U.S. Department of Commerce Economics and Statistics Administration U.S. Census Bureau

Please complete this form and return it as soon as possible after receiving it in the mail. This form asks for information about the people who are living or staying at the address on the mailing label and about the house, apartment, or mobile home located at the address on the mailing label. If you need help or have questions about completing this form, please call 1-800-354-7271.

For more information about the American Community Survey, visit our web site at: http://www.census.gov/acs/www/.

Start Here:

Please print today's date: ______

Please print the name and telephone number of the person who is filling out this form. We may contact you if there is a question.

Area Code + Number: ______________

How many people are living or staying at this address?

• Include everyone who is living or staying here for more than 2 months.
• Include yourself if you are living here for more than 2 months.
• Include anyone else staying here who does not have another place to stay, even if they are here for 2 months or less.
• Do 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.

Number of people: ____

Fill out pages 2, 3, and 4 for everyone, including yourself, who is living or staying at this address for more than 2 months. Then complete the rest of the form.

Person 1-5

1. What is this person's name?

2. How is this person related to Person 1? _____

3. What is this person's sex?

4. What is this person's age and date of birth?

Please report babies as age 0 when the child is less than 1 year old.

Age (in years) : ____ Month: _____ Day: ____ Year of birth: _______

Note: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.

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

6. What is Person 1's race? Mark (X) one or more boxes.

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.

[Repeat for Persons 6 - 12.]
Last Name: ____
First Name: ____
MI: ____

Sex:

Age (in years): ____

Housing

Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

1. Which best describes this building? Include all apartments, flats, etc., even if vacant.

2. About when was this building first built?

3. When did person 1 (listed on page 2) move into this house, apartment, or mobile home?

Section A
Answer questions 4-6 only if this is a house or mobile home; otherwise, skip to question 7a.

4. How many acres is this house or mobile home on?

5. In the past twelve months, what were the actual sales of all agricultural products from this property?

6. Is there a business (such as a store or barber shop) or a medical office on this property?

7. 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.

• Include bedrooms, kitchens, etc.
• Exclude bathrooms, porches, balconies, foyers, halls, or unfinished basements.

Number of rooms: ___

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".

Number of bedrooms: ___

8. Does this house, apartment, or mobile home have:

a) Hot and cold running water?

b) A flush toilet?

c) A bathtub or shower?

d) A sink with a faucet?

e) A stove or range?

f) A refrigerator?

g) Telephone service from which you can both make and receive calls? Include cell phones.

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

10. Which fuel is used most for heating this house, apartment or mobile home?

11. a) Last month, what was the cost of electricity for this house, apartment, or mobile home? Last month's cost Dollars $________________.00 or

b) Last month, what was the cost of gas for this house, apartment or mobile home? Last month's cost Dollars $________________.00 or

c) In the past twelve months, what was the cost of water and sewer for this house, apartment, or mobile home? If you have listed here less than 12 months, estimate the cost. Past 12 months' cost
Dollars $________________.00 or

d) In the past twelve 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 month's cost Dollars $________________.00 or

12. In the past twelve months, did anyone in this household receive food stamps or a food stamp benefit card? Include government benefits from the Supplemental Nutrition Assistance Program (SNAP). Do not include WIC or the National School Lunch Program.

13. Is this house, apartment, or mobile home part of a condominium?

14. Is this house, apartment, or mobile home Mark (X) one box.

Section B

Answer questions 15a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 16.

15. a) What is the monthly rent for this house, apartment, or mobile home? Monthly amount Dollars $____.00

b) Does this monthly rent include any meals?

Section C

Answer questions 16-20 If you or someone else in this household owns or is buying this house, apartment, or mobile home. Otherwise, skip to section E on the next page.

16. About how much do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale? Amount Dollars $____.00

17. What are the annual real estate taxes on THIS property? Annual amount Dollars $____.00 or

18. What is the annual payment for fire, hazard, and flood insurance on THIS property? Annual amount Dollars $____.00 or

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

b) How much is the regular monthly mortgage payment on this property? Include payments only on FIRST mortgage or contract to purchase Monthly amount - Dollars $____.00 or

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

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

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

b) How much is the regular monthly payment on all second or junior mortgages and all home equity loans on this property? Monthly amount - Dollars $____.00 or

Section D
Answer question 24 if this is a mobile home. Otherwise, skip to Section E.

21. 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. Annual costs - Dollars $____.00

Section E
Answer questions about person 1 on the next page if you listed at least one person on page 2. Otherwise, skip to page 28 for the mailing instructions.

Person 1 [This form repeats for each person listed]

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

7. Where was this person born?

8. Is this person a citizen of the United States?

9. When did this person come to live in the United States? Print numbers in boxes. Year: ____

10. a) At any time in the last three 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.

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

11. 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.

