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1981 Census of Canada

Please complete your questionnaire on Wednesday, June 3, 1981

Legal requirement
The census of Canada is taken under the authority of the Statistics Act, which requires everyone to provide the information requested.

Confidential when completed
The information you will give will be kept confidential and used only for the production of statistics. No one will see the answers you give except for persons sworn to secrecy under the Statistics Act. These persons are subject to prosecution and legal penalties if they disclose personal census information.

Please complete address or exact location:
Street and No. or lot and concession ____
City, town, village, municipality ____
Province or territory ____
Postal code _ _ _ _ _ _
Telephone number ____

To temporary residents
If all members of this household are temporary residents (i.e., persons staying here temporarily who have a usual home elsewhere in Canada), enter the total number of temporary residents in this box [] and do not complete this questionnaire. Follow the return instructions indicated on the envelope which contained this questionnaire.

To foreign residents
If all members of this household are Foreign Residents (see below), mark this box . . . . . . . . . . . . . . . . . . . . . . and do not complete this questionnaire. Follow the return instructions indicated on the envelope which contained this questionnaire.
Foreign residents
(any person in the following categories):
Government representatives of another country attached to the legation, embassy or other diplomatic body of that country in Canada, and their families;
Members of the Armed Forces of another country, and their families;
Students from another country attending school in Canada, and their families;
Workers from another country in Canada on employment visas, and their families; and
Residents of another country visiting in Canada temporarily.

A message to all Canadians
Every five years Canada takes a census - a national stock-taking of its people and their housing. From the information it provides, we, as a nation, are better equipped to meet the many challenges facing us at every level, national, regional and local.
The answers you give, when compiled into statistics, are used in determining economic and social policies, planning industrial development, and estimating needs for schools, roads and many other public services.
Population figures are used to determine electoral district boundaries, and to calculate per capita grants to provinces and municipalities. For every person who does not initially respond, additional funds must be spent on follow-up procedures. The failure to count yourself in could result in the loss of revenue to your own community.
The Statistics Act, under which the census is carried out, not only defines your obligation to co-operate, but ensures that the information you provide will be kept confidential and used only for the purposes of that Act.
Your co-operation is essential. Please do your part by completing this questionnaire promptly, as of June 3, 1981, in accordance with the instructions provided.
Thank you for your co-operation.

Question Guidelines

Question 1. Refer to the instructions adjacent to Question 1 when considering whom to (or not to) include as members of your household. If you have doubts as to whether a person should be listed, enter the person's name and the reason in the space provided in question 9.
If there are more than six persons in your household and you do not have a second questionnaire, note this in the "Comments" section of your questionnaire, complete the questionnaire for six persons in your household and return as instructed. A Census Representative will contact you later with an additional questionnaire.

Question 2. To enable us to identify family groups within the household, it is necessary to select a reference person (Person l), and to state the relationship of each household member to that person. For example, if John Smith lives with his father Thomas Smith, and Thomas Smith has been entered as Person 1, John Smith would mark "Son or daughter of Person 1". There may be a member or members of your household whose relationship to Person 1 is not described in Question 2. In such cases, mark either "Other relative of Person 1" or "Other non-relative", and also print the exact relationship to Person 1 in the space provided.
"Other relative" includes persons such as uncles, aunts, cousins, grandfathers, grandmothers, and so on. "Other non-relative" refers to household members who are not related to Person 1 by blood, marriage, adoption or common-law. Some examples are employee's wife, employee's daughter, room-mate's son, landlord, and so on.
The term "common-law", as used in "Common-law partner of Person l" or as may be used to describe any other such partnership in the household (for example, "Lodger's common-law partner"), should be interpreted as applying to any case of a couple living together in this type of union.

Note that stepchildren, adopted children, and children of a common-law partner should be considered as sons and daughters. Foster children, wards and guardianship children who are not related to Person l by blood, marriage, adoption or common-law should be listed as lodgers.

Question 5. Mark "Now married" if you have a husband or wife who is now living, even if you are temporarily living apart because one of you is employed away from home, hospitalized, etc., but not if you are actually separated or have obtained a divorce.
For census purposes, couples living in a common-law type of arrangement are considered as "Now married", regardless of their legal marital status.
Mark "Separated" if you are separated from your husband or wife due to causes such as desertion or marriage breakdown, or because you no longer want to live together, provided that no divorce has been obtained.
Mark "Divorced" if you have obtained a divorce and have not remarried.

