13199013 DC U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU THE American Community Survey ➜ Respond online today at: https://respond.census.gov/acs OR Complete this form and mail it back as soon as possible. Year O Please print the name and telephone number of the person who is filling out this form. We will only contact you if needed for official Census Bureau business. A TI ➜ RM Last Name FO First Name — ➜ How many people are living or staying at this address? • INCLUDE everyone who is living or staying here for more than 2 months. • INCLUDE yourself if you are living here for more than 2 months. • INCLUDE anyone else staying here who does not have another place to stay, even if they are here for 2 months or less. • DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment. Number of people ➜ Fill out pages 2, 3, and 4 for everyone, including yourself, who is living or staying at this address for more than 2 months. Then complete the rest of the form. ¿NECESITA AYUDA? Si usted habla español y necesita ayuda para completar su cuestionario, llame sin cargo alguno al 1-877-833-5625. Usted también puede completar su entrevista por teléfono con un entrevistador que habla español. O puede responder por Internet en: https://respond.census.gov/acs ACS-1(INFO)(2019) FORM (08-02-2018) §.4{.¤ MI Area Code + Number IN If you need help or have questions about completing this form, please call 1-800-354-7271. The telephone call is free. For more information about the American Community Survey, visit our website at: http://www.census.gov/acs Day N Month This form asks for information about the people who are living or staying at the address on the mailing label and about the house, apartment, or mobile home located at the address on the mailing label. Telephone Device for the Deaf (TDD): Call 1–800–582–8330. The telephone call is free. Please print today’s date. A Start Here L CO PY This booklet shows the content of the American Community Survey questionnaire. OMB No. 0607-0810 OMB No. 0607-0936 13199021 Person 1 Person 2 1 What is Person 2’s name? Last Name (Please print) (Person 1 is the person living or staying here in whose name this house or apartment is owned, being bought, or rented. If there is no such person, start with the name of any adult living or staying here.) First Name MI 2 How is this person related to Person 1? Mark (X) ONE box. What is Person 1’s name? Last Name (Please print) 2 First Name MI How is this person related to Person 1? X 3 Person 1 4 Female Same-sex husband/wife/spouse Parent-in-law Same-sex unmarried partner Son-in-law or daughter-in-law Biological son or daughter Other relative Adopted son or daughter Roommate or housemate Stepson or stepdaughter Foster child Brother or sister Other nonrelative Male CO Day Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Year of birth Age (in years) Month Day Year of birth A L Month Female 4 What is Person 2’s age and what is Person 2’s date of birth? What is Person 1’s age and what is Person 1’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age (in years) Grandchild 3 What is Person 2’s sex? Mark (X) ONE box. What is Person 1’s sex? Mark (X) ONE box. Male Father or mother Opposite-sex unmarried partner PY 1 Opposite-sex husband/wife/spouse ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 2 of Hispanic, Latino, or Spanish origin? Is Person 1 of Hispanic, Latino, or Spanish origin? TI No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano A Yes, Puerto Rican RM Yes, Cuban FO Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C What is Person 1’s race? Mark (X) one or more boxes. IN 6 White No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C 6 What is Person 2’s race? Mark (X) one or more boxes. White Black or African Am. Black or African Am. American Indian or Alaska Native — Print name of enrolled or principal tribe. C American Indian or Alaska Native — Print name of enrolled or principal tribe. C Asian Indian Japanese Native Hawaiian Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan Filipino Vietnamese Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. C Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Some other race – Print race. C 2 Question 6 about race. For this survey, Hispanic origins are not races. O 5 ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and N Question 6 about race. For this survey, Hispanic origins are not races. §.4{6¤ Some other race – Print race. C Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. C 13199039 Person 3 1 What is Person 4’s name? What is Person 3’s name? Last Name (Please print) 3 First Name MI 2 How is this person related to Person 1? Mark (X) ONE box. How