No schooling completed

Nursery or preschool through grade 12

High school graduate

College or some college

After bachelor's degree

Section F
Answer question 12 if this person has a bachelor's degree or higher. Otherwise, skip to question 13.

12. This question focuses on this person's bachelor's degree. Please print below the specific major(s) of any bachelor's degrees this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology): ____

13. What is this person's ancestry or ethnic origin? ____ (For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

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

b) What is this language? ____

c) How well does this person speak English?

15. a) Did this person live in this house or apartment 1 year ago?

b) Where did this person live 1 year ago?

16. 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. Yes No

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

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

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

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

e) TRICARE or other military health care

f) VA (including those who have ever used or enrolled for VA health care)

g) Indian Health Service

h) Any other type of health insurance or health coverage plan

17. a) Is this person deaf or does he/she have serious difficulty hearing?

b) Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

Section G
Answer question 18a-c if this person is 5 years old or over. Otherwise, skip to the questions for person 2 on page 12.

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

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

c) Does this person have difficulty dressing or bathing?

Section H
Answer question 19 if this person is 15 years old or over. Otherwise, skip to the questions for Person 2 on page 12.

19. 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?

20. What is this person's marital status?

21. In the past 12 months did this person get

a) Married?

b) Widowed?

c) Divorced?

22. How many times has this person been married?

23. In what year did this person last get married? Year: _____

Section I
Answer question 24 if this person is female and 15-50 years old. Otherwise, skip to question 25a.

24. Has this person given birth to any children in the past 12 months?

25. a) Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?

25. b) Is this grandparent currently responsible for most of the basic needs of any grandchild(ren) under the age of 18 who live(s) in this house or apartment?

25 c) How long has this grandparent been responsible for the(se) grandchild(ren)? 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.

26. Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

27. 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.

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

b) What is this person's service-connected disability rating?

29. a) Last week, did this person work for pay at a job (or business)?

b) Last week, did this person do any work for pay, even for as little as one hour?

30. At what location did this person work last week? If this person worked at more than one location, print where he or she worked most last week.
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.
b) Name of city, town, or post office ____

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

d) Name of county ____
e) Name of U.S. state or foreign country ____
f) ZIP Code: ____

31. How did this person usually get to work last week? If this person usually used more than one method of transportation during the trip, mark (X) the box of the one used for most of the distance

Section J
Answer question 32 if you marked "car, truck or van" in question 31. Otherwise, skip to question 33.

32. How many people, including this person, usually rode to work in the car, truck or van last week?
Person(s): _____

33. What time did this person usually leave home to go to work last week? Hour: _ _ Minute: _ _ [] am [] pm

34. How many minutes did it usually take this person to get from home to work last week? Minutes: _____

Section K
Answer questions 35-38 only if this person did not work last week. Otherwise, skip to question 39a.

35. a) Last week, was this person on layoff from a job?

b) Last week, was this person temporarily absent from a job or business?

c) Has this person been informed that he or she will be recalled to work within the next 6 months or been given a date to return to work?

36. During the last 4 weeks, has this person been actively looking for work?

37. Last week, could this person have started a job if offered one, or returned to work if recalled?

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

39. a) During the past 12 months (52 weeks), did this person work 50 or more weeks? Count paid time off as work.

b) How many weeks did this person work, even for a few hours, including paid vacation, paid sick leave, and military service?

During the past 12 months (52 weeks), in the weeks worked, how many hours did this person usually work each week? Usual hours worked each week: _____

Section L
Answer questions 41-46 if this person worked in the past 5 years. Otherwise, skip to question 47.

41-46 Current or more recent job activity.

Describe clearly this person's chief job activity or business last week. If this person had more than one job, describe the one at which this person worked the most hours. If this person had no job or business last week, give information for his/her last job or business.

41. Was this person... Mark (X) ONE box

42. For whom did this person work? If now on active duty in the armed forces, mark (X) this box - [ ] and print the branch of the Armed Forces Name of company, business, or other employer ____

43. What kind of business or industry was this? Describe the activity at the location where employed. (For example: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank) ____

44. Is this mainly - Mark (X) one box

45. What kind of work was this person doing? (For example: registered nurse, personal manager, supervisor of order department, secretary, and accountant) ____

46. What were this person's most important activities or duties? (For example: patient care, directing hiring policies, supervising order clerks, typing and filing, reconciling financial records) ____

47. Income in the past 12 months. 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.) Mark (X) the "No" box to show types of income not received. 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.

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

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

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

d) Social Security or Railroad Retirement

e) Supplemental Security Income (SSI)

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

g) Retirement, survivor, or disability pensions. Do not include Social Security.

h) Any such 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

48. What was this person's total income during the past 12 months? Add entries in questions 47a to 47h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.

Continue with the questions for Person 2 on the next page. If only 1 person is listed on page 2, skip to page 28 for mailing instructions.

[The document repeats the above "person" form for up to five residents]