Questionnaire Text

Questionnaire form view entire document:  text  image

H12. Answer this question if you pay rent for your living quarters.

"Report the rent agreed to or contracted for, even if the furnishings, utilities, or services are included."

a. If rent is paid by the month --
What is the monthly rent?

$ (Nearest dollar) _____.00
and
Fill one circle


[] Less than $30
[] $30 to $39
[] $40 to $49
[] $50 to $59
[] $60 to $69
[] $70 to $79
[] $80 to $89
[] $90 to $99
[] $100 to $119
[] $120 to $149
[] $150 to $199
[] $200 to $249
[] $250 to $299
[] $300 or more


"If you pay rent by the month, write in the amount of rent and fill one circle."

b. If rent is not paid by the month -
What is the rent, and what period of time does it cover?

$ (Nearest dollar) _____.00 per (Week, half-month, year, etc.) _____


"If rent is not paid by the month, answer both parts of b. For example, $20 per week, $1,500 per year, etc."