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DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
Puerto Rico Community Survey
Please complete this form and return
it as soon as possible after receiving
it in the mail.
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.
Start Here
➜
➜
Please print today’s date.
Year
Month Day
Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name
First Name
MI
Area Code + Number
—
If you need help or have questions
about completing this form, please call
1-800-717-7381. The telephone call is free.
➜
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.
Telephone Device for the Deaf (TDD):
Call 1-800-786-9448. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-800-814-8385.
For more information about the Puerto Rico
Community Survey, visit our web site at:
http://www.census.gov/acs/www/
ACS-1(2013)PR KFI
FORM
(02-06-2012) Draft 2
§.2?3¤
ACS-1(X)PINT(2011)KFI, Page 1, Base (Black) Green Pantone 354 (20 and 40%)
OMB No. 0607-0810
Approval Expires 09/30/2014
13173026
Person 1
Person 2
1 What is Person 2’s name?
(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.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
X
3
Female
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’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)
Month Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
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.
What is Person 1’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
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
Roomer or boarder
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month Day
Year of birth
Is Person 1 of Hispanic, Latino, or Spanish origin?
6
Other relative
Adopted son or daughter
Male
What is Person 1’s age and what is Person 1’s date of birth?
5
Biological son or daughter
3 What is Person 2’s sex? Mark (X) ONE box.
What is Person 1’s sex? Mark (X) ONE box.
4
Son-in-law or daughter-in-law
Parent-in-law
Person 1
Male
Husband or wife
Some other race – Print race. C
§.2?;¤
ACS-1(X)T(2010)KFI, Page 2, Base (Black)
Page 2, Green Pantone 354 (20 and 40%)
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and so on. C
13173034
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
5
6
MI
2 How is this person related to Person 1? Mark (X) ONE box.
Son-in-law or daughter-in-law
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Male
4
First Name
Husband or wife
Parent-in-law
3
Last Name (Please print)
Female
Male
What is Person 3’s age and what is Person 3’s date of birth?
Female
4 What is Person 4’s age and what is Person 4’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)
Month Day
Year of birth
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 4 of Hispanic, Latino, or Spanish origin?
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
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.
What is Person 3’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
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
Some other race – Print race. C
§.2?C¤
ACS-1(X)T(2010)KFI, Page 3, Base (Black)
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and so on. C
3
Page 3, Green Pantone 354 (20 and 40%)
13173042
➜
Person 5
1
What is Person 5’s name?
Last Name (Please print)
First Name
MI
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.
Person 6
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
Sex
3
Male
Female
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Age (in years)
Person 8
Female
What is Person 5’s age and what is Person 5’s date of birth?
Last Name (Please print)
First Name
MI
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month Day
Year of birth
Sex
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Male
Female
Person 9
Last Name (Please print)
Is Person 5 of Hispanic, Latino, or Spanish origin?
Age (in years)
First Name
MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Sex
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
6
Male
Female
Age (in years)
Person 10
Last Name (Please print)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black, African Am., or Negro
American Indian or Alaska Native – Print name of enrolled or principal tribe. C
Male
Female
Person 11
Last Name (Please print)
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
Sex
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and so on. C
Age (in years)
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race. C
Sex
4
Male
Female
§.2?K¤
ACS-1(X)T(2010)KFI, Page 4, Base (Black)
MI
Page 4, Green Pantone 354 (20 and 40%)
Age (in years)
MI
13173059
Housing
➜
1
Please answer the following questions
about the house, apartment, or mobile
home at the address on the mailing label.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
8 Does this house, apartment, or mobile
Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.
home have –
mobile home on?
c. a flush toilet?
A mobile home
1 to 9.9 cuerdas
e. a sink with a faucet?
A one-family house detached from any
other house
10 or more cuerdas
f. a stove or range?
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
About when was this building first built?
2000 or later – Specify year
g. a refrigerator?
5 IN THE PAST 12 MONTHS, what were the
A building with 3 or 4 apartments
No
b. a water heater?
4 How many cuerdas is this house or
d. a bathtub or shower?
A building with 2 apartments
Yes
a. running water?
Less than 1 cuerda ➔ SKIP to question 6
A one-family house attached to one or
more houses
2
A
h. telephone service from
which you can both make
and receive calls? Include
cell phones.
9 At this house, apartment, or mobile home –
do you or any member of this household
own or use any of the following computers?
• EXCLUDE GPS devices, digital music players,
and devices with only limited computing
capabilities, for example: household
appliances.
Yes
No
a. Desktop, laptop, netbook, or
notebook computer
b. Handheld computer,
smart mobile phone, or other
handheld wireless computer
6 Is there a business (such as a store or
barber shop) or a medical office on this
property?
c. Some other type of computer
Specify C
Yes
No
1990 to 1999
1980 to 1989
7 a. How many separate rooms are in this
10 At this house, apartment, or mobile home –
do you or any member of this household
access the Internet?
