Questionnaire Text

Questionnaire form view entire document:  text  image
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 d dta 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 the other person.

a. Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items.
[] Yes - _ , _ _ _ , _ _ _ .00 (total amount for past 12 months)
[] No
b. Self-employment income from own nonfarm businesses or farm businesses, including propietirships and partnerships. Report net income after business expenses.
[] Yes
- _ , _ _ _ , _ _ _ .00 (total amount for past 12 months)
[] Loss
[] No
Questionnaire instructions view entire document:  text  image
Questions 7-48 are a continuation of the questions for each person. Questions 7-48 are a continuation of the questions for each person. (Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)

Answer person questions 19 through 48 if this person is 15 years old or over.

Answer person questions 47 through 48 only if this person is 15 years old or over.

Mark the "yes" or "no" box for each type of income, and enter the amount received in the past 12 months for each "Yes" response.

If income from any source was received jointly by household members, report, if possible, the appropriate share for each person; otherwise, report the whole amount for only one person and mark the "no" box for the other person.

When reporting income received jointly, do not include the amount for a person not listed on pages 2, 3, or 4.

Do not include the following as income in any item:

  • Refunds or rebates of any kind
  • Withdrawals from savings of any kind
  • Capital gains or losses from the sale of homes, shares of stock, etc.
  • Inheritances or insurance settlements
  • Any type of loan
  • Pay in-kind such as food, free rent
47b. Include nonfarm profit (or loss) from self-employment in sole proprietorships and partnerships. Mark the "Loss" box if there is a loss. Exclude profit (or loss) of incorporated businesses the person owns.

Include farm profit (or loss) from self-employment in sole proprietorships and partnerships. Mark the "loss" box if there is a loss. Exclude profit (or loss) of incorporated farm businesses you own. Also exclude amounts from land rented for cash but include amounts from land rented for shares.