Consumer Response Intake Forms

Attachment 4 - New Household and Income Questions (OMB No. 3170-0011)
Question: How many people (total number of adults and children) are part of the primary
consumer’s household?
Answer options: Drop-down menu containing the following values:
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8 or more
Question: What is the total combined income of all the people living in the primary consumer’s
household in the last twelve months?
Answer options: Drop-down menu containing the following income ranges:
 $0-$25,000
 $25,001-$40,000
 $40,001-$60,000
 $60,001-$85,000
 $85,001 or more