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.
1970 to 1979
1960 to 1969
1940 to 1949
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
1939 or earlier
Number of rooms
1950 to 1959
Yes, with a subscription to an Internet
service
Yes, without a subscription to an Internet
service ➔ SKIP to question 12
No Internet access at this house, apartment,
or mobile home ➔ SKIP to question 12
11 At this house, apartment, or mobile home –
3
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
Year
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
Number of bedrooms
do you or any member of this household
subscribe to the Internet using –
Yes
No
a. Dial-up service?
b. DSL service?
c. Cable modem service?
d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite service?
g. Some other service?
Specify service C
§.2?\¤
ACS-1(X)T(2010)KFI, Page 5, Base (Black)
5
Page 5, Green Pantone 354 (10, 20, 40 and 50%)
13173067
Housing (continued)
14 a. LAST MONTH, what was the cost of
12 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
electricity for this house, apartment,
or mobile home?
Last month’s cost – Dollars
$
.00
,
None
Included in rent or condominium fee
2
No charge or electricity not used
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
$
Yes
16 Is this house, apartment, or mobile home
part of a condominium?
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.
.00
,
13 Which FUEL is used MOST for heating this
member of this household receive benefits
from the Nutritional Assistance Program?
Do NOT include WIC, the School Lunch Program,
or assistance from food banks.
No
OR
1
3
15 IN THE PAST 12 MONTHS, did you or any
Monthly amount – Dollars
OR
house, apartment, or mobile home?
$
Gas: from underground pipes serving the
neighborhood
OR
Included in electricity payment
entered above
Gas: bottled, tank, or LP
No charge or gas not used
.00
,
Included in rent or condominium fee
None
No
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
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.
Past 12 months’ cost – Dollars
$
.00
,
No fuel used
OR
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?
Included in rent or condominium fee
No charge
Occupied without payment of
rent? ➔ SKIP to C on the next page
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
6
§.2?d¤
ACS-1(X)T(2010)KFI, Page 6, Base (Black)
Page 6, Green Pantone 354 (10, 20, 40 and 50%)
13173075
Housing (continued)
B
22 a. Do you or any member of this
Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.
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?
Yes, home equity loan
Yes, mortgage, deed of trust, or
similar debt
Yes, second mortgage
Yes, contract to purchase
18 a. What is the monthly rent for this house,
No ➔ SKIP to question 23a
apartment, or mobile home?
Monthly amount – Dollars
$
.00
,
b. Does the monthly rent include any
meals?
No
C
19 About how much do you think this house
and lot, apartment, or mobile home (and
lot, if owned) would sell for if it were for
sale?
Amount – Dollars
,
.00
,
20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?
Monthly amount – Dollars
,
Monthly amount – Dollars
.00
$
.00
,
OR
No regular payment required ➔ SKIP
to question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
.00
,
OR
Answer questions 19–23 if you or someone
else in this household OWNS or IS BUYING
this house, apartment, or mobile home.
Otherwise, SKIP to E .
$
No ➔ SKIP to D
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
$
Yes
Yes, second mortgage and home
equity loan
No regular payment required
D
Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
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.
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
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.
OR
None
21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
.00
,
OR
None
§.2?l¤
ACS-1(X)T(2010)KFI, Page 7, Base (Black)
7
Page 7, Green Pantone 354 (10, 20, 40 and 50%)
13173083
Person 1
➜
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Please copy the name of Person 1 from page 2,
then continue answering questions below.
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Last Name
First Name
7
15 What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
MI
Where was this person born?
In the United States – Print name of state.
College undergraduate years (freshman to
16 a. Does this person speak a language other than
senior)
English at home?
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
Yes
program, or medical or law school)
No ➔ SKIP to question 17a
13 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
b. What is this language?
If currently enrolled, mark the previous grade or
highest degree received.
NO SCHOOLING COMPLETED
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
8
Kindergarten
Is this person a citizen of the United States?
Grade 1 through 11 – Specify
grade 1 – 11
Yes, born in Puerto Rico ➔ SKIP to 10a
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
c. How well does this person speak English?
Very well
Well
Not well
Not at all
12th grade – NO DIPLOMA
17 a. Did this person live in this house or apartment
1 year ago?
HIGH SCHOOL GRADUATE
Yes, U.S. citizen by naturalization – Print year
of naturalization
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Some college credit, but less than 1 year of
college credit
When did this person come to live in
Puerto Rico? Print numbers in boxes.
Year
Person is under 1 year old ➔ SKIP to
question 18
Yes, this house ➔ SKIP to question 18
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 18.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
10 In what country was this person’s FATHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
Address
Development or condominium name
Number and street name
Doctorate degree (for example: PhD, EdD)
11 In what country was this person’s MOTHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
12 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Answer question 14 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 15.
