a. Salary or gross income? _ _ _ _ _
b. Thirteenth-month payment? _ _ _ _ _
c. Income for independent work or self-employment? _ _ _ _ _
d. Retirement or old-age pension? _ _ _ _ _
e. Pension (due to accident, illness, survival benefits or other)? _ _ _ _ _
f. Assistance from institutions or other person(s) who do not live with you?

1) Food allowance? _ _ _ _ _
2) Money? _ _ _ _ _
3) Other? (specify) ____

g. Leases, rents, interests, or benefits? _ _ _ _ _
h. Scholarships? _ _ _ _ _
i. Agricultural sales? _ _ _ _ _
j. Other income? _ _ _ _ _