Questionnaire Text

Questionnaire form view entire document:  text  image
43. 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.
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
Person questions 43-44

P43. 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, 4, 5, 6, or 7.

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

f. 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:

  • Unemployment compensation
  • Supplemental Security Income (SSI)
  • Food assistance (such as food stamps and benefits from the Supplemental Nutrition Assistance Program, or SNAP)
  • Rental assistance, education assistance, child care assistance, transportation assistance, or assistance with heating or cooling costs or any other noncash benefit.