Section 21, Part B - Work Experience and Income - Second Quarter, Fifth Quarter, or New Households Only - Ask for entire household as a group

Section 21, Part B deals with income earned by the household as a whole, including interest income, dividends, rental income, pension income, unemployment and workers' compensation, alimony and child support, tax refunds, inheritance or estate tax, money from food stamps and other government assistance, and other income.

Up until this point, we have discussed earnings for individual members. Now, I would like to talk to you about your household as a whole.

DURING THE PAST 12 MONTHS – ,b> did you or any member of your household receive any interest or dividends? Report even small amounts credited to an account.

  1. Yes
  2. No

What was the total amount earned by all household members?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the amount you or any member of your household received in interest or dividends during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS –
did you or any member of your household receive any net rental income or a loss?

* Net rental income is the total amount after expenses.

  1. Yes
  2. No

What was the total amount earned by all household members?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total net rental income or loss during the PAST 12 MONTHS?

  1. Loss
  2. $0-$999
  3. $1,000-$1,999
  4. $2,000-$2,999
  5. $3,000-$3,999
  6. $4,000-$4,999
  7. $5,000-$9,999
  8. $10,000-$14,999
  9. $15,000-$19,999
  10. $20,000-$29,999
  11. $30,000-$39,999
  12. $40,000-$49,999
  13. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS –
did you or any member of your household receive any royalty income or income from estates and trusts?

  1. Yes
  2. No

What was the amount?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total amount received in royalty income or income from estates and trusts during PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS –
did you or any member of your household receive any retirement, survivor, or disability pensions?

  1. Yes
  2. No

What was the amount?


[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total amount received in retirement, survivor, or disability pensions during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS –
did you or any member of your household receive income on a REGULAR basis from any other source such as Veteran’s Administration (VA) payments, unemployment compensation, child support, or alimony?

  1. Yes
  2. No

What was the amount from all sources?
(Do not include lump sum payments such as money from an inheritance or sale of a home.)

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total amount received in Veteran’s Administration (VA) payments, unemployment compensation, child support, or alimony during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS -
did you or any member of your household receive any lump sum payments from insurance, estates, trusts, royalties, child support, alimony, prizes or games of chance, or from persons outside your household?

  1. Yes
  2. No

What was the total amount received by all household members?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total lump sum payments during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS -
did you or any member of your household receive any other money income, including money received from cash scholarship and fellowship, stipends not based on working, or from the care of foster children, not already reported?

  1. Yes
  2. No

What was the total amount received by all household members?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total amount of other money income received during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS -
did you or any member of your household receive any REFUNDS from any of the following –

Federal income tax in addition to that withheld from earnings?

  1. Yes
  2. No

What was the total amount received by ALL household members? [enter value] ______________

DURING THE PAST 12 MONTHS -
did you or any member of your household receive any REFUNDS from any of the following –

State and local income tax?

  1. Yes
  2. No

What was the total amount received by ALL household members? [enter value] ______________

The Earned Income Tax Credit is a benefit for certain people who work and have low to moderate wages. A tax credit means more money in your pocket. It reduces the amount of tax you owe and may also give you a refund.

During the past 12 months, did you or any member of your household claim an Earned Income Tax Credit on your federal income tax return?

  1. Yes
  2. No

DURING THE PAST 12 MONTHS -
did you or any member of your household PAY any of the following –

Federal income tax in addition to that withheld from earnings?

>
  1. Yes
  2. No

What was the total amount paid by ALL household members? [enter value] ______________

did you or any member of your household PAY any –

State and local income tax in addition to that withheld from earnings?

  1. Yes
  2. No

What was the total amount paid by ALL household members? [enter value] ______________

DURING THE PAST 12 MONTHS -
did you or any member of your household PAY any –

Other taxes such as inheritance or estate taxes?

  1. Yes
  2. No

What was the total amount PAID by ALL household members? [enter value] ______________

DURING THE PAST 12 MONTHS -
Did anyone in this household receive Food Stamps or a Food Stamp benefit card? Include government benefits from the Supplemental Nutritional Assistance Program (SNAP). Do NOT include WIC of the National School Lunch Program.

  1. Yes
  2. No

In how many of the last 12 months were food stamps or EBTs received?

[enter value] ______________

What was the dollar value of the last food stamps or EBT received?

[enter value] ______________

DURING THE PAST 12 MONTHS -
Did you/you or any members of this household, including any children, receive any welfare payments or cash assistance from the state or local welfare office?

Please include even if only for one month. Do NOT include benefits from food, energy, or rental assistance programs.

  1. Yes
  2. No

What was the amount for the PAST 12 MONTHS?

[enter value] ______________

  1. Do not know the exact amount

Could you tell me which range on CARD C best reflects the total amount of income from cash assistance from state or local government welfare programs during the PAST 12 MONTHS?

  1. $0-$999
  2. $1,000-$1,999
  3. $2,000-$2,999
  4. $3,000-$3,999
  5. $4,000-$4,999
  6. $5,000-$9,999
  7. $10,000-$14,999
  8. $15,000-$19,999
  9. $20,000-$29,999
  10. $30,000-$39,999
  11. $40,000-$49,999
  12. $50,000 and over

For definitions Information Booklet »

DURING THE PAST 12 MONTHS –
Have you or any member of your household received any free meals at work as part of your pay?

  1. Yes
  2. No

About what was the WEEKLY dollar value of these meals?

[enter value] ______________

How many weeks did members of your household receive such meals during the last 12 months?

[enter value] ______________

End of Section 21B

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Last Modified Date: April 3, 2013