DC

U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration
U.S. CENSUS BUREAU

THE American Community Survey

This booklet shows the

content of the
American Community Survey
questionnaire.

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People are our most important resource.

This Census Bureau survey collects Start Here
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information about education,

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This form asks for three types of information:

employment, income, and housing— • basic information about the people who are living or staying at
the address on the mailing label above
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information your community uses to • specific information about this house, apartment, or mobile
home
plan and fund programs. Your • more detailed information about each person living or staying
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here
response is important, and we
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➜ What is your name? Please PRINT the name of the person who
is filling out this form. Include the telephone number so we can
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keep your answers confidential. contact you if there is a question, and today’s date.
Last Name
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First Name MI
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
Area Code + Number
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español Date (Month/Day/Year)
y necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1–877–833–5625.
For more information about the American ➜ How many people are living or staying at this address?
Community Survey, visit our web site at: Number of people
http://www.census.gov/acs/www/

➜ Please turn to the next page to continue.

USCENSUSBUREAU
FORM ACS-1(INFO)(2005) OMB No. 0607-0810
(5-20-2004)

ACS-1(INFO)(2005), Page 1, GREEN Pantone 354 (20% and 100%)

ACS-1(INFO)(2005), Page 1, Base (Black)
 List of Residents 1 What
is this
person’s
2 What is this person’s
age and what is this
person’s date of birth?
3 How is this person related
to Person 1?
sex? Print numbers in boxes.

READ THESE Person 1

INSTRUCTIONS
FIRST Last Name (Please print) Age (in years) X Person 1
Male (Person 1 is the person living or staying
here in whose name this house or
Please fill out this form Female apartment is owned, being bought, or
as soon as possible after First Name MI rented. If there is no such person, start
Month Day Year of birth
receiving it in the mail. with the name of any adult living or
staying here.)
• LIST everyone who is
living or staying here for
more than 2 months. Relationship of Person 2 to Person 1.
Person 2
• LIST anyone else staying
Age (in years) Husband or wife Roomer, boarder

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here who does not have Last Name (Please print)
another usual place to Son or daughter Housemate,
stay. Male roommate
Brother or sister
• DO NOT LIST anyone who Female O Father or mother Unmarried partner
First Name MI Month Day Year of birth
is living somewhere else Grandchild Foster child
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for more than 2 months, Other nonrelative
such as a college student In-law
living away. Other relative
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Person 3 Relationship of Person 3 to Person 1.

Age (in years) Husband or wife Roomer, boarder

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If this place is a Last Name (Please print)

vacation home or a Son or daughter Housemate,
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temporary residence Male Brother or sister roommate

where no one in this Unmarried partner
Female Father or mother
household stays for more First Name MI
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Month Day Year of birth Foster child

than 2 months, do not Grandchild
list any names in the List In-law Other nonrelative
of Residents. Complete
only pages 4, 5, and 6 Other relative
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and return the form.

Person 4 Relationship of Person 4 to Person 1.
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IF YOU ARE NOT SURE Age (in years) Husband or wife Roomer, boarder
Last Name (Please print)
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WHOM TO LIST, CALL Son or daughter Housemate,

1–800–354–7271. Male Brother or sister roommate
Father or mother Unmarried partner
Female
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First Name MI Month Day Year of birth Foster child

Grandchild
In-law Other nonrelative
Other relative

Person 5 Relationship of Person 5 to Person 1.

Last Name (Please print) Age (in years) Husband or wife Roomer, boarder
Son or daughter Housemate,
Male roommate
Brother or sister
Female Father or mother Unmarried partner
First Name MI Month Day Year of birth
Grandchild Foster child
In-law Other nonrelative
Other relative
➜ If there are more than
five people, list them
here. We may call you Person 6 Person 7 Person 8
for more information
about them. Last Name (Please print) Last Name (Please print) Last Name (Please print)

➜ After you’ve created

the List of Residents,
answer the questions First Name MI First Name MI First Name MI
across the top of the
page for the first five
people on the list.