Question 6. You must still understand the language you report in this question. For infants, report the first language they are or will be learning.

Question 8. If your household has more than six persons you will require more than one questionnaire. Please see the guideline for Question 1.
If you are using more than one questionnaire, please answer this question on the first questionnaire only.

Question 9. If you have difficulty determining if a person should be included on your questionnaire, please refer to the "Whom to include" item in the column adjacent to Question 1.


Question 11. Special cases
Mark "Owned" if the dwelling you occupy is owned or being bought by you and/or a member of this household even if (a) it is situated on rented or leased land or (b) it is part of a condominium (whether registered or unregistered). For census purposes, a condominium is a multi-unit residential complex in which dwellings are owned individually while land is held in joint ownership with others.
Mark "Rented" in all other cases even if the dwelling you occupy is (a) provided without cash rent or at a reduced rent, such as a clergyman's residence, a superintendent's dwelling in an apartment building, etc., or is (b) part of a co-operative. For census purposes, in a co-operative all members jointly own the co-operative and occupy their dwelling units under a lease agreement.

Question 12.
Single and semi-detached house
If you live in what is referred to as a "linked home" (a single house which is not attached to any other dwelling above ground, but is attached below ground), mark "Single house".
Duplex and apartment
Two dwellings, one above the other, attached to other dwellings are to be considered as apartments and not as duplexes.
Apartment
Do not count as storeys floors that are used solely for parking, storage or laundry and recreation facilities.
If you are in doubt concerning the number of storeys in an apartment building, mark "Apartment in a building that has five or more storeys" if there is at least one passenger elevator in the building. If there is no passenger elevator in the building, mark "Apartment in a building that has less than five storeys".

Instructions for question 1
Order of listing of household members
To ensure that all persons in the same family group are listed together, the following order should be used when entering the names of all members of the household in Question 1:
a) Person 1:
Choose one of the following as Person 1:

Either the husband or the wife in any married couple living here;
Either partner in a common-law relationship;
The parent, where one parent only lives with his or her never-married son(s) or daughter(s) of any age;

If none of the above applies, choose the adult member of this household.
b) Husband or wife (or common-law partner) of Person 1;
c) Never-married children or stepchildren of Person 1;
d) Other children of Person 1, and their families;
e) Other relatives of Person 1 (whether related by blood, marriage, adoption or common-law), and their families;
(f) Persons not related to Person 1, and their families.

Whom to include
To make certain that every resident of Canada is counted in the census (and that no one is counted more than once), the following guidelines should be used when deciding who should be included on this questionnaire.
Include

All persons who usually live here, even if they are temporarily away (such as on business or at school);
Any persons staying or visiting here who have no other usual home;
Persons who usually live here but are now in an institution (such as a hospital, correctional institution), if they have been there for less than six months;
Unmarried persons who have a home elsewhere but stay in the dwelling most of the week while working;
Infants born on or before June 2, 1981; deceased persons who were alive at midnight between June and June 3, 1981.
Do not include
Persons who are now in an institution and have been there for the past six months or longer;
Infants born on or after June 3,1981;
Persons permanently away in the Armed Forces;
Post-secondary students who are financially independent and who live elsewhere;
Unmarried sons or daughters who live elsewhere most of the week while working, even if they return home on the weekend
Foreign residents (see front cover).

Households with more than six persons
If there are more than six persons in this household, enter the first six on one questionnaire and continue with the seventh person on a second questionnaire, starting in the row marked "Person 2". If you need additional questionnaires, see the guidelines for Question 1.

1. Name

Last name ____
Given name and initial ____

Using the instructions given on the left, print below the names of all persons usually living here as of Wednesday, June 3, 1981.

