Person 2 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.lK6¤

22

13754239

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.lKH¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

23

13754247

Person 2 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.lKP¤

24

13754254

Person 2 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.lKW¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

25

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 4,
SKIP to page 48 for mailing instructions.

13754262

Person 3
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.lK_¤

26

13754270

Person 3 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.lKg¤

27

Yes

No

13754288

Person 3 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.lKy¤

28

C

13754296

Person 3 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.lK£¤

29

13754304

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.lL%¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

30

13754312

Person 3 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.lL-¤

31

13754320

Person 3 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.lL5¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

32

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 5,
SKIP to page 48 for mailing instructions.

13754338

Person 4
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.lLG¤

33

13754346

Person 4 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.lLO¤

34

Yes

No

13754353

Person 4 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.lLV¤

35

C

13754361

Person 4 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.lL^¤

36

13754379

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.lLp¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

37

13754387

Person 4 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.lLx¤

38

13754395

Person 4 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.lL¢¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

39

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 6,
SKIP to page 48 for mailing instructions.

13754403

Person 5
➜

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

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

Last Name

First Name

No, has not attended in the last 3
months ➔ SKIP to question 12

MI

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

8

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

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

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

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

College undergraduate years (freshman to senior)

9

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

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 11a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

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

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

NO SCHOOLING COMPLETED

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

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten

No, not a U.S. citizen

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.lM$¤

40

13754411

Person 5 (continued)
16 a. Did this person live in this house or apartment

F

1 year ago?

Answer question 13 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 14.

Person is under 1 year old ➔ SKIP to question 17
Yes, this house ➔ SKIP to question 17
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 17

13 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

No, different house in the United States or
Puerto Rico

b. Where did this person live 1 year ago?
Address (Number and street name)

14 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office

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

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

15 a. Does this person speak a language other

ZIP Code

than English at home?
Yes
No ➔ SKIP to question 16a

17 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.

b. What is this language?

a. Insurance through a current or
former employer or union (of this
person or another family member)

For example: Korean, Italian, Spanish, Vietnamese

b. Insurance purchased directly from
an insurance company (by this
person or another family member)

c. How well does this person speak English?
Very well

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

Well

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

Not well
Not at all

e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.lM,¤

41

Yes

No

13754429

Person 5 (continued)
I
G

Answer question 18a if this person is covered by
health insurance. Otherwise, SKIP to question 19a.

18 a. Is there a premium for this plan? A premium

Answer question 21 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.

21 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

Yes

Yes

No

No ➔ SKIP to question 19a

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

22 What is this person’s marital status?
Now married
Widowed

Yes

Divorced
No
Separated

19 a. Is this person deaf or do they have serious

Never married ➔ SKIP to

difficulty hearing?
Yes

J on the next page

23 In the PAST 12 MONTHS did this person get –
Yes

No

No

a. Married?

b. Is this person blind or do they have serious
difficulty seeing even when wearing glasses?

b. Widowed?

Yes

c. Divorced?

No

24 How many times has this person been married?

H

Once

Answer questions 20a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.

Two times
Three or more times

20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?

25 In what year did this person last get married?
Year

Yes
No

26 Which of the following best represents how this
person thinks of themselves?
Mark (X) ONE box.

b. Does this person have serious difficulty
walking or climbing stairs?
Yes

Gay or lesbian

No

Straight, that is not gay or lesbian
Bisexual

c. Does this person have difficulty dressing or
bathing?

This person uses a different term – Specify

Yes
No

§.lM>¤

42

C

13754437

Person 5 (continued)
J

Answer question 27 if this person’s sex at birth
was female and they are 15-50 years old.
Otherwise, SKIP to question 28a.

29 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 32a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 31a

27 In the PAST 12 MONTHS, has this person given
birth to any children?

Now on active duty

Yes

On active duty in the past, but not now

No

30 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

28 a. Does this person have any of their own
grandchildren under the age of 18 living in
this house or apartment?

September 2001 or later (Post 9/11)

Yes

August 1990 through August 2001
(including the Persian Gulf War)

No ➔ SKIP to question 29

June 1975 through July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

August 1964 through May 1975
(including the Vietnam War)
February 1955 through July 1964

Yes

June 1950 through January 1955
(including the Korean War)

No ➔ SKIP to question 29

January 1947 through May 1950

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months

December 1941 through December 1946
(including World War II)
November 1941 or earlier

31 a. Does this person have a VA service-connected
disability rating?