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ACS-1(INFO)(2005), Page 2, Base (Black) ACS-1(INFO)(2005), Page 2, GREEN Pantone 354 (10%, 20% and 100%)
4 What is this NOTE: Please answer BOTH Questions 5 and 6.
person’s
marital 5 Is this person Spanish/ 6 What is this person’s race? Mark (X) one or more races to indicate what this
status? Hispanic/Latino? person considers himself/herself to be.
Mark (X) the "No" box if
not Spanish/Hispanic/Latino.

Now married No, not Spanish/Hispanic/Latino White Asian Indian Native Hawaiian
Widowed Yes, Mexican, Mexican Am., Black or African American Chinese Guamanian or Chamorro
Divorced Chicano American Indian or Alaska Filipino Samoan
Yes, Puerto Rican Native – Print name of enrolled Japanese Other Pacific Islander – Print race below.
Separated or principal tribe.
Never married Yes, Cuban Korean Some other race – Print race below.
Yes, other Spanish/Hispanic/ Vietnamese
Latino — Print group.
Other Asian –
Print race.

Now married No, not Spanish/Hispanic/Latino White Asian Indian Native Hawaiian
Widowed Yes, Mexican, Mexican Am., Black or African American Chinese Guamanian or Chamorro
Chicano

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Divorced American Indian or Alaska Filipino Samoan
Yes, Puerto Rican Native – Print name of enrolled Japanese Other Pacific Islander – Print race below.
Separated or principal tribe.
Never married Yes, Cuban O Korean Some other race – Print race below.
Yes, other Spanish/Hispanic/ Vietnamese
Latino — Print group.
Other Asian –
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Print race.
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Now married No, not Spanish/Hispanic/Latino White Asian Indian Native Hawaiian
Widowed Yes, Mexican, Mexican Am., Black or African American Chinese Guamanian or Chamorro
Chicano
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Divorced American Indian or Alaska Filipino Samoan

Yes, Puerto Rican Native – Print name of enrolled Japanese Other Pacific Islander – Print race below.
Separated
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or principal tribe.
Never married Yes, Cuban Korean Some other race – Print race below.
Yes, other Spanish/Hispanic/ Vietnamese
Latino — Print group.
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Other Asian –
Print race.
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Now married No, not Spanish/Hispanic/Latino White Asian Indian Native Hawaiian
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Widowed Yes, Mexican, Mexican Am., Black or African American Chinese Guamanian or Chamorro
Divorced Chicano American Indian or Alaska Filipino Samoan
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Yes, Puerto Rican Native – Print name of enrolled Japanese Other Pacific Islander – Print race below.
Separated or principal tribe.
Never married Yes, Cuban Korean Some other race – Print race below.
Yes, other Spanish/Hispanic/ Vietnamese
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Latino — Print group.

Other Asian –
Print race.

Now married No, not Spanish/Hispanic/Latino White Asian Indian Native Hawaiian
Widowed Yes, Mexican, Mexican Am., Black or African American Chinese Guamanian or Chamorro
Divorced Chicano American Indian or Alaska Filipino Samoan
Yes, Puerto Rican Native – Print name of enrolled Japanese Other Pacific Islander – Print race below.
Separated or principal tribe.
Never married Yes, Cuban Korean Some other race – Print race below.
Yes, other Spanish/Hispanic/ Vietnamese
Latino — Print group.
Other Asian –
Print race.

Person 9 Person 10 Person 11 Person 12

Last Name (Please print) Last Name (Please print) Last Name (Please print) Last Name (Please print)

First Name MI First Name MI First Name MI First Name MI

➜ When you are finished, turn the page and continue with the Housing section. 3
ACS-1(INFO)(2005), Page 3, Base (Black) ACS-1(INFO)(2005), Page 3, Tone, 20% (Pantone 354)

Housing
➜ Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
Housing information helps your community
plan for police and fire protection.
8 How many bedrooms are in this house,
A Answer questions 4–6 ONLY if this is a
apartment, or mobile home; that is, how
one-family house or a mobile home;
many bedrooms would you list if this
otherwise, SKIP to question 7.
house, apartment, or mobile home were
on the market for sale or rent?
No bedroom

4 How many acres is this house or 1 bedroom

1 Which best describes this building?
Include all apartments, flats, etc., even if mobile home on? 2 bedrooms
vacant. Less than 1 acre → SKIP to question 6 3 bedrooms
A mobile home 1 to 9.9 acres

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4 bedrooms
A one-family house detached from any 10 or more acres
other house 5 or more bedrooms
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A one-family house attached to one or
more houses 9 Does this house, apartment, or mobile
5 IN THE PAST 12 MONTHS, what were
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A building with 2 apartments the actual sales of all agricultural home have COMPLETE plumbing facilities;
A building with 3 or 4 apartments products from this property? that is, 1) hot and cold piped water, 2) a
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flush toilet, and 3) a bathtub or shower?

