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.
c. Interest, dividends, net rental income, royalty income, or income from estates and trusts.
Report even small amounts credited to an account

[] Yes -- $_,_ _ _,_ _ _.00 (Total amount for past 12 months)
[] No
[] Loss
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

c. Include interest received or credited to checking and saving accounts, money market funds, certificates of deposit (CDs), IRAs, KEOGHs, and government bonds.

Include dividends received, credited, or reinvested from ownership of stocks or mutual funds.

Include profit (or loss) from royalties and the rental of land, buildings or real estate, or from roomers or boarders. Mark the"Loss" box if there is a loss. Income received by self-employed persons whose primary source of income is from renting property or from royalties should be included in 47b. Include regular payments from an estate or trust fund.