Questionnaire Text

Questionnaire form view entire document:  text  image
g. Retirement, survivor, or disability pensions.
Do not include Social Security.
[] 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
47g. Include retirement, survivor or disability benefits received from companies and unions, federal, state, Puerto Rico and municipio governments, and the U.S. military. Include regular income from annuities and IRA or KEOGH retirement plans.