A building with 5 to 9 apartments None
A building with 10 to 19 apartments Yes, has all three facilities
$1 to $999
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A building with 20 to 49 apartments No

$1,000 to $2,499
A building with 50 or more apartments
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$2,500 to $4,999
Boat, RV, van, etc. $5,000 to $9,999
10 Does this house, apartment, or mobile
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$10,000 or more home have COMPLETE kitchen facilities;

that is, 1) a sink with piped water, 2) a
2 About when was this building first built? stove or range, and 3) a refrigerator?
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2005 or later 6 Is there a business (such as a store or Yes, has all three facilities
barber shop) or a medical office on
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2000 to 2004 No
this property?
1990 to 1999
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Yes
1980 to 1989
No 11 Is there telephone service available in this
1970 to 1979
house, apartment, or mobile home from
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1960 to 1969 which you can both make and receive

1950 to 1959 7 calls?
How many rooms are in this house,
1940 to 1949 apartment, or mobile home? Do NOT count Yes
1939 or earlier bathrooms, porches, balconies, foyers, halls, or No
half-rooms.
1 room
3 When did PERSON 1 (listed in the List 2 rooms 12 How many automobiles, vans, and trucks
of Residents on page 2) move into this of one-ton capacity or less are kept at
3 rooms
house, apartment, or mobile home? home for use by members of this
4 rooms
Month Year household?
5 rooms
None
6 rooms
1
7 rooms
2
8 rooms
3
9 or more rooms
4
5
6 or more

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ACS-1(INFO)(2005), Page 4, Base (Black) ACS-1(INFO)(2005), Page 4, GREEN Pantone 354 (10%, 20%, and 100%)
 Housing (continued)

13 Which FUEL is used MOST for heating this d. IN THE PAST 12 MONTHS, what was the
house, apartment, or mobile home? cost of oil, coal, kerosene, wood, etc., B Answer questions 18a and b ONLY IF you
for this house, apartment, or mobile PAY RENT for this house, apartment,
Gas: from underground pipes serving the
neighborhood home? If you have lived here less than 12 or mobile home. Otherwise, SKIP to
months, estimate the cost. question 19.
Gas: bottled, tank, or LP
Electricity Past 12 months’ cost – Dollars
Fuel oil, kerosene, etc. $ .00 18 a. What is the monthly rent for this
Coal or coke house, apartment, or mobile home?
Wood OR
Monthly amount – Dollars
Solar energy Included in rent or condominium fee
Other fuel No charge or these fuels not used $ .00
No fuel used
b. Does the monthly rent include any
15 At any time DURING THE PAST meals?
12 MONTHS, did anyone in this Yes
14 a. LAST MONTH, what was the cost of household receive Food Stamps?
electricity for this house, No
apartment, or mobile home? Yes → What was the value of the
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Food Stamps received
Last month’s cost – Dollars during the past 12 months?
C Answer questions 19–23 ONLY IF you or
$ .00 Past 12 months’ value – Dollars someone else in this household OWNS or
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IS BUYING this house, apartment, or

OR
$ .00 mobile home. Otherwise, SKIP to E on
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No the next page.