is this person related to Person 1? Mark (X) ONE box. Opposite-sex husband/wife/spouse Father or mother Opposite-sex husband/wife/spouse Father or mother Opposite-sex unmarried partner Grandchild Opposite-sex unmarried partner Grandchild Same-sex husband/wife/spouse Parent-in-law Same-sex husband/wife/spouse Parent-in-law Same-sex unmarried partner Son-in-law or daughter-in-law Same-sex unmarried partner Son-in-law or daughter-in-law Biological son or daughter Other relative Biological son or daughter Other relative Adopted son or daughter Roommate or housemate Adopted son or daughter Roommate or housemate Stepson or stepdaughter Foster child Stepson or stepdaughter Foster child Brother or sister Other nonrelative Brother or sister Other nonrelative 3 What is Person 4’s sex? Mark (X) ONE box. What is Person 3’s sex? Mark (X) ONE box. Male 4 Last Name (Please print) MI Female Male Day Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Year of birth Age (in years) Month Day Year of birth A L Month Female 4 What is Person 4’s age and what is Person 4’s date of birth? What is Person 3’s age and what is Person 3’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age (in years) PY 2 First Name CO 1 Person 4 ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 4 of Hispanic, Latino, or Spanish origin? Is Person 3 of Hispanic, Latino, or Spanish origin? TI No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano A Yes, Puerto Rican RM Yes, Cuban FO Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C What is Person 3’s race? Mark (X) one or more boxes. IN 6 White Question 6 about race. For this survey, Hispanic origins are not races. O 5 ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and N Question 6 about race. For this survey, Hispanic origins are not races. No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C 6 What is Person 4’s race? Mark (X) one or more boxes. White Black or African Am. Black or African Am. American Indian or Alaska Native — Print name of enrolled or principal tribe. C American Indian or Alaska Native — Print name of enrolled or principal tribe. C Asian Indian Japanese Native Hawaiian Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan Filipino Vietnamese Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. C Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Some other race – Print race. C §.4{H¤ Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. C Some other race – Print race. C 3 13199047 Person 5 1 ➜ If there are more than five people living or staying here, print their names in the spaces for Person 6 through Person 12. We may call you for more information about them. What is Person 5’s name? Last Name (Please print) First Name MI Person 6 Last Name (Please print) 2 First Name MI How is this person related to Person 1? Mark (X) ONE box. Father or mother Opposite-sex unmarried partner Grandchild Same-sex husband/wife/spouse Parent-in-law Same-sex unmarried partner Son-in-law or daughter-in-law Biological son or daughter Other relative Adopted son or daughter Roommate or housemate Stepson or stepdaughter Foster child Brother or sister Other nonrelative Sex Last Name (Please print) Sex Female Day CO Month Year of birth A Sex First Name A Yes, Puerto Rican RM Yes, Cuban FO Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C Age (in years) Last Name (Please print) First Name MI Sex Male Female Age (in years) Person 10 Last Name (Please print) First Name MI IN What is Person 5’s race? Mark (X) one or more boxes. White Sex Black or African Am. American Indian or Alaska Native — Print name of enrolled or principal tribe. C Male Female Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. C Age (in years) Person 11 Last Name (Please print) Sex Male First Name Female Person 12 Last Name (Please print) Sex §.4{P¤ MI Age (in years) First Name Some other race – Print race. C 4 MI Person 9 O Yes, Mexican, Mexican Am., Chicano 6 Female Age (in years) TI No, not of Hispanic, Latino, or Spanish origin Male MI N Question 6 about race. For this survey, Hispanic origins are not races. Is Person 5 of Hispanic, Latino, or Spanish origin? Female Last Name (Please print) ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Male Person 8 What is Person 5’s age and what is Person 5’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age (in years) Age (in years) First Name PY 4 Female Person 7 What is Person 5’s sex? Mark (X) ONE box. Male Male L 3 Opposite-sex husband/wife/spouse Male Female Age (in years) MI 13199054 Housing ➜ A Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label. 7 Does this house, apartment, or mobile Answer questions 4 – 5 if this is a HOUSE OR A MOBILE HOME; otherwise, SKIP to question 6a. home have – b. a bathtub or shower? 