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. The telephone call is free.

Necesita ayuda? Si usted habla espanol y necesita ayuda para completar su cuestionario, llame sin cargo alguno al 1-800-354-7271. Usted tambien puede pedir un cuestionario en espanol o completar su entrevista por telefono con un entrevistador que habla espanol.

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.

Last name _ _ _ _ _ _ _ _ _ _ _ _ _
First name _ _ _ _ _ _ _ _ _ _ _ _ _
Middle initial _
Area code and phone 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
(Person 1 is the person living or staying here in whose name this house or apartment is owned, bought, or being rented. If there is no such person, start with the name of any adult living or staying here.)

1. What is Person 1's name?

2. How is this person related to Person 1?

3. What is Person 1's sex? Mark (X) in one box.

4. What is Person 1's age and what is Person 1's date of birth? Please report babies as age 0 when the child is less than 1 year old.

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.

[Repeat for persons X = 2 - 5.]

1. What is Person X's name?

2. How is this person related to Person 1?

3. What is Person X's sex? Mark (X) ONE box.
4. What is Person X's age and what is Person X's date of birth? Please report babies as age 0 when the child is less than 1 year old.

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 X of Hispanic, Latino, or Spanish origin?

6. What is Person X'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 Y = 6 - 12.]

Person Y

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?

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

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

5. In the past 12 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?

b) How many of these rooms are bedrooms?

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

9. At this house, apartment, or mobile home- do you or any member of this household own or use any of the following computers? Excludes GPS devices, digital music players, and devices with only limited computing capabilities, for example: household appliances.

10. At this house, apartment, or mobile home - do you or any member of this household access the Internet?

11. At this house, apartment, or mobile home - do you or any member of this household subscribe to the Internet using

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

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

14. a) Last month, what was the cost of electricity for this house, apartment, or mobile home?

b) Last, what was the cost of gas for this house, apartment or mobile home?

c) In the past 12 months, what was the cost of water and sewer for this house, apartment, or mobile home?

d) In the past 12 months, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?

15. In the past 12 months, did anyone in this household receive Food Stamps or a Food Stamp benefit card?

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

17. Is this house, apartment, or mobile home

[B] - Answer questions 18a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 19.

18. a) What is the monthly rent for this house, apartment, or mobile home?

b) Does this monthly rent include any meals?

[C] - Answer questions 19-23 IF you or someone else in this household owns or is buying this house, apartment, or mobile home. Otherwise, skip to [E] on the next page.

19. 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?

20. What are the annual real estate taxes on this property?

21. What is the annual payment for fire, hazard, and flood insurance on this property?

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?

b) How much is the regular monthly mortgage payment on this property? Include payments only on first mortgage or contract to purchase

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?

23. 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?

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

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?

[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, then continue answering questions below
Last name ________
First name ________
Middle initial ____

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?

10. a) At any time in the last 3 months, has this person attended school or college?

b) What grade or level was this person attending?

11. What is the highest degree or level of school this person has completed?

[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.

13. What is this person's ancestry or ethnic origin?

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?

15. 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.

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?

[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?

[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

22. How many times has this person been married?

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

[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?

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?

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

26. Has this person ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

27. When did this person serve on active duty in the U.S. Armed Forces?

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

28.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

30.a) Address (Number and street name)________

30.b) Name of city, town, or post office________

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

30.d) Name of county _________

30.e) Name of U.S. state or foreign country________

30.f) ZIP Code _ _ _ _ _

31. How did this person usually get to work last week?

[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?

33. What time did this person usually leave home to go to work last week?

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

[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 week, 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?

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

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

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

41-46 Current or most 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?

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...

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

48. What was this person's total income during the past 12 months?

Continue with the questions for Person 2 on the next page. If no one is listed as person 2 on page 2, skip to page 28 for mailing instructions.

(Document repeats the above "person" form for up to 5 residents)