Included in rent or condominium fee
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No charge or electricity not used

16 Is this house, apartment, or mobile home 19 What is the value of this property; that
b. LAST MONTH, what was the cost of
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part of a condominium? is, how much do you think this house

gas for this house, apartment, or and lot, apartment, or mobile home and
Yes → What is the monthly condominium
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mobile home? lot, would sell for if it were for sale?

fee? For renters, answer only if you
Last month’s cost – Dollars pay the condominium fee in addition Less than $10,000
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$ .00 to your rent; otherwise, mark the $10,000 to $14,999

"None" box. $15,000 to $19,999
OR
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Monthly amount – Dollars $20,000 to $24,999

Included in rent or condominium fee $ .00 $25,000 to $29,999
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Included in electricity payment $30,000 to $34,999

entered above
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OR $35,000 to $39,999
No charge or gas not used None $40,000 to $49,999
No $50,000 to $59,999
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c. IN THE PAST 12 MONTHS, what was the

$60,000 to $69,999
cost of water and sewer for this
house, apartment, or mobile home? If $70,000 to $79,999
you have lived here less than 12 months, 17 Is this house, apartment, or mobile $80,000 to $89,999
estimate the cost. home –
$90,000 to $99,999
Owned by you or someone in this
Past 12 months’ cost – Dollars household with a mortgage or $100,000 to $124,999
loan? $125,000 to $149,999
$ .00
Owned by you or someone in this $150,000 to $174,999
OR household free and clear (without a $175,000 to $199,999
mortgage or loan)?
Included in rent or condominium fee $200,000 to $249,999
Rented for cash rent?
No charge $250,000 or more – Specify
Occupied without payment of cash
rent? → SKIP to C $ .00

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ACS-1(INFO)(2005), Page 5, Base (Black) ACS-1(INFO)(2005), Page 5, GREEN Pantone 354 (10%, 20%, and 100%)
 Housing (continued)
20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$ .00
OR
None
21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$ .00
OR
None
22 a. Do you or any member of this
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
No → SKIP to question 23a
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
Monthly amount – Dollars
$ .00
OR
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No regular payment required → SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes not
required
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ACS-1(INFO)(2005), Page 6, Base (Black)
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS E Answer questions 25a–c ONLY IF you
listed at least one person on page 2.
property?
Otherwise, SKIP to page 24 for the
Yes, insurance included in mortgage mailing instructions.
payment
No, insurance paid separately or no
insurance
25 a. Do you or any member of this
23 a. Do you or any member of this household live or stay at this address
household have a second mortgage year round?
or a home equity loan on THIS
property? Yes → SKIP to the questions for Person 1
on the next page
Yes, home equity loan
No
Yes, second mortgage
Yes, second mortgage and home
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equity loan
b. How many months a year do members
No → SKIP to D
of this household stay at this address?
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Months
C
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
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on THIS property?
Monthly amount – Dollars c. What is the main reason members of this
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household are staying at this address?
$ .00
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This is their permanent address
OR This is their seasonal or vacation address
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No regular payment required To be close to work
To attend school or college
Looking for permanent housing
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Other reason(s)– Specify
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D
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Answer question 24 ONLY IF this is a
MOBILE HOME. Otherwise, SKIP to E .
➜ Continue with the questions about
PERSON 1 on the next page.
24 What are the total annual costs for
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
Annual costs – Dollars
$ .00
ACS-1(INFO)(2005), Page 6, GREEN Pantone 354 (10%, 20%, and 100%)