14 This question focuses on this person’s
Include only nursery or preschool, kindergarten,
elementary school, home 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 13
Yes, public school, public college
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
Yes, private school, private college,
home school
8
§.2?t¤
ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
ZIP Code
13173091
Person 1 (continued)
H
18 Is this person CURRENTLY covered by any of the
Answer question 21 if this person is
15 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
of coverage in items a – h.
21 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Widowed
Never served in the military ➔ SKIP to
question 31a
Divorced
23 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
No
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 30a
Now on active duty
On active duty in the past, but not now
a. Married?
b. Widowed?
c. Divorced?
24 How many times has this person been married?
serious difficulty hearing?
Once
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
25 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
G
Less than 6 months
28 Has this person ever served on active duty in the
Now married
19 a. Is this person deaf or does he/she have
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.
22 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
g. Indian Health Service
c. How long has this grandparent been
responsible for these grandchildren?
29 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)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
Answer question 20a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
I
Answer question 26 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 27a.
November 1941 or earlier
30 a. Does this person have a VA service-connected
disability rating?
26 Has this person given birth to any children in
the past 12 months?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 31a
Yes
No
27 a. Does this person have any of his/her own
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
grandchildren under the age of 18 living in
this house or apartment?
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
Yes
30 or 40 percent
No ➔ SKIP to question 28
50 or 60 percent
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who lives in this house or
apartment?
Yes
Yes
No
No ➔ SKIP to question 28
70 percent or higher
§.2?|¤
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13173109
Person 1 (continued)
J
31 a. LAST WEEK, did this person work for pay
Answer question 34 if you marked "Car,
truck, or van" in question 33. Otherwise,
SKIP to question 35.
at a job (or business)?
38 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 40
Yes ➔ SKIP to question 32
No – Did not work (or retired)
34 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
39 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 37a
No, because of own temporary illness
32 At what location did this person work LAST
WEEK? If this person worked at more than one
35 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
a. Address
Development or condominium name
Number and street name
40 When did this person last work, even for a few
Minute
:
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
36 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 49
41 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 42
c. Is the work location inside the limits of that
city or town?
K
Answer questions 37 – 40 if this person
did NOT work last week. Otherwise,
SKIP to question 41a.
Yes
No, outside the city/town limits
37 a. LAST WEEK, was this person on layoff from
d. Name of municipio in Puerto Ricoor U.S.
county
a job?
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
Yes ➔ SKIP to question 37c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
e. Enter Puerto Rico or name of U.S. stateor
foreign country
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 40
f. ZIP Code
No ➔ SKIP to question 38
33 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 41a
Ferryboat
Other method
13 weeks or less
42 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
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?
Yes ➔ SKIP to question 39
No
Taxicab
10
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13173117
Person 1 (continued)
L
47 What kind of work was this person doing?
Answer questions 43 – 48 if this person
worked in the past 5 years. Otherwise,
SKIP to question 49.
43 – 48 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
49 INCOME IN THE PAST 12 MONTHS
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?
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.)
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
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?
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 Was this person –
Mark (X) ONE box.
.00
,
e. Supplemental Security Income (SSI).
48 What were this person’s most important
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 week, give
information for his/her last job or business.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Yes ➔
$
No
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.
,
.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. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
44 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Yes ➔ $
No
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
46 Is this mainly – Mark (X) ONE box.
manufacturing?
.00
Yes ➔
No
$
,
Yes ➔
$
No
,
,
.00
$
Loss
TOTAL AMOUNT for past
12 months
TOTAL AMOUNT for past
12 months
None OR
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
retail trade?
No
$
,
,
TOTAL AMOUNT for past
12 months
.00
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.
§.2@2¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
.00
b. Self-employment income from own nonfarm 50 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 49a
businesses or farm businesses, including
to 49h; subtract any losses. If net income was a loss,
proprietorships and partnerships. Report
enter the amount and mark (X) the "Loss" box next to
NET income after business expenses.
the dollar amount.
wholesale trade?
other (agriculture, construction, service,
government, etc.)?
,
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
45 What kind of business or industry was this?
,
11
Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13173125
Person 2
➜
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Please copy the name of Person 2 from page 2,
then continue answering questions below.
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Last Name
First Name
7
15 What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
MI
Where was this person born?
In the United States – Print name of state.
College undergraduate years (freshman to
16 a. Does this person speak a language other than
senior)
English at home?
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
Yes
program, or medical or law school)
No ➔ SKIP to question 17a
13 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
b. What is this language?
If currently enrolled, mark the previous grade or
highest degree received.
NO SCHOOLING COMPLETED
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
8
Kindergarten
Is this person a citizen of the United States?
