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Survey form
view entire document:
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10a. How much income did -- receive in (month) before deductions form all jobs? Include any tips, bonuses, overtime pay, and commissions.

(Dollars) $____

9999999[] DK

9999999[] DK

Ask 11a and b if box 2 or 3 in 9; otherwise, go to NP.

11a. How much income did -- receive in (month) from self-employment? Report NET income, after business expenses.

Read if necessary: For farms, include any earnings as a tenant farmer or sharecropper.

1[] Already included

0[] Loss

(Dollars) $____

9999999[] DK

0[] Loss

(Dollars) $____

9999999[] DK

Ask 12d for each person with "SS/RR" in 12b.

d. How much income did -- receive in (month) from Social Security or Railroad Retirement?

1[] Already included

(Dollars) $____

9999[] DK

(Dollars) $____

9999[] DK

Ask 13d for each person with "SSI" in 13b.

d. How much income did -- receive in (month) from Supplemental Security Income or SSI?

(Dollars) $____

9999[] DK

9999[] DK

Ask 15d for each person with "Pension" marked in 15b.

d. How much income did -- receive BEFORE deductions from retirement or survivor pensions (other than (Social Security or Railroad Retirement/(or) disability pension)) in (month)?

1[] Already included

(Dollars) $____

999999[] DK

(Dollars) $____

999999[] DK

f. How much income did -- receive from public assistance or welfare in (month)?

1[] Already included

(Dollars) $____

9999[] DK

(Dollars) $____

9999[] DK

Ask 18d for each person with "Interest" marked in 18b.

d. What is your best estimate of the total amount of interest that -- earned in (month)?

1[] Already included

(Dollars) $____

99999[] DK

(Dollars) $____

99999[] DK

Ask 19d for each person with "Dividends" marked in 19b.

d. What is your best estimate of the total amount that -- received form dividends, net rental property income, royalties, estates, or trusts in (month)?

1[] Already included

0[] Loss

(Dollars) $____

99999[] DK

0[] Loss

(Dollars) $____

99999[] DK

Ask 20d for each person with "Other income" marked in 20b.

d. How much income did -- receive in (month) from all other sources?

1[] Already included

(Dollars) $____

99999[] DK

(Dollars) $____

99999[] DK

Survey form
view entire document:
text
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7a. How much income did -- receive in (month) BEFORE deductions from ALL jobs? Include any tips, bonuses, overtime pay, or commissions.

(Dollars) $____

9999999[] DK

9999999[] DK

Ask 8a and b if box 2 or 3 in 6; otherwise, go to NP.

8a. How much income did -- receive in (month) from self-employment? Report NET income, after business expenses.

Read if necessary: For farms, include any earnings as a tenant farmer or sharecropper.

1[] Already included

0[] Loss

(Dollars) $____

9999999[] DK

0[] Loss

(Dollars) $____

9999999[] DK

Ask 9d for each person with "SS/RR" in 9b.

d. How much income did -- receive in (month) from Social Security or Railroad Retirement?

1[] Already included

(Dollars) $____

9999[] DK

(Dollars) $____

9999[] DK

Ask 10d for each person with "SSI" in 10b.

d. How much income did -- receive in (month) from Supplemental Security Income or SSI?

(Dollars) $____

9999[] DK

9999[] DK

Ask 11d for each person with "Disability" marked in 11b.

d. How much did -- receive in (month) BEFORE deductions from a disability pension?

1[] Already included

(Dollars) $____

9999[] DK

(Dollars) $____

9999[] DK

Ask 12d for each person with "Pension" marked in 12b.

d. How much income did -- receive BEFORE deductions from retirement or survivor pensions (other than (Social Security or Railroad Retirement/(or) disability pension)) in (month)?

1[] Already included

(Dollars) $____

9999999[] DK

(Dollars) $____

9999999[] DK

f. How much income did -- receive from public assistance or welfare in (month)?

1[] Already included

(Dollars) $____

9999[] DK

(Dollars) $____

9999[] DK

Ask 15d for each person with "Interest" marked in 15b.

d. What is your best estimate of the total amount of interest that -- earned in (month)?

1[] Already

(Dollars) $____

99999[] DK

(Dollars) $____

99999[] DK

Ask 16d for each person with "Dividends" marked in 16b.

d. What is your best estimate of the total amount that -- received from dividends, NET rental property income, royalties, estates, or trusts in (month)?

1[] Already included

0[] Loss

(Dollars) $____

99999[] DK

0[] Loss

(Dollars) $____

99999[] DK

Ask 17d for each person with "Other income" marked in 17b.

d. How much income did -- receive in (month) from ALL OTHER sources?

1[] Already included

(Dollars) $____

99999[] DK

(Dollars) $____

99999[] DK

Survey form
view entire document:
text
image

7a. How much did -- receive in (month) before deductions from all jobs? Include any tips, bonuses, overtime pay, or commissions.

Dollars $ ____

9999999[] DK

9999999[] DK

Ask 8a and b if box 2 or 3 in 6; otherwise, go to NP.

8a. How much did -- receive in (month) from self-employment? Report NET Income, after business expenses.

Read if necessary: For farms, include any earnings as a tenant farmer or sharecropper.

1[] Already included

0[] Loss

Dollars $ ____

9999999[] DK

0[] Loss

Dollars $ ____

9999999[] DK

Ask 9d for each person with SS/RR in 9b

d. How much did -- receive in (month) from Social Security or Railroad Retirement?

1[] Already included

Dollars $ ____

9999[] DK

Dollars $ ____

9999[] DK

Ask 10d for each person with "SSI" in 10b

d. How much did -- receive in (month) from Supplemental Security Income or SSI?

Dollars $ ____

9999[] DK

9999[] DK

Ask 11d for each person with "Disability" marked in 11b.

d. How much did -- receive in (month) before deductions from a disability pension?

1[] Already included

Dollars $ ____

9999[] DK

Dollars $ ____

9999[] DK

Ask 12d for each person with "Pension" marked in 12b.

d. How much did -- receive before deductions from retirement or survivor pensions (other than (Social Security or Railroad Retirement/(or) disability pension)) in (month)?

1[] Already included

Dollars $ ____

999999[] DK

Dollars $ ____

999999[] DK

e. How much did -- receive from public assistance or welfare in (month)?

1[] Already included

Dollars $ ____

9999[] DK

Dollars $ ____

9999[] DK

d. What was the total value of the food stamp allotment received in (month)?

Dollars $ ____

9999[] DK

9999[] DK

Ask 15d for each person with "Interest" marked in 15b.

d. What is your best estimate of the total amount of interest that -- earned in (month)?

1[] Already included

Dollars $ ____

99999[] DK

Dollars $ ____

99999[] DK

Ask 16d for each person with "Dividends" marked in 16b.

d. What is your best estimate of the total amount that -- received from dividends, net rental property income, royalties, estates, or trusts in (month)?

1[] Already included

0[] Loss

Dollars $ ____

99999[] DK

0[] Loss

Dollars $ ____

99999[] DK

Ask 17d for each person with "Other income" marked in 17b.

d. How much did -- receive in (month) from all other sources?

1[] Already included

Dollars $ ____

99999[] DK

Dollars $ ____

99999[] DK