4 How many acres is this house or Which best describes this building? Include all apartments, flats, etc., even if vacant. c. a sink with a faucet? Less than 1 acre ➔ SKIP to question 6a 8 Can you or any member of this household 10 or more acres A one-family house detached from any other house A one-family house attached to one or more houses A building with 2 apartments both make and receive phone calls when at this house, apartment, or mobile home? Include calls using cell phones, land lines, or other phone devices. 5 IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property? None A building with 5 to 9 apartments $1 to $999 A building with 10 to 19 apartments $1,000 to $2,499 A building with 20 to 49 apartments $2,500 to $4,999 A building with 50 or more apartments $5,000 to $9,999 Boat, RV, van, etc. $10,000 or more Yes No PY A building with 3 or 4 apartments N A L CO 9 At this house, apartment, or mobile home – O About when was this building first built? TI house, apartment, or mobile home? Rooms must be separated by built-in archways or walls that extend out at least 6 inches and go from floor to ceiling. A RM • INCLUDE bedrooms, kitchens, etc. • EXCLUDE bathrooms, porches, balconies, foyers, halls, or unfinished basements. 1990 to 1999 FO 1960 to 1969 1950 to 1959 IN 1970 to 1979 1940 to 1949 1939 or earlier 3 When did PERSON 1 (listed on page 2) move into this house, apartment, or mobile home? Month Year do you or any member of this household own or use any of the following types of computers? Yes No a. Desktop or laptop b. Smartphone c. Tablet or other portable wireless computer d. Some other type of computer Specify 6 a. How many separate rooms are in this 2000 or later – Specify year 1980 to 1989 d. a stove or range? e. a refrigerator? 1 to 9.9 acres A mobile home 2 No a. hot and cold running water? mobile home on? 1 Yes Number of rooms 10 At this house, apartment, or mobile home – do you or any member of this household have access to the Internet? Yes, by paying a cell phone company or Internet service provider Yes, without paying a cell phone company or Internet service provider ➔ SKIP to question 12 No access to the Internet at this house, apartment, or mobile home ➔ SKIP to question 12 b. How many of these rooms are bedrooms? Count as bedrooms those rooms you would 11 Do you or any member of this household list if this house, apartment, or mobile home have access to the Internet using a – were for sale or rent. If this is an Yes No efficiency/studio apartment, print "0". a. cellular data plan for a smartphone or other mobile Number of bedrooms device? b. broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed in this household? c. satellite Internet service installed in this household? d. dial-up Internet service installed in this household? e. some other service? Specify service §.4{W¤ 5 13199062 Housing (continued) 14 a. LAST MONTH, what was the cost 15 IN THE PAST 12 MONTHS, did you or of electricity for this house, apartment, or mobile home? 12 How many automobiles, vans, and trucks any member of this household receive benefits from the Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks. Last month’s cost – Dollars of one-ton capacity or less are kept at home for use by members of this household? $ .00 , None OR 1 Yes No Included in rent or condominium fee 2 No charge or electricity not used 16 Is this house, apartment, or mobile home 3 part of a condominium? b. LAST MONTH, what was the cost of gas for this house, apartment, or mobile home? 4 5 Last month’s cost – Dollars 6 or more .00 , OR 13 Which FUEL is used MOST for heating this house, apartment, or mobile home? Gas: from underground pipes serving the neighborhood Gas: bottled, tank, or LP N O Coal or coke TI Wood $ , RM Other fuel A Past 12 months’ cost – Dollars Solar energy .00 OR No fuel used IN FO Included in rent or condominium fee No charge d. IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost. Past 12 months’ cost – Dollars $ .00 , OR Included in rent or condominium fee No charge or these fuels not used .00 , OR L A c. IN THE PAST 12 MONTHS, what was the cost of water and sewer for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost. Fuel oil, kerosene, etc. §.4{_¤ $ Included in electricity payment entered above No charge or gas not used Electricity 6 Monthly amount – Dollars CO Included in rent or condominium fee PY $ Yes ➔ What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box. None No 17 Is this house, apartment, or mobile home – Mark (X) ONE box. Owned by you or someone in this household with a mortgage or loan? Include home equity loans. Owned by you or someone in this household free and clear (without a mortgage or loan)? Rented? Occupied without payment of rent? ➔ SKIP to C on the next page 13199070 Housing (continued) B 22 a. Do you or any member of this 23 a. Do you or any member of this household have a second mortgage or a home equity loan on THIS property? household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property? Answer questions 18a and b if this house, apartment, or mobile home is RENTED. Otherwise, SKIP to question 19. 