2. Relationship to Person 1

[] Husband or wife or Person 1
[] Common-law partner of Person 1
[] Son or daughter of Person 1
[] Father or mother of Person 1
[] Brother or sister of Person 1
[] Son-in-law or daughter-in-law of Person 1
[] Father-in-law or mother-in-law of Person 1
[] Brother-in-law or sister-in-law of Person 1
[] Grandchild of Person 1
[] Nephew or niece of Person 1
[] Other relative of Person 1 (Print below) ____
[] Lodger
[] Lodger's husband or wife
[] Lodger's son or daughter
[] Room-mate
[] Employee
[] Other non-relative (Print below) ____

For each person in this household, mark "X" one box only to describe his or her relationship to Person 1. If you mark the box "Other relative" or "Other non-relative", print in the relationship to Person 1. Some examples of the "Other" relationships are:
Grandmother
Uncle
Room-mate's daughter
Employee's husband

For further examples and special cases, see guidelines.

3. Date of birth

If exact date is not known, enter best estimate.
Day _ _
Month _ _
Year _ _ _ _

4. Sex

[] Male
[] Female

5. Marital status
What is your marital status?
(See guidelines for further information.)

Mark one box only.
[] Now married (excluding separated)
[] Separated
[] Divorced
[] Widowed
[] Never married (single)

6. What is the language you first learned in childhood and still understand?

Mark one box only.
[] English
[] French
[] German
[] Italian
[] Ukrainian
[] Other (specify) ____


A dwelling is a separate set of living quarters with a private entrance from the outside or from a common hallway or stairway inside the building. This entrance should not be through someone else's living quarters.

7. Enter the name of the person (or one of the persons) who lives here, and is responsible for paying the rent, or mortgage, or taxes, or electricity, etc., for this dwelling.
Last name ____
Given name and initial ____

This person should answer the following questions about this dwelling.
Note: if no one is living here makes any such payments, mark here __ and answer the dwelling questions yourself.

8. How many persons usually live here (according to the "Whom to include" item in the instructions of question 1)?

Number of persons _ _

9. Did you leave anyone out of Question 1 because you were not sure whether he or she should be listed? For example, a student, a lodger who also has another home, a new baby still in hospital, or a former occupant of this household who has become a patient in a hospital or sanatorium within the past six months.

[] Yes
[] No
If "Yes", print the name of each person left out and the reason.
Name ____
Reason ________

10. How many persons who have a usual home elsewhere in Canada are staying or visiting here temporarily (as of Census day, June 3)?

[] None
or
Number of persons _ _

11. Is this dwelling:
Mark one box only

[] Owned or being bought by you or a member of this household?
[] Rented (even if no cash rent is paid)?

12. Is this dwelling a:

Mark one box only
[] Single house - a single dwelling not attached to any other building and surrounded on all sides by open space?
[] Semi-detached or double house -one of two dwellings attached side by side but not attached to any other building and surrounded on all other sides by open space?
[] Duplex - one of two dwellings, one above the other, not attached to any other building and surrounded on all sides by open space?
[] Row house - one of three or more dwellings joined side by side but not having any other dwellings either above or below?
[] Apartment in a building that has five or more storeys: for example, a dwelling unit in a high-rise apartment building?
[] Apartment in a building that has less than five storeys - for example, a dwelling unit in a triplex, quadruplex or a dwelling unit in a non-residential building or in a house that has been converted?
[] House attached to a non-residential building - a single dwelling attached at ground level to another building (such as a store, etc.) but separated from it by a common wall running from ground to roof?
[] Mobile home (designed and constructed to be transported on its own chassis and capable of being moved on short notice)?
[] Other movable dwelling (such as a tent, travel trailer, railroad car or houseboat)?

13. When was this dwelling or the building containing this dwelling originally built? (To the best of your knowledge, mark the period in which the building was completed, not the time of any later remodeling, additions or conversions.)

Mark one box only
[] 1920 or before
[] 1921-1945
[] 1946-1960
[] 1961- 1970
[] 1971-1975
[] 1976-1979
[] 1980
[] 1981

14. How long have you lived in this dwelling?

Mark one box only
[] Less than one year
[] One to two years
[] Three to five years
[] Six to ten years
[] More than ten years

15. How many rooms are there in this dwelling? (include kitchen, bedrooms, finished rooms in attic or basement, etc. Do not count bathrooms, halls, vestibules and rooms used solely for business purposes.)

