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.
g. Retirement income, pensions, survivor, or disability income.
Include income from a previous employer or union, or any regular withdrawals or distributions from IRA, Roth IRA, 401(k), 403(b), or other accounts specifically designed for retirement. Do not include Social Security.

[] 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

g. Include regular income from a company pension, union pension, Federal government pension, state government pension, local government pension, U.S. Railroad pension, KEOGH retirement plan, SEP (Simplified Employee Pension), U.S. military pension or any other type of pension, retirement account or annuity such as IRA, Roth IRA, 401(k) or 403(b).

Include survivor income paid to spouses or children of a deceased person. Include regular income from a disability pension paid to those who are unable to work due to a disability.

Do not include Social Security or income that is "rolled over" or reinvested in another retirement account.