The American Community Survey 2010
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/.
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.
First Name: ___________
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.
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.
First Name: ____________________
2. How is this person related to Person 1? _____
 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.
[For persons 2 - 5]
Relationship of Person [2 - 5] to Person 1.
 Husband or wife
 Son or daughter
 Brother or sister
 Other relative
 Roomer, boarder
 Housemate, roommate
 Unmarried partner
 Foster child
 Other nonrelative
Please report babies as age 0 when the child is less than 1 year old.
Age (in years) : ____ Month: _____ Day: ____ Year of birth: _______
5. Is Person 1 of Hispanic, Latino, or Spanish origin?
 Yes, Mexican, Mexican Am., Chicano
 Yes, Puerto Rican
 Yes, Cuban
 Yes, another Hispanic, Latino, or Spanish origin
Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on ____
6. What is Person 1's race? Mark (X) one or more boxes.
 African Am. or Negro
 American Indian or Alaska Native
Print name of enrolled or principal tribe ____
 Asian Indian
 Native Hawaiian
 Guamanian or Chamorro
 Other Asian Print race: ____
 Other Pacific Islander Print race, for example, for example, Hmong, Laotian, Fijian, Tongan, and so on: ____
Thai, Pakistani, Cambodian, and so on. ____
 Some other race Print race. ____
We may call you for more information about them.
Age (in years): ____
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.
 A one-family house detached from any other house
 A one-family house attached to one or more houses
 A building with 2 apartments
 A building with 3 or 4 apartments
 A building with 5 to 9 apartments
 A building with 10 to 19 apartments
 A building with 20-49 apartments
 A building with 50 or more apartments
 Boat, RV, van, etc.
5. In the past twelve months, what were the actual sales of all agricultural products from this property?
 $1 to $999
 $1,000 to $2,499
 $2,500 to $4,999
 $5,000 to $9,999
 $10,000 or more
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.
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: ___
10. Which fuel is used most for heating this house, apartment or mobile home?
 Gas: bottled, tank or LP
 Fuel oil, kerosene, etc.
 Coal or coke
 Solar energy
 Other fuel
 No fuel used
11. a) Last month, what was the cost of electricity for this house, apartment, or mobile home? Last month's cost Dollars $________________.00 or
 No charge or electricity not used
b) Last month, what was the cost of gas for this house, apartment or mobile home? Last month's cost Dollars $________________.00 or
 Included in electricity payment entered above
 No charge or gas not used
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
 No charge
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
 No charge or these fuels not used
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.
 Owned by you or someone in this household free and clear (without a mortgage or loan)?
 Occupied without payment of rent? Skip to C
Answer questions 15a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 16.
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.
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?
 Yes, contract to purchase
 No skip to question 23a
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
d) Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on this property?
 No, insurance paid separately or no insurance
20. a) Do you or any member of this household have a second mortgage or a home equity loan on this property?
 Yes, second mortgage
 Yes, second mortgage and home equity loan
 No -> skip to Section D
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
First Name ____ MI _
8. Is this person a citizen of the United States?
 Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas
 Yes, born abroad of U.S. citizen parent or parents
 Yes, U.S. citizen by naturalization. Print year of naturalization: ____
 No, not a U.S. citizen
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.
 Yes, public school, public college
 Yes, private school, private college, home school
b) What grade or level was this person attending? Mark (X) one box.
 Grade 1 through 12 Specify grade 1-12: ____
 College undergraduate years (freshman to senior)
 Graduate or professional school beyond a bachelor's degree (for example: MA or PhD program, or medical or law school)
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
 Grade 1 through 11 Specify grade 1-11: ____
 12th grade - No diploma
High school graduate
 GED or alternative credential
College or some college
 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
 Professional degree beyond a bachelor's degree (for example: MD, DDS, DVM, LLB, JD)
 Doctorate degree (for example: PhD, EdD)
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.)
 Yes, this house -> skip to question 16
 No, outside the United States and Puerto Rico - Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then skip to question 16. ____
 No, different house in the United States or Puerto Rico
b) Where did this person live 1 year ago?
Name of city, town, or post office ____
Name or U.S. county or municipio in Puerto Rico ____
Name of U.S. state or Puerto Rico zip code ____
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.
 6 to 11 months
 1 or 2 years
 3 or 4 years
 5 or more years
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.
 Yes, on active duty during the last 12 months, but not now
 Yes, on active duty in past, but not during the last 12 months
 No, training for Reserves or National Guard only skip to question 28a
 No, never served in the military ->skip to question 29a
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.
 August 1990 to August 2001 (including Persian Gulf War)
 September 1980 to July 1990
 May 1975 to August 1980
 Vietnam era (August 1964 to April 1975)
 March 1961 to July 1964
 February 1955 to February 1961
 Korean War (June 1950 to January 1955)
 January 1947 to June 1950
 World War II (December 1941 to December 1946)
 November 1941 or earlier 28.
28. a) Does this person have a VA service-connected disability rating?
 No SKIP to question 29a
b) What is this person's service-connected disability rating?
 10 or 20 percent
 30 or 40 percent
 50 or 60 percent
 70 percent or higher
 No, skip to question 35a
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?
 No, outside the city/town limits
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
 Bus or trolley bus
 Streetcar or trolley car
 Subway or elevated
 Worked at home -> skip to question 38a
 Other method
37. Last week, could this person have started a job if offered one, or returned to work if recalled?
 No, because of own temporary illness
 No, because of all other reasons (in school, etc.)
 1 to 5 years ago -> skip to Section L
 Over 5 years ago or never worked -> skip to question 47
b) How many weeks did this person work, even for a few hours, including paid vacation, paid sick leave, and military service?
 48 to 49 weeks
 40 to 47 weeks
 27 to 39 weeks
 14 to 26 weeks
 13 weeks or less 40.
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: _____
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
 an employee of a private not for profit, tax-exempt, or charitable organization?
 a local government employee (city, county, etc.)?
 a state government employee?
 a federal government employee?
 Self-employed in own not incorporated business, professional practice, or farm?
 Self-employed in own incorporated business, professional practice, or farm?
 Working without pay in family business or farm
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) ____
 wholesale trade
 retail trade
 other (agriculture, service, government, etc.)
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.
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
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.
[The document repeats the above "person" form for up to five residents]