18 a. What is the monthly rent for this house, apartment, or mobile home? Yes, mortgage, deed of trust, or similar debt Yes, contract to purchase Yes, home equity loan No ➔ SKIP to question 23a Yes, second mortgage and home equity loan No ➔ SKIP to D Yes, second mortgage Monthly amount – Dollars b. How much is the regular monthly mortgage payment on THIS property? Include payment only on FIRST mortgage or contract to purchase. .00 , b. Does the monthly rent include any meals? Monthly amount – Dollars $ Yes , No Monthly amount – Dollars .00 OR No regular payment required ➔ SKIP to question 23a CO Answer questions 19 – 23 if you or any member of this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to E . c. Does the regular monthly mortgage payment include payments for real estate taxes on THIS property? A L C , .00 OR None Answer question 24 if this is a MOBILE HOME. Otherwise, SKIP to E . personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site? Exclude real estate taxes. A FO IN Annual amount – Dollars OR 24 What are the total annual costs for RM .00 20 What are the annual real estate taxes on $ D d. Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property? THIS property? .00 N TI Amount – Dollars , , O house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale? , $ No regular payment required Yes, taxes included in mortgage payment No, taxes paid separately or taxes not required 19 About how much do you think this $ b. How much is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property? PY $ Annual costs – Dollars Yes, insurance included in mortgage payment No, insurance paid separately or no insurance $ E , .00 Answer questions about PERSON 1 on the next page if you listed at least one person on page 2. Otherwise, SKIP to page 28 for the mailing instructions. 21 What is the annual payment for fire, hazard, and flood insurance on THIS property? Annual amount – Dollars $ .00 , OR None §.4{g¤ 7 13199088 Person 1 11 What is the highest degree or level of school this person has COMPLETED? Mark (X) ONE box. ➜ If currently enrolled, mark the previous grade or highest degree received. Please copy the name of Person 1 from page 2, then continue answering questions below. Last Name NO SCHOOLING COMPLETED No schooling completed First Name NURSERY OR PRESCHOOL THROUGH GRADE 12 MI Nursery school Where was this person born? (For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.) 14 a. Does this person speak a language other than Kindergarten 7 13 What is this person’s ancestry or ethnic origin? English at home? Grade 1 through 11 – Specify grade 1 – 11 In the United States – Print name of state. Yes No ➔ SKIP to question 15a b. What is this language? Outside the United States – Print name of foreign country, or Puerto Rico, Guam, etc. 12th grade – NO DIPLOMA HIGH SCHOOL GRADUATE PY For example: Korean, Italian, Spanish, Vietnamese Regular high school diploma Is this person a citizen of the United States? Yes, born in the United States ➔ SKIP to question 10a c. How well does this person speak English? GED or alternative credential CO 8 COLLEGE OR SOME COLLEGE Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas Some college credit, but less than 1 year of college credit 1 or more years of college credit, no degree Yes, U.S. citizen by naturalization – Print year of naturalization Associate’s degree (for example: AA, AS) N A L Yes, born abroad of U.S. citizen parent or parents Bachelor’s degree (for example: BA, BS) O AFTER BACHELOR’S DEGREE No, not a U.S. citizen TI When did this person come to live in the United States? If this person came to live in the A 9 Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) United States more than once, print latest year. Year 10 a. At any time IN THE LAST 3 MONTHS, has this person attended school or college? FO RM Doctorate degree (for example: PhD, EdD) F No, has not attended in the last 3 months ➔ SKIP to question 11 IN Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree. Yes, public school, public college Well Not well Not at all 15 a. Did this person live in this house or apartment 1 year ago? Person is