Person 1
➜ Please copy the name of Person 1 from the
List of Residents on page 2, then continue
answering questions below.
Last Name
First Name MI
7 Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of foreign
country, or Puerto Rico, Guam, etc.
8 Is this person a CITIZEN of the United States?
Yes, born in the United States → Skip to 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of American parent or parents
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
9 When did this person come to live in the
United States? Print numbers in boxes.
Year
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended regular school or college?
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Include only nursery or preschool, kindergarten,
elementary school, and schooling which leads to a
high school diploma or a college degree.
No, has not attended in the last 3
months → SKIP to question 11
Yes, public school, public college
Yes, private school, private college
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 to grade 4
Grade 5 to grade 8
Grade 9 to grade 12
College undergraduate years (freshman to
senior)
Graduate or professional school
(for example: medical, dental, or law school)
ACS-1(INFO)(2005), Page 7, Base (Black)
Your answers are important! Every person
in the American Community Survey counts.
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
14 a. Did this person live in this house or
apartment 1 year ago?
If currently enrolled, mark the previous grade or
highest degree received. Person is under 1 year old → SKIP to the
questions for Person 2 on page 10.
No schooling completed
Yes, this house → SKIP to F
Nursery school to 4th grade
No, outside the United States – Print name of
5th grade or 6th grade foreign country, or Puerto Rico, Guam, etc.,
7th grade or 8th grade below; then SKIP to F
9th grade
10th grade
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11th grade No, different house in the United States
12th grade – NO DIPLOMA
b. Where did this person live 1 year ago?
HIGH SCHOOL GRADUATE – high school
O
DIPLOMA or the equivalent (for example: GED) Name of city, town, or post office
C
Some college credit, but less than 1 year
1 or more years of college, no degree
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Associate degree (for example: AA, AS) c. Did this person live inside the limits of the
Bachelor’s degree (for example: BA, AB, BS) city or town?
N
Master’s degree (for example: MA, MS, MEng, Yes
MEd, MSW, MBA)
No, outside the city/town limits
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Professional degree (for example: MD, DDS, DVM,
LLB, JD) Name of county
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Doctorate degree (for example: PhD, EdD)
Name of state ZIP Code
12 What is this person’s ancestry or ethnic origin?
M
R
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(For example: Italian, Jamaican, African Am., F Answer questions 15 and 16 ONLY IF this person
Cambodian, Cape Verdean, Norwegian, is 5 years old or over. Otherwise, SKIP to the
Dominican, French Canadian, Haitian, Korean, questions for PERSON 2 on page 10.
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
15 Does this person have any of the following
13 a. Does this person speak a language other long-lasting conditions:
than English at home? Yes No
a. Blindness, deafness, or a severe
Yes vision or hearing impairment?
No → SKIP to question 14 b. A condition that substantially limits
one or more basic physical activities
b. What is this language? such as walking, climbing stairs,
reaching, lifting, or carrying?
For example: Korean, Italian, Spanish, Vietnamese 16 Because of a physical, mental, or emotional
condition lasting 6 months or more, does this
person have any difficulty in doing any of the
c. How well does this person speak English?
following activities:
Very well
Yes No
Well a. Learning, remembering, or
concentrating?
Not well
b. Dressing, bathing, or getting around
Not at all inside the home?
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ACS-1(INFO)(2005), Page 7, GREEN Pantone 354 (10%, 20%, and 100%)
 Person 1 (continued)

G Answer question 17 ONLY IF this person is 21 When did this person serve on active duty in 25 How did this person usually get to work LAST
15 years old or over. Otherwise, SKIP to the the U.S. Armed Forces? Mark (X) a box for EACH WEEK? If this person usually used more than one
questions for PERSON 2 on page 10. period in which this person served, even if just for method of transportation during the trip, mark (X) the
part of the period. box of the one used for most of the distance.
September 2001 or later Car, truck, or van Motorcycle
17 Because of a physical, mental, or emotional August 1990 to August 2001 (including Bus or trolley bus Bicycle
condition lasting 6 months or more, does this Persian Gulf War)
person have any difficulty in doing any of the Streetcar or trolley car Walked
September 1980 to July 1990
following activities: Subway or elevated Worked at home →
Yes No May 1975 to August 1980 SKIP to question 33
a. Going outside the home alone to Railroad
shop or visit a doctor’s office? Vietnam era (August 1964 to April 1975) Other method
Ferryboat
b. Working at a job or business? March 1961 to July 1964
Taxicab
February 1955 to February 1961
H Answer question 18 ONLY IF this person is Korean War (July 1950 to January 1955)
I Answer question 26 ONLY IF you marked
female and 15–50 years old. Otherwise, SKIP January 1947 to June 1950 "Car, truck, or van" in question 25.
to question 19a. World War II (December 1941 to December 1946) Otherwise, SKIP to question 27.
November 1941 or earlier PY
18 Has this person given birth to any children in
the past 12 months? 22 In total, how many years of active-duty 26 How many people, including this person,
military service has this person had? usually rode to work in the car, truck, or van
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Yes LAST WEEK?
Less than 2 years
No Person(s)
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2 years or more
19 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
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this house or apartment?