Grade 1 through 11 – Specify
grade 1 – 11
Yes, born in Puerto Rico ➔ SKIP to 10a
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
c. How well does this person speak English?
Very well
Well
Not well
Not at all
12th grade – NO DIPLOMA
17 a. Did this person live in this house or apartment
1 year ago?
HIGH SCHOOL GRADUATE
Yes, U.S. citizen by naturalization – Print year
of naturalization
Regular high school diploma
Person is under 1 year old ➔ SKIP to
question 18
GED or alternative credential
Yes, this house ➔ SKIP to question 18
COLLEGE OR SOME COLLEGE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Some college credit, but less than 1 year of
college credit
When did this person come to live in
Puerto Rico? Print numbers in boxes.
Year
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 18.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
10 In what country was this person’s FATHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
Address
Development or condominium name
Number and street name
Doctorate degree (for example: PhD, EdD)
11 In what country was this person’s MOTHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
12 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Answer question 14 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 15.
14 This question focuses on this person’s
Include only nursery or preschool, kindergarten,
elementary school, home 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 13
Yes, public school, public college
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
Yes, private school, private college,
home school
12
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ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
ZIP Code
13173133
Person 2 (continued)
H
18 Is this person CURRENTLY covered by any of the
Answer question 21 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
21 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Widowed
Never served in the military ➔ SKIP to
question 31a
Divorced
23 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
No
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 30a
Now on active duty
On active duty in the past, but not now
a. Married?
b. Widowed?
c. Divorced?
24 How many times has this person been married?
serious difficulty hearing?
Once
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
25 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
G
Less than 6 months
28 Has this person ever served on active duty in the
Now married
19 a. Is this person deaf or does he/she have
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.
22 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
g. Indian Health Service
c. How long has this grandparent been
responsible for these grandchildren?
29 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)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
Answer question 20a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
I
Answer question 26 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 27a.
November 1941 or earlier
30 a. Does this person have a VA service-connected
disability rating?
26 Has this person given birth to any children in
the past 12 months?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 31a
Yes
No
27 a. Does this person have any of his/her own
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
grandchildren under the age of 18 living in
this house or apartment?
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
Yes
30 or 40 percent
No ➔ SKIP to question 28
50 or 60 percent
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who lives in this house or
apartment?
Yes
Yes
No
No ➔ SKIP to question 28
70 percent or higher
§.2@B¤
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Page 9, Green Pantone 354 (10, 20, 40 and 50%)
13173141
Person 2 (continued)
J
31 a. LAST WEEK, did this person work for pay
Answer question 34 if you marked "Car,
truck, or van" in question 33. Otherwise,
SKIP to question 35.
at a job (or business)?
38 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 40
Yes ➔ SKIP to question 32
No – Did not work (or retired)
34 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
39 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 37a
No, because of own temporary illness
32 At what location did this person work LAST
WEEK? If this person worked at more than one
35 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
a. Address
Development or condominium name
Number and street name
40 When did this person last work, even for a few
Minute
:
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
36 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 49
41 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 42
c. Is the work location inside the limits of that
city or town?
K
Answer questions 37 – 40 if this person
did NOT work last week. Otherwise,
SKIP to question 41a.
Yes
No, outside the city/town limits
37 a. LAST WEEK, was this person on layoff from
d. Name of municipio in Puerto Ricoor U.S.
county
a job?
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
Yes ➔ SKIP to question 37c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
e. Enter Puerto Rico or name of U.S. stateor
foreign country
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 40
f. ZIP Code
No ➔ SKIP to question 38
33 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 41a
Ferryboat
Other method
13 weeks or less
42 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
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?
Yes ➔ SKIP to question 39
No
Taxicab
14
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13173158
Person 2 (continued)
L
47 What kind of work was this person doing?
Answer questions 43 – 48 if this person
worked in the past 5 years. Otherwise,
SKIP to question 49.
43 – 48 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
49 INCOME IN THE PAST 12 MONTHS
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?
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.)
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
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?
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 Was this person –
Mark (X) ONE box.
.00
,
e. Supplemental Security Income (SSI).
48 What were this person’s most important
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 week, give
information for his/her last job or business.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Yes ➔
$
No
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.
,
.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. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
44 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Yes ➔ $
No
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
46 Is this mainly – Mark (X) ONE box.
manufacturing?
.00
Yes ➔
No
$
,
Yes ➔
$
No
,
,
.00
$
Loss
TOTAL AMOUNT for past
12 months
TOTAL AMOUNT for past
12 months
None OR
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
retail trade?
No
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
➜
Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on
page 3, SKIP to page 28 for mailing instructions.