6 to 11 months

Yes (such as 0%, 10%, 20%, ... , 100%)

1 or 2 years

No ➔ SKIP to question 32a

3 or 4 years

b. What is this person’s service-connected
disability rating?

5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.lMF¤

43

13754445

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

K

Yes ➔ SKIP to question 33

Answer question 35 if you marked "Car, truck,
or van" in question 34. Otherwise, SKIP to
question 36.

No – Did not work (or retired)

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

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

Person(s)

Yes
No ➔ SKIP to question 38a

33 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where they worked most last week.

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

Minute

a. Address (Number and street name)

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

:

a.m.
p.m.

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

b. Name of city, town, or post office

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

L

Yes

Answer questions 38 – 41 if this person
did NOT work last week. Otherwise, SKIP
to question 42a.

No, outside the city/town limits

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

d. Name of county

a job?
Yes ➔ SKIP to question 38c
No

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

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 41

f. ZIP Code

No ➔ SKIP to question 39

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

Taxi or ride-hailing
services

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 42a

Ferryboat

Other method

§.lMN¤

c. Has this person been informed that they will be
recalled to work within the next 6 months OR
been given a date to return to work?
Yes ➔ SKIP to question 40
No

44

13754452

Person 5 (continued)
39 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 44a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 45.

Yes
No ➔ SKIP to question 41

44 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

40 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

41 When did this person last work, even for a
few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months
1 to 5 years ago ➔ SKIP to

For-profit company or organization

M

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 45

GOVERNMENT EMPLOYEE

42 a. During the PAST 12 MONTHS (52 weeks), did

Local government (for example: city or
county school district)

this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.

State government (including state
colleges/universities)

Yes ➔ SKIP to question 43

Active duty U.S. Armed Forces or
Commissioned Corps

No

Federal government civilian employee

b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

Weeks

Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per week

43 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Usual hours worked each WEEK

c. What kind of business or industry was this?
Include the main activity, product, or service provided
at the location where employed. (For example:
elementary school, residential construction)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.lMU¤

45

13754460

Person 5 (continued)
d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)

Yes ➔
No

f. Describe this person’s most important activities
or duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)

$

.00



TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
Yes ➔
No

$

.00



TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.

45 INCOME IN THE PAST 12 MONTHS

Yes ➔

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

No

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

No





.00

TOTAL AMOUNT for past
12 months

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔

$

No





No

$





No

TOTAL AMOUNT for past
12 months

.00



Yes ➔

$

No

TOTAL AMOUNT for past
12 months

.00



Loss

OR
None

$





TOTAL AMOUNT for past
12 months

.00

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

§.lM]¤

$

PAST 12 MONTHS? Add entries in questions 45a to
45h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔

Yes ➔

46 What was this person’s total income during the

.00

TOTAL AMOUNT for past
12 months

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.

a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.

$

.00



g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b), or
other accounts specifically designed for retirement.
Do not include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

Yes ➔

$

46

Now continue with the mailing instructions
on page 48.

13754478

Page 47 is intentionally
left blank

§.lMo¤

47

13754486

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(X)SGO (02-26-2024)

§.lMw¤

48

(05-05-2023) 6385-47(2024) envelope 9 x 11-3/4" W open window 5 x 1-1/8

C

Attachment C: Return Envelope
OFFICIAL BUSINESS
Penalty for Private Use $300

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

BUSINESS REPLY MAIL
FIRST-CLASS MAIL

PERMIT NO. 16081

WASHINGTON DC

U.S. CENSUS BUREAU
NATIONAL PROCESSING CENTER
PO BOX 5240
JEFFERSONVILLE IN 47199-5240

FFATTFADDDTAADTFADDFAFTDFFAADFFFAFDTFDTAFATFDFATADTTFDFDTFFFFATTF
6385-47(2024) (05-05-2023)

00 708 200644 000000000 47199 5240

Flap side

POSTAGE WILL BE PAID BY THE U.S. CENSUS BUREAU

(05-05-2023) 6385-47(2024) envelope 9 x 11-3/4"

Flap

➟
➟