Number of rooms _ _


16. How many bathrooms are there within this dwelling? (See Guide for further information.)
[] None
or
[] Number of complete bathrooms _ _
[] Number of half bathrooms _ _

17. What is the main type of heating equipment for this dwelling?

Mark one box only
[] Steam or hot water furnace
[] Forced hot air furnace
[] Installed electric heating system
[] Heating stove, cooking stove, space heater
[] Other (fireplace, etc.)

18. a. Which fuel is used most for heating this dwelling?

[] Oil or kerosene
[] Piped gas, e.g., natural gas
[] Bottled gas, e.g., propane
[] Electricity
[] Wood
[] Coal or coke
[] Other fuel

18. b. Which fuel is used most for water heating this dwelling?

[] Oil or kerosene
[] Piped gas, e.g., natural gas
[] Bottled gas, e.g., propane
[] Electricity
[] Wood
[] Coal or coke
[] Other fuel

19. Is this dwelling in need of any repairs? (Do not include desirable remodeling or additions.)

[] No, only regular maintenance is needed (painting, furnace cleaning, etc.)
[] Yes, minor repairs are needed (missing or loose floor tiles, bricks or shingles, defective steps, railing or siding, etc.)
[] Yes, major repairs are needed (defective plumbing or electrical wiring, structural repairs to walls, floors or ceilings, etc.)

Answer Questions 20 to 22 for only the dwelling that you now occupy, even if you own or rent more than one dwelling. If exact amount is not known, please enter your best estimate.
Note: If you are a farm operator living on the farm you operate, mark here __ and go to page 6.

20. For this dwelling, what are the yearly payments (last 12 months) for:

a. Electricity

[] None, or included in rent or other payments
Or
[] _ _ _Dollars _ _ Cents per year

b. Oil, gas, coal, wood or other fuels?

[] None, or included in rent or other payments,
Or,
[] _ _ _ Dollars _ _ Cents per year.

c. Water and other municipal services?

[] None, or included in rent, municipal taxes or other payments,
Or
[] _ _ _ Dollars _ _ Cents per year

21. For renters only: What is the monthly cash rent you pay for this dwelling?

[] Rented without payment of cash rent
Or
[] _ _ Dollars _ _ cents per month

22. For owners only:

a. What are your total regular monthly mortgage (or debt) payments for this dwelling?

[] None : Go to question 22c.
Or
[] _ _ Dollars _ _ cents per month

b. Are your property taxes (municipal and school) included in the amount shown in Question 22a?

[] Yes: Go to question 22d.
[] No

c. What are your estimated yearly property taxes (municipal and school) for this dwelling?

[] None
Or
[] _ _ Dollars _ _ cents per year

d. If you were to sell this dwelling now, for how much would you expect to sell it?

_ _ Dollars _ _ cents

e. Is this dwelling part of a registered condominium?

[] Yes
[] No

23. Where were you born? (Mark according to present boundaries.)

[] In Canada

Mark one box only
[] Newfoundland
[] Prince Edward Island
[] Nova Scotia
[] New Brunswick
[] Quebec
[] Ontario
[] Manitoba
[] Saskatchewan
[] Alberta
[] British Colombia
[] Yukon
[] Northwest Territories

[] Outside Canada

Mark one box only
[] United Kingdom
[] Italy
[] U.S.A.
[] West Germany
[] East Germany
[] Poland
[] Other (specify)

24. Of what country are you a citizen?

Mark as many boxes as apply.
[] Canada, by birth: Go to Question 26.
[] Canada, by naturalization
[] Same as country of birth (other than Canada): Go to Question 25.
[] Other

25. In what year did you first immigrate to Canada?

[Question 25 was asked of persons who immigrated to Canada, per question 24.]
Print year below.
If exact year is not known, please enter best estimate.
Year _ _ _ _

26. To which ethnic or cultural group did you or your ancestors belong on first coming to this continent?

See guide for further information.
[] French
[] English
[] Irish
[] Scottish
[] German
[] Italian
[] Ukrainian
[] Dutch (Netherlands)
[] Polish
[] Jewish
[] Chinese
[] Other (specify) ____

Native peoples
[] Inuit
[] Status or registered Indian
[] Non-status Indian
[] Metis

27. What is your religion?

Mark one box only.
[] Roman Catholic
[] United Church
[] Anglican
[] Presbyterian
[] Lutheran
[] Baptist
[] Greek Orthodox
[] Jewish
[] Ukrainian Catholic
[] Pentecostal
[] Jehovah's Witnesses
[] Mennonite
[] Salvation Army
[] Islam
[] No religion
[] Other (specify) ____

28. What language do you yourself speak at home now?
(If more than one language, which language do you speak most often?)