§.2@[¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
.00
b. Self-employment income from own nonfarm 50 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 49a
businesses or farm businesses, including
to 49h; subtract any losses. If net income was a loss,
proprietorships and partnerships. Report
enter the amount and mark (X) the "Loss" box next to
NET income after business expenses.
the dollar amount.
wholesale trade?
other (agriculture, construction, service,
government, etc.)?
,
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
45 What kind of business or industry was this?
,
15
Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13173166
Person 3
➜
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Please copy the name of Person 3 from page 3,
then continue answering questions below.
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Last Name
First Name
7
15 What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
MI
Where was this person born?
In the United States – Print name of state.
College undergraduate years (freshman to
16 a. Does this person speak a language other than
senior)
English at home?
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
Yes
program, or medical or law school)
No ➔ SKIP to question 17a
13 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
b. What is this language?
If currently enrolled, mark the previous grade or
highest degree received.
NO SCHOOLING COMPLETED
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
8
Kindergarten
Is this person a citizen of the United States?
Grade 1 through 11 – Specify
grade 1 – 11
Yes, born in Puerto Rico ➔ SKIP to 10a
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
c. How well does this person speak English?
Very well
Well
Not well
Not at all
12th grade – NO DIPLOMA
17 a. Did this person live in this house or apartment
1 year ago?
HIGH SCHOOL GRADUATE
Yes, U.S. citizen by naturalization – Print year
of naturalization
Regular high school diploma
Person is under 1 year old ➔ SKIP to
question 18
GED or alternative credential
Yes, this house ➔ SKIP to question 18
COLLEGE OR SOME COLLEGE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Some college credit, but less than 1 year of
college credit
When did this person come to live in
Puerto Rico? Print numbers in boxes.
Year
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 18.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
10 In what country was this person’s FATHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
Address
Development or condominium name
Number and street name
Doctorate degree (for example: PhD, EdD)
11 In what country was this person’s MOTHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
12 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Answer question 14 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 15.
14 This question focuses on this person’s
Include only nursery or preschool, kindergarten,
elementary school, home 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 13
Yes, public school, public college
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
Yes, private school, private college,
home school
16
§.2@c¤
ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
ZIP Code
13173174
Person 3 (continued)
H
18 Is this person CURRENTLY covered by any of the
Answer question 21 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
21 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Widowed
Never served in the military ➔ SKIP to
question 31a
Divorced
23 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
No
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 30a
Now on active duty
On active duty in the past, but not now
a. Married?
b. Widowed?
c. Divorced?
24 How many times has this person been married?
serious difficulty hearing?
Once
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
25 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
G
Less than 6 months
28 Has this person ever served on active duty in the
Now married
19 a. Is this person deaf or does he/she have
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.
22 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
g. Indian Health Service
c. How long has this grandparent been
responsible for these grandchildren?
29 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)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
Answer question 20a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
I
Answer question 26 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 27a.
November 1941 or earlier
30 a. Does this person have a VA service-connected
disability rating?
26 Has this person given birth to any children in
the past 12 months?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 31a
Yes
No
27 a. Does this person have any of his/her own
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
grandchildren under the age of 18 living in
this house or apartment?
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
Yes
30 or 40 percent
No ➔ SKIP to question 28
50 or 60 percent
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who lives in this house or
apartment?
Yes
Yes
No
No ➔ SKIP to question 28
70 percent or higher
§.2@k¤
ACS-1(X)T(2010)KFI, Page 9, Base (Black)
17
Page 9, Green Pantone 354 (10, 20, 40 and 50%)
13173182
Person 3 (continued)
J
31 a. LAST WEEK, did this person work for pay
Answer question 34 if you marked "Car,
truck, or van" in question 33. Otherwise,
SKIP to question 35.
at a job (or business)?
38 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 40
Yes ➔ SKIP to question 32
No – Did not work (or retired)
34 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
39 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 37a
No, because of own temporary illness
32 At what location did this person work LAST
WEEK? If this person worked at more than one
35 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
a. Address
Development or condominium name
Number and street name
40 When did this person last work, even for a few
Minute
:
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
36 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 49
41 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 42
c. Is the work location inside the limits of that
city or town?
K
Answer questions 37 – 40 if this person
did NOT work last week. Otherwise,
SKIP to question 41a.
Yes
No, outside the city/town limits
37 a. LAST WEEK, was this person on layoff from
d. Name of municipio in Puerto Ricoor U.S.
county
a job?
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
Yes ➔ SKIP to question 37c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
e. Enter Puerto Rico or name of U.S. stateor
foreign country
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 40
f. ZIP Code
No ➔ SKIP to question 38
33 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 41a
Ferryboat
Other method
13 weeks or less
42 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
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?
Yes ➔ SKIP to question 39
No
Taxicab
18
§.2@s¤
ACS-1(X)T(2010)KFI, Page 10, Base (Black)
Page 10, Green Pantone 354 (10, 20, 40 and 50%)
13173190
Person 3 (continued)
L
47 What kind of work was this person doing?
Answer questions 43 – 48 if this person
worked in the past 5 years. Otherwise,
SKIP to question 49.