23 LAST WEEK, did this person do ANY work for
either pay or profit? Mark (X) the "Yes" box even if
Yes the person worked only 1 hour, or helped without 27 What time did this person usually leave home to
go to work LAST WEEK?
N

No → SKIP to question 20 pay in a family business or farm for 15 hours or more,

or was on active duty in the Armed Forces. Hour Minute
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b. Is this grandparent currently responsible for . a.m.

Yes
most of the basic needs of any . p.m.
grandchild(ren) under the age of 18 who No → SKIP to question 29
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live(s) in this house or apartment?

28 How many minutes did it usually take this
Yes 24 At what location did this person work LAST WEEK? person to get from home to work LAST WEEK?
If this person worked at more than one location, print
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No → SKIP to question 20 Minutes

where he or she worked most last week.
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c. How long has this grandparent been

responsible for the(se) grandchild(ren)? If a. Address (Number and street name)
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the grandparent is financially responsible for

more than one grandchild, answer the question
for the grandchild for whom the grandparent has If the exact address is not known, give a J Answer questions 29–32 ONLY IF this person
been responsible for the longest period of time. description of the location such as the building did NOT work last week. Otherwise, SKIP to
IN

name or the nearest street or intersection. question 33.

Less than 6 months
6 to 11 months b. Name of city, town, or post office
1 or 2 years
29 a. LAST WEEK, was this person on layoff from
3 or 4 years a job?
5 or more years c. Is the work location inside the limits of that Yes → SKIP to question 29c
city or town?
20 Has this person ever served on active duty in the No
U.S. Armed Forces, military Reserves, or National Yes
Guard? Active duty does not include training for the b. LAST WEEK, was this person TEMPORARILY
Reserves or National Guard, but DOES include No, outside the city/town limits absent from a job or business?
activation, for example, for the Persian Gulf War. d. Name of county Yes, on vacation, temporary illness, labor
Yes, now on active duty dispute, etc. → SKIP to question 32
Yes, on active duty during No → SKIP to question 30
the last 12 months, but not now
e. Name of U.S. state or foreign country c. Has this person been informed that he or she
Yes, on active duty in the past, but not will be recalled to work within the next
during the last 12 months 6 months OR been given a date to return to
No, training for Reserves or National Guard work?
only → SKIP to question 23 f. ZIP Code
Yes → SKIP to question 31
No, never served in the military → SKIP to No
question 23

8
ACS-1(INFO)(2005), Page 8, Base (Black) ACS-1(INFO)(2005), Page 8, GREEN Pantone 354 (10%, 20%, and 100%)
30 Has this person been looking for work during 36 For whom did this person work? b. Self-employment income from own nonfarm
the last 4 weeks? businesses or farm businesses, including
If now on active duty in the proprietorships and partnerships. Report NET
Yes Armed Forces, mark (X) this box → income after business expenses.
No → SKIP to question 32 and print the branch of the Armed Forces.
Name of company, business, or other employer Yes → $ .00 Loss
31 LAST WEEK, could this person have started a job No TOTAL AMOUNT for past
if offered one, or returned to work if recalled? 12 MONTHS
Yes, could have gone to work
No, because of own temporary illness 37 What kind of business or industry was this? c. Interest, dividends, net rental income, royalty
Describe the activity at the location where employed. income, or income from estates and trusts.
No, because of all other reasons (in school, etc.) (For example: hospital, newspaper publishing, mail Report even small amounts credited to an account.
order house, auto engine manufacturing, bank)
32 When did this person last work, even for a Yes → $ .00 Loss
few days? No TOTAL AMOUNT for past
Within the past 12 months 12 MONTHS
1 to 5 years ago → SKIP to question 35 38 Is this mainly – Mark (X) one box.
d. Social Security or Railroad Retirement.
Over 5 years ago or never worked → SKIP to manufacturing?
question 41 wholesale trade? Yes → $ .00

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retail trade? No TOTAL AMOUNT for past
33 During the PAST 12 MONTHS, how many
WEEKS did this person work? Count paid other (agriculture, construction, service, 12 MONTHS
vacation, paid sick leave, and military service. government, etc.)?
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e. Supplemental Security Income (SSI).
Weeks
39
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What kind of work was this person doing? (For
example: registered nurse, personnel manager,
Yes → $ .00
supervisor of order department, secretary, accountant) No TOTAL AMOUNT for past
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12 MONTHS
34 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK? f. Any public assistance or welfare payments
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from the state or local welfare office.