Mark one box only
[] English
[] French
[] German
[] Italian
[] Ukrainian
[] Other (specify) ____

29. Can you speak English or French well enough to conduct a conversation?

See guide for further information. Mark one box only.
[] English only
[] French only
[] Both English and French
[] Neither English nor French

30. Were you born before June 3, 1966?

[] No: End here for this person
[] Yes: Continue with questions 31 to 46.

[Questions 31-46 were asked of persons age 15+, per question 30.]

31. What is the highest grade or year of secondary (high) or elementary school you ever attended?

See guide for further information.
[] No schooling or kindergarten only
Or
[] Highest grade or year (1 to 13) of secondary or elementary school _ _

32. How many years of education have you ever completed at university?

[] None
[] Less than 1 year (of completed courses)
[] Number of completed years _ _

33. How many years of schooling have you ever completed at an institution other than a university, secondary (high) or elementary school? Include years of schooling at community colleges, institutes of technology, CEGEPs (general and professional), private trade schools or private business colleges, diploma schools of nursing, etc.

See guide for further information.
[] None
[] Less than 1 year (of completed courses)
[] Number of completed years _ _

34. What degrees, certificates or diplomas have you ever obtained?

See Guide for further information. Mark as many boxes as apply.
[] None
[] Secondary (high) school graduation certificate
[] Trades certificate or diploma
[] Other non-university certificate or diploma (obtained at
community college, CEGEP, institute of technology, etc.)
[] University certificate or diploma below bachelor level
[] Bachelor's degree(s) (e.g., B.A., B.Sc., B.A.Sc., LL.B.)
[] University certificate or diploma above bachelor level
[] Master's degree(s) (e.g., M.A., M.Sc., M.Ed.)
[] Degree in medicine, dentistry, veterinary medicine or optometry (M.D., D.D.S., D.M.D., D.V.M., O.D.)
[] Earned doctorate (e.g., Ph.D., D.Sc., D.Ed.)

35. Have you attended a school, college or university at any time since last September? (Include attendance at elementary or secondary schools, business or trade schools, community colleges, institutes of technology, CEGEPs, etc.)

Mark one box only.
[] No
[] Yes, full-time
[] Yes, part-time, day or evening

36. Where did you live 5 years ago on June 1, 1976?

Mark one box only.
Note: If your place of residence 5 years ago was a municipality within a large urban area, be careful not to confuse suburban municipalities with the largest city. For example, distinguish between Montreal-Nord and Montreal, Scarborough and Toronto, West Vancouver and Vancouver.
[] This dwelling
[] Different dwelling in this city, town, village, borough, or municipality : Go to question 37.
[] Outside Canada
[] Different city, town, village, borough, or municipality in Canada (specify below)

City, town, village, borough, or municipality ____
County ____
Province or territory ____

37. How many children were born to you?

For women who are married or have ever been married.
Count all children including those who may have died since birth or who may now be living elsewhere. However do not include stillbirths.)
[] None
Or
[] Number of children _ _

38. What were the month and year of your first marriage?

For all persons who are married or have ever been married. If exact month or year are not known, enter best estimate.
_ _ Month
_ _ Year

39a. Last week, how many hours did you work (not excluding house-work or other work around your home)?

Include:
Working for wages, salary, tips or commission,
Working in your own business, farm or professional practice,
Working without pay in a family farm or business.
[] None: Continue with questions 39b to 46.
Or
[] Hours (to the nearest hour): _ _ Go to question 41

[Questions 39b to 40 was asked of persons 15+ who did not work for pay last week, per question 39a.]
b. Last week, were you on temporary lay-off or absent from your job or business?

