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
f. Any public assistance or welfare payments from the state or local welfare office.
[] Yes
- _ , _ _ _ , _ _ _ .00 (total amount for past 12 months)
[] 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
47f. Include any public assistance or welfare payments received by check or electronic transfer from the state or local welfare office, even if received for only one month or less than a year. Include benefits received on behalf of children. These payments are sometimes referred to as Temporary Assistance for Needy Families (TANF), Aid to Families with Dependent Children (AFDC), Aid to Dependent Children (ADC), Welfare or welfare to work, General Assistance, General Relief, Emergency Assistance, and Diversion Payments. Do not include assistance received from private charities.

Do not include Supplemental Security Income (SSI), food assistance (such as food stamps and benefits from the Nutritional Assistance Program (PAN), or the Supplemental Nutrition Assistance Program [SNAP]), rental assistance, education assistance, child care assistance, transportation assistance, or assistance with heating or cooling costs or any other energy assistance (such as Low Income Home Energy Assistance Program, or LIHEAP).