under 1 year old ➔ SKIP to question 16 Yes, this house ➔ SKIP to question 16 No, outside the United States and Puerto Rico – Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then SKIP to question 16 No, different house in the United States or Puerto Rico b. Where did this person live 1 year ago? Address (Number and street name) 12 This question focuses on this person’s Yes, private school, private college, home school b. What grade or level was this person attending? Mark (X) ONE box. Answer question 12 if this person has a bachelor’s degree or higher. Otherwise, SKIP to question 13. Very well BACHELOR’S DEGREE. Please print below the specific major(s) of any BACHELOR’S DEGREES this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology) Name of city, town, or post office Nursery school, preschool Kindergarten Grade 1 through 12 – Specify grade 1 – 12 College undergraduate years (freshman to senior) Graduate or professional school beyond a bachelor’s degree (for example: MA or PhD program, or medical or law school) 8 §.4{y¤ Name of U.S. county or municipio in Puerto Rico Name of U.S. state or Puerto Rico ZIP Code 13199096 Person 1 (continued) H 16 Is this person CURRENTLY covered by any of the J Answer questions 19a – c if this person is 5 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12. following types of health insurance or health coverage plans? Mark "Yes" or "No" for EACH type 19 a. Because of a physical, mental, or emotional of coverage in items a – h. condition, does this person have serious Yes No difficulty concentrating, remembering, or a. Insurance through a current or former employer or union (of this making decisions? person or another family member) Yes b. Insurance purchased directly from an insurance company (by this No person or another family member) b. Does this person have serious difficulty c. Medicare, for people 65 and older, walking or climbing stairs? or people with certain disabilities d. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability Yes No 26 a. Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment? Yes No ➔ SKIP to question 27 No h. Any other type of health insurance or health coverage plan – Specify Answer question 20 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12. A L I CO g. Indian Health Service 20 Because of a physical, mental, or emotional O N condition, does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping? Answer question 17a if this person is covered by health insurance. Otherwise, SKIP to question 18a. 17 a. Is there a premium for this plan? A premium Widowed IN No ➔ SKIP to question 18a b. Does this person or another family member receive a tax credit or subsidy based on family income to help pay the premium? Yes No 18 a. Is this person deaf or does he/she have serious difficulty hearing? Yes If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time. Less than 6 months 6 to 11 months 27 Has this person ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard? Mark (X) ONE box. Now married FO Yes c. How long has this grandparent been responsible for these grandchildren? 5 or more years 21 What is this person’s marital status? RM is a fixed amount of money paid on a regular basis for health coverage. It does not include copays, deductibles, or other expenses such as prescription costs. No ➔ SKIP to question 27 3 or 4 years A No Yes 1 or 2 years TI Yes b. Is this grandparent currently responsible for most of the basic needs of any grandchildren under the age of 18 who live in this house or apartment? PY c. Does this person have difficulty dressing or bathing? Yes Never served in the military ➔ SKIP to question 30a Divorced Separated Never married ➔ SKIP to J Only on active duty for training in the Reserves or National Guard ➔ SKIP to question 29a Now on active duty 22 In the PAST 12 MONTHS, did this person get – Yes No a. Married? b. Widowed? c. Divorced? 23 How many times has this person been married? No b. Is this person blind or does he/she have serious difficulty seeing even when wearing glasses? No given birth to any children? No f. VA (enrolled for VA health care) Yes 25 In the PAST 12 MONTHS, has this person Yes e. TRICARE or other military health care G Answer question 25 if this person is female and 15 – 50 years old. Otherwise, SKIP to question 26a. 28 When did this person serve on active duty in the U.S. Armed Forces? Mark (X) a box for EACH period in which this person served, even if just for part of the period. September 2001 or later August 1990 to August 2001 (including Persian Gulf War) Once May 1975 to July 1990 Two times Vietnam era (August 1964 to April 1975) Three or more times February 1955 to July 1964 24 In what year did this person last get married? Year On active duty in the past, but not now Korean War (July 1950 to January 1955) January 1947 to June 1950 World War II (December 1941 to December 1946) November 1941 or earlier §.4{£¤ 9 13199104 Person 1 (continued) 32 How did this person usually get to work LAST transportation used for most of the distance. 