43 – 48 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
49 INCOME IN THE PAST 12 MONTHS
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?
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.)
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
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?
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 Was this person –
Mark (X) ONE box.
.00
,
e. Supplemental Security Income (SSI).
48 What were this person’s most important
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 week, give
information for his/her last job or business.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Yes ➔
$
No
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.
,
.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. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
44 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Yes ➔ $
No
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
46 Is this mainly – Mark (X) ONE box.
manufacturing?
.00
Yes ➔
No
$
,
Yes ➔
$
No
,
,
.00
$
Loss
TOTAL AMOUNT for past
12 months
TOTAL AMOUNT for past
12 months
None OR
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
retail trade?
No
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
➜
Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on
page 3, SKIP to page 28 for mailing instructions.
§.2@{¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
.00
b. Self-employment income from own nonfarm 50 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 49a
businesses or farm businesses, including
to 49h; subtract any losses. If net income was a loss,
proprietorships and partnerships. Report
enter the amount and mark (X) the "Loss" box next to
NET income after business expenses.
the dollar amount.
wholesale trade?
other (agriculture, construction, service,
government, etc.)?
,
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
45 What kind of business or industry was this?
,
19
Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13173208
Person 4
➜
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Please copy the name of Person 4 from page 3,
then continue answering questions below.
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Last Name
First Name
7
15 What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
MI
Where was this person born?
In the United States – Print name of state.
College undergraduate years (freshman to
16 a. Does this person speak a language other than
senior)
English at home?
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
Yes
program, or medical or law school)
No ➔ SKIP to question 17a
13 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
b. What is this language?
If currently enrolled, mark the previous grade or
highest degree received.
NO SCHOOLING COMPLETED
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
8
Kindergarten
Is this person a citizen of the United States?
Grade 1 through 11 – Specify
grade 1 – 11
Yes, born in Puerto Rico ➔ SKIP to 10a
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
c. How well does this person speak English?
Very well
Well
Not well
Not at all
12th grade – NO DIPLOMA
17 a. Did this person live in this house or apartment
1 year ago?
HIGH SCHOOL GRADUATE
Yes, U.S. citizen by naturalization – Print year
of naturalization
Regular high school diploma
Person is under 1 year old ➔ SKIP to
question 18
GED or alternative credential
Yes, this house ➔ SKIP to question 18
COLLEGE OR SOME COLLEGE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Some college credit, but less than 1 year of
college credit
When did this person come to live in
Puerto Rico? Print numbers in boxes.
Year
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 18.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
10 In what country was this person’s FATHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
Address
Development or condominium name
Number and street name
Doctorate degree (for example: PhD, EdD)
11 In what country was this person’s MOTHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
12 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Answer question 14 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 15.
14 This question focuses on this person’s
Include only nursery or preschool, kindergarten,
elementary school, home 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 13
Yes, public school, public college
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
Yes, private school, private college,
home school
20
§.2A)¤
ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
ZIP Code
13173216
Person 4 (continued)
H
18 Is this person CURRENTLY covered by any of the
Answer question 21 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
21 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Widowed
Never served in the military ➔ SKIP to
question 31a
Divorced
23 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
No
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 30a
Now on active duty
On active duty in the past, but not now
a. Married?
b. Widowed?
c. Divorced?
24 How many times has this person been married?
serious difficulty hearing?
Once
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
25 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
G
Less than 6 months
28 Has this person ever served on active duty in the
Now married
19 a. Is this person deaf or does he/she have
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.
22 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
g. Indian Health Service
c. How long has this grandparent been
responsible for these grandchildren?
29 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)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
Answer question 20a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
I
Answer question 26 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 27a.
November 1941 or earlier
30 a. Does this person have a VA service-connected
disability rating?
26 Has this person given birth to any children in
the past 12 months?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 31a
Yes
No
27 a. Does this person have any of his/her own
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
grandchildren under the age of 18 living in
this house or apartment?
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
Yes
30 or 40 percent
No ➔ SKIP to question 28
50 or 60 percent
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who lives in this house or
apartment?
Yes
Yes
No
No ➔ SKIP to question 28
70 percent or higher
§.2A1¤
ACS-1(X)T(2010)KFI, Page 9, Base (Black)
21
Page 9, Green Pantone 354 (10, 20, 40 and 50%)
13173224
Person 4 (continued)
J
31 a. LAST WEEK, did this person work for pay
Answer question 34 if you marked "Car,
truck, or van" in question 33. Otherwise,
SKIP to question 35.
at a job (or business)?