Usual hours worked each WEEK 40 What were this person’s most important
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activities or duties? (For example: patient care,

directing hiring policies, supervising order clerks, Yes → $ .00
typing and filing, reconciling financial records) No TOTAL AMOUNT for past
AT

12 MONTHS
K Answer questions 35–40 ONLY IF this person
g. Retirement, survivor, or disability pensions.
worked in the past 5 years. Otherwise, SKIP
M

to question 41. Do NOT include Social Security.

41 INCOME IN THE PAST 12 MONTHS.
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Mark (X) the "Yes" box for each type of income this Yes → $ .00
35–40 CURRENT OR MOST RECENT JOB ACTIVITY. person received, and give your best estimate of the No TOTAL AMOUNT for past
FO

Describe clearly this person’s chief job activity or
business last week. If this person had more than one
job, describe the one at which this person worked the
most hours. If this person had no job or business last
IN
TOTAL AMOUNT during the PAST 12 MONTHS. 12 MONTHS
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
h. Any other sources of income received regularly

week, give information for his/her last job or business.
35 Was this person –
Mark (X) ONE box.
an employee of a PRIVATE FOR PROFIT company
or business, or of an individual, for wages, salary,
or commissions?
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?
such as Veterans’ (VA) payments, unemploy-
Mark (X) the "No" box to show types of income ment compensation, child support or alimony.
NOT received. Do NOT include lump sum payments such as money
from an inheritance or the sale of a home.
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
Yes → $ .00
For income received jointly, report the appropriate No TOTAL AMOUNT for past
share for each person – or, if that’s not possible, 12 MONTHS
report the whole amount for only one person and
mark the "No" box for the other person. 42 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 41a to
a. Wages, salary, commissions, bonuses, or tips 41h; subtract any losses. If net income was a loss, enter
from all jobs. Report amount before deductions the amount and mark (X) the "Loss" box next to the
for taxes, bonds, dues, or other items. dollar amount.
Yes → $ .00 None OR $ .00 Loss
TOTAL AMOUNT for past
No TOTAL AMOUNT for past 12 MONTHS
12 MONTHS
➜ Continue with the questions for Person 2 on the
next page. If only 1 person is listed in the List of
Residents, SKIP to page 24 for mailing instructions.

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 Survey information helps your community
get financial assistance for roads, hospitals,
Person 2 schools, and more.

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.
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IN

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ACS-1(INFO)(2005), Page 10, Base (Black) ACS-1(INFO)(2005), Page 10, GREEN Pantone 354 (10%, 20%, and 100%)
 PY
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IN

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ACS-1(INFO)(2005), Page 11, Base (Black) ACS-1(INFO)(2005), Page 11, GREEN Pantone 354 (100%)
 Mailing
Instructions
Please make sure you have..
• put all names on the List of Residents and answered
the questions across the top of the page
• answered all Housing questions
• answered all Person questions for each person on the

PY
List of Residents.
Then...
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• put the completed questionnaire into the postage-paid
C
return envelope. If the envelope has been misplaced,
AL

please mail the questionnaire to:

U. S. Census Bureau
N

P.O. Box 5240

IO

Jeffersonville, IN 47199-5240
AT

• make sure the barcode above your address shows

in the window of the return envelope.
M
R

Thank you for participating in

the American Community Survey.
FO
IN

The Census Bureau estimates that, for the average

household, this form will take 38 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, U.S. Census Bureau,
POP EDIT PHONE JIC1 JIC2 4700 Silver Hill Road, Stop 1500, Washington, D.C.
20233-1500. You may e-mail comments to
Paperwork@census.gov; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
EDIT CLERK TELEPHONE CLERK JIC3 JIC4 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)(2005) (5-20-2004)

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ACS-1(INFO)(2005), Page 12, Base (Black) ACS-1(INFO)(2005), Page 12, GREEN Pantone 354 (20% and 100%)