Mark one box only.
[] No
[] Yes, on temporary lay-off
[] Yes, on vacation, ill, on strike or locked out, or absent for other reasons

c. Last week, did you have definite arrangements to start a new job within the next four weeks?
[] No
[] Yes

d) Did you look for work during the past four weeks? For example, did you contact a Canada Employment Centre, check with employers, place or answer newspaper ads?
Mark one box only
[] No : Go to Question 40
[] Yes, looked for full-time work
[] Yes, looked for part-time work (less than 30 hours per week)

e. Was there any reason why you could not start work last week?
Mark one box only
[] No, could have started work
[] Yes, already had a job
[] Yes, temporary illness or disability
[] Yes, personal or family responsibilities
[] Yes, going to school
[] Yes, other reasons

40. When did you last work, even for a few days (not including housework or other work around your home)?

Mark one box only
[] In 1981: Answer questions 41 to 46
[] In 1980: Answer questions 41 to 46
[] Before 1980: Go to question 46
[] Never worked in lifetime: Go to question 46


Note: Questions 41 to 44 refer to your job or business last week. If none, answer for your job of longest duration since January 1, 1980. If you held more than one job last week, answer for the job at which you worked the most hours.

41. a. For whom did you work?

Name of firm, government agency, etc. ____
Department, branch, division, section or plant ____


41. b. What kind of business, industry or service was this?
Give full description. For example, paper box manufacturing, road construction, retail shoe store, secondary school, dairy farm. ____


42. At what address did you work? If no usual place of work, see Guide.
Mark one box only.
[] Worked at home (includes living and working on the same farm)
[] Worked outside Canada
[] Worked at address below (please specify)

Number ____
Street ____

If street address is not known, give the building name, shopping centre or street intersection, etc.
City, town, village, borough, township or other municipality ____

Important: If you worked in a suburban municipality within a large urban area, specify that municipality, not the main city.
County ____
Province or territory ____

43. a. What kind of work were you doing? ________

For example, accounting clerk, safes representative, civil engineer, secondary school teacher, chief electrician, metal worker.

(b) In this work, what were your most important activities or duties? ________
For example, verifying invoices, selling electrical tools, managing the research department, reaching mathematics, supervising construction electricians, operating lathe. (If in the Armed Forces give rank.)

44 a. In this job, you were mainly:

[] Working for wages, salary, tips or commission?: Go to Question 45
[] Working without pay for a relative in a family farm or business? : Go to Question 45
[] Self-employed without paid help?: Continue with question 44b.
[] Self-employed with paid help?: Continue with question 44b.

b. If self-employed, was your farm or business incorporated?
[Question 44b was asked of persons 15+ who were self-employed last week, per question 44a.]
[] No
[] Yes


45. a. In how many weeks did you work during 1980 (non including housework or other work around your home)?
Include those weeks in which you: worked full-time or part-time; were on a vacation or sick leave with pay; were self-employed.
[] None: Go to question 46.
Or
[] Weeks _ _

b. During most of those weeks, did you work full-time or part-time?
Mark one box only
[] Full-time
[] Part-time

46. During the year ending December 31, 1980, did you receive any income or suffer any loss from the sources listed below?

If yes, please check the "Yes" box and enter the amount; in case of a loss, also check the "toss" box. If no, please check the "No" box and proceed to the next source. Do not include family allowances. Please consult the Guide for details.
a. Total wages and salaries including commissions, bonuses, tips, etc., before any deductions

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No

b. Net non-farm (gross receipts minus expenses) from unincorporated business, professional practice, etc., on own account or in partnership.

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No
[] Loss

c. Net farm self-employment income (gross receipts minus expenses) from agricultural operations on own account

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No
[] Loss

d. Old age security pension and guaranteed from federal government only, income supplement and benefits from Canada or Quebec Pension Plan (Provincial income supplements should be reported in f )

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No

e. Benefits from Unemployment Insurance.

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No

f. Other income from government sources including provincial income supplements and social assistance, e.g., veterans" pensions, workers' compensation, welfare payments (Do not include family allowances)

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No

g. Dividends and interest on bonds, deposits and savings certificates, and other investment income, e.g., net rents from real estate, interest from mortgages

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No
[] Loss

h. Retirement pensions, superannuation and annuities and other money income, e.g., alimony, scholarships (Do not include family allowances)

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No

i. Total income from all of the above sources (Do not include family allowances)

[] Yes

Amount: _ _ Dollars _ _ Cents

[] No
[] Loss