38 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 40
Yes ➔ SKIP to question 32
No – Did not work (or retired)
34 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
39 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 37a
No, because of own temporary illness
32 At what location did this person work LAST
WEEK? If this person worked at more than one
35 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
a. Address
Development or condominium name
Number and street name
40 When did this person last work, even for a few
Minute
:
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
36 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 49
41 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 42
c. Is the work location inside the limits of that
city or town?
K
Answer questions 37 – 40 if this person
did NOT work last week. Otherwise,
SKIP to question 41a.
Yes
No, outside the city/town limits
37 a. LAST WEEK, was this person on layoff from
d. Name of municipio in Puerto Ricoor U.S.
county
a job?
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
Yes ➔ SKIP to question 37c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
e. Enter Puerto Rico or name of U.S. stateor
foreign country
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 40
f. ZIP Code
No ➔ SKIP to question 38
33 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 41a
Ferryboat
Other method
13 weeks or less
42 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
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?
Yes ➔ SKIP to question 39
No
Taxicab
22
§.2@7¤
ACS-1(X)T(2010)KFI, Page 10, Base (Black)
Page 10, Green Pantone 354 (10, 20, 40 and 50%)
13173232
Person 4 (continued)
L
47 What kind of work was this person doing?
Answer questions 43 – 48 if this person
worked in the past 5 years. Otherwise,
SKIP to question 49.
43 – 48 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
49 INCOME IN THE PAST 12 MONTHS
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?
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.)
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
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?
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 Was this person –
Mark (X) ONE box.
.00
,
e. Supplemental Security Income (SSI).
48 What were this person’s most important
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 week, give
information for his/her last job or business.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Yes ➔
$
No
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.
,
.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. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
44 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Yes ➔ $
No
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
46 Is this mainly – Mark (X) ONE box.
manufacturing?
.00
Yes ➔
No
$
,
Yes ➔
$
No
,
,
.00
$
Loss
TOTAL AMOUNT for past
12 months
TOTAL AMOUNT for past
12 months
None OR
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
retail trade?
No
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
➜
Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on
page 4, SKIP to page 28 for mailing instructions.
§.2AA¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
.00
b. Self-employment income from own nonfarm 50 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 49a
businesses or farm businesses, including
to 49h; subtract any losses. If net income was a loss,
proprietorships and partnerships. Report
enter the amount and mark (X) the "Loss" box next to
NET income after business expenses.
the dollar amount.
wholesale trade?
other (agriculture, construction, service,
government, etc.)?
,
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
45 What kind of business or industry was this?
,
23
Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13173240
Person 5
➜
b. What grade or level was this person
attending? Mark (X) ONE box.
Nursery school, preschool
Please copy the name of Person 5 from page 4,
then continue answering questions below.
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Last Name
First Name
7
15 What is this person’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
MI
Where was this person born?
In the United States – Print name of state.
College undergraduate years (freshman to
16 a. Does this person speak a language other than
senior)
English at home?
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
Yes
program, or medical or law school)
No ➔ SKIP to question 17a
13 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
b. What is this language?
If currently enrolled, mark the previous grade or
highest degree received.
NO SCHOOLING COMPLETED
Outside the United States – Print Puerto Rico or
name of foreign country, or U.S. Virgin Islands,
Guam, etc
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
8
Kindergarten
Is this person a citizen of the United States?
Grade 1 through 11 – Specify
grade 1 – 11
Yes, born in Puerto Rico ➔ SKIP to 10a
Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
c. How well does this person speak English?
Very well
Well
Not well
Not at all
12th grade – NO DIPLOMA
17 a. Did this person live in this house or apartment
1 year ago?
HIGH SCHOOL GRADUATE
Yes, U.S. citizen by naturalization – Print year
of naturalization
Regular high school diploma
Person is under 1 year old ➔ SKIP to
question 18
GED or alternative credential
Yes, this house ➔ SKIP to question 18
COLLEGE OR SOME COLLEGE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Some college credit, but less than 1 year of
college credit
When did this person come to live in
Puerto Rico? Print numbers in boxes.
Year
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 18.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
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)
10 In what country was this person’s FATHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?
Address
Development or condominium name
Number and street name
Doctorate degree (for example: PhD, EdD)
11 In what country was this person’s MOTHER born?
Print name of country, or Puerto Rico, U.S. Virgin Islands, etc.
12 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Answer question 14 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 15.
14 This question focuses on this person’s
Include only nursery or preschool, kindergarten,
elementary school, home 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 13
Yes, public school, public college
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
Name of municipio in Puerto Rico or
U.S. county
Enter Puerto Rico or
name of U.S. state
Yes, private school, private college,
home school
24
§.2AI¤
ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
ZIP Code
13173257
Person 5 (continued)
H
18 Is this person CURRENTLY covered by any of the
Answer question 21 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
21 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
e. TRICARE or other military health care
Separated
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Widowed
Never served in the military ➔ SKIP to
question 31a
Divorced
23 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
No
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 30a
Now on active duty
On active duty in the past, but not now
a. Married?
b. Widowed?
c. Divorced?