29 a. Does this person have a VA service-connected disability rating? Yes (such as 0%, 10%, 20%, ... , 100%) No ➔ SKIP to question 30a b. What is this person’s service-connected disability rating? 0 percent 10 or 20 percent 30 or 40 percent 36 c. Has this person been informed that he or she will be recalled to work within the next 6 months OR been given a date to return to work? WEEK? Mark (X) ONE box for the method of Car, truck, or van Taxicab Bus Motorcycle Subway or elevated rail Bicycle Long-distance train or commuter rail Walked Light rail, streetcar, or trolley Worked from home ➔ SKIP to question 40a Ferryboat Other method Yes ➔ SKIP to question 38 No 37 During the LAST 4 WEEKS, has this person been ACTIVELY looking for work? Yes No ➔ SKIP to question 39 38 LAST WEEK, could this person have started a 50 or 60 percent 30 a. LAST WEEK, did this person work for pay at a job (or business)? Yes ➔ SKIP to question 31 Yes, could have gone to work CO 33 How many people, including this person, job if offered one, or returned to work if recalled? PY K 70 percent or higher Answer question 33 if you marked "Car, truck, or van" in question 32. Otherwise, SKIP to question 34. usually rode to work in the car, truck, or van LAST WEEK? No – Did not work (or retired) b. LAST WEEK, did this person do ANY work for pay, even for as little as one hour? A L Person(s) N Yes No ➔ SKIP to question 36a O 34 LAST WEEK, what time did this person’s trip to 31 At what location did this person work LAST WEEK? If this person worked at more than one location, print where he or she worked most last week. Hour TI work usually begin? A : a.m. RM p.m. 35 How many minutes did it usually take this person to get from home to work LAST WEEK? FO Minutes IN b. Name of city, town, or post office c. Is the work location inside the limits of that city or town? L No, because of all other reasons (in school, etc.) 39 When did this person last work, even for a few days? Within the past 12 months 1 to 5 years ago ➔ SKIP to M Over 5 years ago or never worked ➔ SKIP to question 43 Minute a. Address (Number and street name) If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection. No, because of own temporary illness 40 a. During the PAST 12 MONTHS (52 weeks), did this person work EVERY week? Count paid vacation, paid sick leave, and military service as work. Yes ➔ SKIP to question 41 No b. During the PAST 12 MONTHS (52 weeks), how many WEEKS did this person work? Include paid time off and include weeks when the person only worked for a few hours. Answer questions 36 – 39 if this person did NOT work last week. Otherwise, SKIP to question 40a. Weeks Yes No, outside the city/town limits d. Name of county e. Name of U.S. state or foreign country f. ZIP Code 36 a. LAST WEEK, was this person on layoff from a job? Yes ➔ SKIP to question 36c WORKED, how many hours did this person usually work each WEEK? No Usual hours worked each WEEK b. LAST WEEK, was this person TEMPORARILY absent from a job or business? Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. ➔ SKIP to question 39 No ➔ SKIP to question 37 10 §.4 %¤ 41 During the PAST 12 MONTHS, in the WEEKS 13199112 Person 1 (continued) M e. What was this person’s main occupation? (For example: 4th grade teacher, entry-level plumber) d. Social Security or Railroad Retirement. Yes ➔ Answer questions 42a – f if this person worked in the past 5 years. Otherwise, SKIP to question 43. No f. Describe this person’s most important activities or duties. (For example: instruct and evaluate students and create lesson plans, assemble and install pipe sections and review building plans for work details) 42 DESCRIPTION OF EMPLOYMENT The next series of questions is about the type of employment this person had last week. Yes ➔ No PY Yes ➔ CO L A N O No TI , , No Yes ➔ .00 , TOTAL AMOUNT for past 12 months $ .00 , TOTAL AMOUNT for past 12 months $ .00 , TOTAL AMOUNT for past 12 months h. Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support or alimony. Do NOT include lump sum payments such as money from an inheritance or the sale of a home. A RM FO b. What was the name of this person’s employer, business, agency, or branch of the Armed Forces? $ No $ 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. a. Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items. Yes ➔ TOTAL AMOUNT for past 12 months f. Any public assistance or welfare payments from the state or local welfare office. a. Which one of the following best describes this person’s employment last week or the most recent employment in the past 5 years? 43 INCOME IN THE PAST 12 MONTHS Mark (X) ONE box. Mark (X) the "Yes" box for each type of income this PRIVATE SECTOR EMPLOYEE person received, and give your best estimate of the TOTAL AMOUNT during the PAST 12 MONTHS. For-profit company or organization (NOTE: The "past 12 months" is the period from today’s date one year ago up through today.) Non-profit organization (including tax-exempt and charitable organizations) Mark (X) the "No" box to show types of income GOVERNMENT EMPLOYEE NOT received. Local government (for example: city or If net income was a loss, mark the "Loss" box to county school district) the right of the dollar amount. State government (including state colleges/universities) For income received jointly, report the appropriate Active duty U.S. Armed Forces or share for each person – or, if that’s not possible, Commissioned Corps report the whole amount for only one person and mark the "No" box for the other person. Federal government civilian employee Owner of non-incorporated business, professional practice, or farm Owner of incorporated business, professional practice, or farm Worked without pay in a for-profit family business or farm for 15 hours or more per week .00 , e. Supplemental Security Income (SSI). If this person had more than one job, describe the one at which the most hours were worked. If this person did not work last week, describe the most recent employment in the past five years. SELF-EMPLOYED OR OTHER $ .00 TOTAL AMOUNT for past 12 months Yes ➔ $ .00 , No d. Was this mainly – Mark (X) ONE box. c. Interest, dividends, net rental income, royalty income, or income from estates and trusts. Report even small amounts credited to an account. IN c. What kind of business or industry was this? Include the main activity, product, or service provided at the location where employed. (For example: elementary school, residential construction) TOTAL AMOUNT for past b. Self-employment income from own nonfarm 12 months businesses or farm businesses, including proprietorships and partnerships. Report 44 What was this person’s total income during the NET income after business expenses. PAST 12 MONTHS? Add entries in questions 43a to 43h; subtract any losses. If net income was a loss, Yes ➔ $ enter the amount and mark (X) the "Loss" box next to .00 , , the dollar amount. No Loss TOTAL AMOUNT for past 12 months OR $ .00 manufacturing? wholesale trade? retail trade? other (agriculture, construction, service, government, etc.)? §.4 -¤ , Yes ➔ No $ , , None , TOTAL AMOUNT for past 12 months Loss .00 TOTAL AMOUNT for past 12 months Loss ➜ Continue with the questions for Person 2 on the next page. If no one is listed as Person 2 on page 2, SKIP to page 28 for mailing instructions. 11 13199120 Person 2 IN FO RM A TI O N A L CO PY The balance of the questionnaire has questions for Person 2, Person 3, Person 4, and Person 5. The questions are the same as the questions for Person 1. 12 §.4 5¤ 13199278 27 13199286 Mailing Instructions ➜ Please make sure you have... • listed all names and answered the questions on pages 2, 3, and 4 • answered all Housing questions PY • answered all Person questions for each person. L N A • put the completed questionnaire into the postage-paid return envelope. If the envelope has been misplaced, please mail the questionnaire to: U.S. Census Bureau P.O. Box 5240 Jeffersonville, IN 47199-5240 CO ➜ Then... IN FO RM Thank you for participating in the American Community Survey. A TI O • make sure the barcode above your address shows in the window of the return envelope. For Census Bureau Use POP EDIT EDIT CLERK PHONE TELEPHONE CLERK JIC1 JIC2 JIC3 JIC4 The Census Bureau estimates that, for the average household, this form will take 40 minutes to complete, including the time for reviewing the instructions and answers. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 0607-0810 and 0607-0936, U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138, Washington, D.C. 20233. You may e-mail comments to AMSD.Paperwork@census.gov; use "Paperwork Project 0607-0810 and 0607-0936" as the subject. Please DO NOT RETURN your questionnaire to this address. Use the enclosed preaddressed envelope to return your completed questionnaire. Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget. This 8-digit number appears in the bottom right on the front cover of this form. Form ACS-1(INFO)(2019) (08-02-2018) 28 §.4}w¤