24 How many times has this person been married?
serious difficulty hearing?
Once
Yes
Two times
No
Three or more times
b. Is this person blind or does he/she have
25 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
G
Less than 6 months
28 Has this person ever served on active duty in the
Now married
19 a. Is this person deaf or does he/she have
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.
22 What is this person’s marital status?
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
g. Indian Health Service
c. How long has this grandparent been
responsible for these grandchildren?
29 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)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
Answer question 20a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
20 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
I
Answer question 26 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 27a.
November 1941 or earlier
30 a. Does this person have a VA service-connected
disability rating?
26 Has this person given birth to any children in
the past 12 months?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 31a
Yes
No
27 a. Does this person have any of his/her own
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
grandchildren under the age of 18 living in
this house or apartment?
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
Yes
30 or 40 percent
No ➔ SKIP to question 28
50 or 60 percent
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who lives in this house or
apartment?
Yes
Yes
No
No ➔ SKIP to question 28
70 percent or higher
§.2AZ¤
ACS-1(X)T(2010)KFI, Page 9, Base (Black)
25
Page 9, Green Pantone 354 (10, 20, 40 and 50%)
13173265
Person 5 (continued)
J
31 a. LAST WEEK, did this person work for pay
Answer question 34 if you marked "Car,
truck, or van" in question 33. Otherwise,
SKIP to question 35.
at a job (or business)?
38 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 40
Yes ➔ SKIP to question 32
No – Did not work (or retired)
34 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
39 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 37a
No, because of own temporary illness
32 At what location did this person work LAST
WEEK? If this person worked at more than one
35 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
location, print where he or she worked most
last week.
Hour
a. Address
Development or condominium name
Number and street name
40 When did this person last work, even for a few
Minute
:
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
36 How many minutes did it usually take this
person to get from home to work LAST WEEK?
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 49
41 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 42
c. Is the work location inside the limits of that
city or town?
K
Answer questions 37 – 40 if this person
did NOT work last week. Otherwise,
SKIP to question 41a.
Yes
No, outside the city/town limits
37 a. LAST WEEK, was this person on layoff from
d. Name of municipio in Puerto Ricoor U.S.
county
a job?
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
Yes ➔ SKIP to question 37c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
e. Enter Puerto Rico or name of U.S. stateor
foreign country
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 40
f. ZIP Code
No ➔ SKIP to question 38
33 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Carro público
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 41a
Ferryboat
Other method
13 weeks or less
42 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
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?
Yes ➔ SKIP to question 39
No
Taxicab
26
§.2Ab¤
ACS-1(X)T(2010)KFI, Page 10, Base (Black)
Page 10, Green Pantone 354 (10, 20, 40 and 50%)
13173273
Person 5 (continued)
L
47 What kind of work was this person doing?
Answer questions 43 – 48 if this person
worked in the past 5 years. Otherwise,
SKIP to question 49.
43 – 48 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
49 INCOME IN THE PAST 12 MONTHS
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?
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.)
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
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?
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 Was this person –
Mark (X) ONE box.
.00
,
e. Supplemental Security Income (SSI).
48 What were this person’s most important
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 week, give
information for his/her last job or business.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Yes ➔
$
No
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.
,
.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. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
44 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Yes ➔ $
No
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
46 Is this mainly – Mark (X) ONE box.
manufacturing?
.00
Yes ➔
No
$
,
Yes ➔
$
No
,
,
.00
$
Loss
TOTAL AMOUNT for past
12 months
TOTAL AMOUNT for past
12 months
None OR
,
,
.00
TOTAL AMOUNT for past
12 months
Loss
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
retail trade?
No
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
➜
Now continue with the mailing instructions
on page 28.
§.2Aj¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
.00
b. Self-employment income from own nonfarm 50 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 49a
businesses or farm businesses, including
to 49h; subtract any losses. If net income was a loss,
proprietorships and partnerships. Report
enter the amount and mark (X) the "Loss" box next to
NET income after business expenses.
the dollar amount.
wholesale trade?
other (agriculture, construction, service,
government, etc.)?
,
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
45 What kind of business or industry was this?
,
27
Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13173281
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ Then...
• 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
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.
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, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. 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
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(2013)PR KFI (02-06-2012) Draft 2
28
§.2Ar¤
ACS-1(X)T(2010)KFI, Page 28, Base (Black)
Page 28, Green Pantone 354 (20, 40 and 50%)
| File Type | application/pdf |
| File Title | acs1pr_p01_13.g |
| File Modified | 2012-03-01 |
| File Created | 2012-02-06 |