1993 Panel Wave 8 Questionnaire

OMB No. 0607-0759: Auuroval Exuires 09/30/95

FORM (12-22-94)



SIPP-13800



NOTICE -Your report to the Census Bureau is confidential by law (title 13, U.S. Code). It may be seen only by sworn Census employees and may be used only for statistical purposes.



1 1 i

U.S. DEPARTMENT OF COMMERCE

EUREAU OF THE CENSUS



I ~ o o k (2. (cc I ) (3a. (cc 2) .

R.O. code PSU



I

SURVEY OF INCOME AND PROGRAM PARTICIPATION

1993 PANEL

WAVE 8 QUESTIONNAIRE



I I I I I I I 1I3 I fl I I I ~ 1

Name (cc 19a)



Check Seament Serial S a m ~ l e diait

v



-



/b.fcc3) Add. ID



4. (cc 17) a. Entry add. ID



I C.



1



1



1



1



I



5. PERSON CHARACTERISTICS - Fill a, 6, c, and d using the control card 1 b. Date of birth (cc 24) 1 C. Sex code I d. Marital status I a. relations hi^

code (cc 19b)

Month Day Year



(cc 28)



code (cc 26a)



IIIIIIIIIII

6. Field representative identification

Code



1 Name



7. PERSON INTERVIEWSTATUS a. Interview

I



rson number begin with an "8"?



Self



fl



(Enter person numbed



1 'Type Z other



) zKLp



EM 7



osoo



I



q Yes

No - SKlP to section I, item 1, page 2 were listed for Wave I?



Noninterview Iq Type Z refusal



2 2



Date of interview for this person F;,,start in iterngar Month Day) then go to lntrod~ction



0901



I



i



q Yes - SKIP to section I, item I, page 2



2uNo



9a. Interview time

for this person Start time

- - +



Initial visit a.m. p.m. a.m. p.m.

-



Callback visit a.m. p.m. a.m. p.m.



13a. O n March 31,1993, was..



Finish time



1 0914



+



b. Total interview time

for this person Start time Finish time



/

b



l i v i n g in any o f t h e k i n d s o f places listed o n t h i s card? (Show Flashcard P) SKlP to I Yes section 1, 2 NO- SKlP to section I, item 1, page 2 o f place. . w a s l i v i n g in o n March 31, 19931 I Armed Forces barracks 3 Nonhousehold 2 q Outside the United States setting



.



Minutes

a.m. p.m. a.m. p.m.



b. Which code o n t h i s card represents t h e kind

0916



10a. Field representative edit time



1



.



NOTES



rlla.

I 12.



b. Total edit time

-



Minutes



Pre-interview transcription time Start time + Finish time



I



a.m. p.m. a.m. p.m.



---+

Minutes

2



b. Total pre-interview

time for transcription

I



q Phone interview



Personal interview



1



INTRODUCTION FIELD REPRESENTATIVE INSTRUCTIONS - Read introduction once to each respondent. Do not repeat to another respondent who was in the room when you earlier read the introduction. (As Idescribed during the last interview,) This survey is about the economic situation of people living i n the United State!. Most of the quest~ons will be about . . .Is a c t ~ v ~ t dur~ng ~es , , and -. Here is a calendar that shows the 4 months we will be talkin about.(Hand respondent Flashcard J.) This time perio is very important, so if you have any questions about-what eriod is being referred t o dur~ng the interv~ew,p ease ask me.



d



I'



I



We need the most accurate and complete information possible. Please think carefully about each question, search your memory, and take our time i n answering. For some of the auestions it wiil help t o look ur, the answers b checkin whatever recoids you have available. !O TO C$CK ITEM N1.I G



I



I



Section 1

(SHOW FLASHCARD J)



- LABOR FORCE AND REClPlENCY (continued)

1 1 1 1 ; , l n 7



6a. Please look a t the calendar. In which weeks did



I

I



. . have a job or business? Please answer bv giving the week number that appears t o theright o f each week on t C a calendar .-



.



,



--.-..--..



El

I.I R A



I n12



I



r



Mark (X) all that apply.

I



- .-



I



b. Of those weeks t h a t .



had a job or business. was. absent from work for any f u l l weeks without pay?



..



..



1

I

I

I



1135



1 myeS

I



2



0



No - SKlPto 7a

I I



C. I n which weeks was.



absent without pay? Please answer by giving the week number that appears t o the right o f each week on the calendar? Mark (X) all that apply. 0 6



..



d. What was the'main reason . . . was absent from



. . .'s



job or business during those weeks?



1 7

I I I

2



I



On layoff



q Own illness

On vacation Bad weather Labor dispute New job to begin within 30 days Other - Specifyz



Mark (X) only one.



I

I I I I I I

I



3 4 5 6



7



7a. Ihave marked that there were some weeks i n

this period i n which did NOT have a job or business. During that week or weeks, did . soend anv time lookinn for work or on lavoff?



. ..



7

I



1



I



..



2



yes No - SKlP to 7e



,



b. I n which o f these weeks was. . . looking for



work or on layoff from a job? Please answer by giving the week number that appears t o the right o f each week on the calendar. Mark (X) all that apply.



118 17

1



15



All weeks without a job



1186

1190



1 1188



0 6

I



I



c. Could . . .have taken a job during those weeks

i f one had been offered?



F] I



q Yes - SKIP to 7e



I

I



20No

1 2



d. What was the main reason . . . could not take a

job during those weeks? Mark (X) only one.



I m

I I



Already had a job



3



I I



Temporary illness School 4 C] Other - Specify3



I



e. During the weeks that



did not have a job, did. do any work at all that earned some money?



..



...



f. I n which o f the months shown on this calendar

did



.. . do that work?



= q 1 ;I q I 1220 I I 1 1224



1 Yes - Mark "55" ISS on 2ONo-SKlPto8a.paged



Mark (X) all that apply.



Last month 2 2 months aao 3 3 months ago 4 q 4 months ago



FORM SIPP-I3800(12 22-94)



I



Page 3



1 - LABOR FORCE AND REClPlENCY (Continued)



8a. In the weeks that.



~rked during the hours did 4-month period, how n ~ny usually work per week



. .v



I



. ..

I I I I

I



Hours per week

X3

XI



rn

DK



SKlP to Check ltem R4



Refer to item 8a. Did . . . usually. qork 35 or more hours per week?



1- '

I I



I0



2



~ e s No - SKIP to 8c yes NO- SKlP to Check ltem R4



8b. Did . . . work fewer tha I 35 hours in any of the

weeks that. . . worked during this period? Exclude time off WITH DAY because of holidavs, vacations, days off, or sickness.



'q 7

I

2



I I



C. How many weeks did.



.work fewer than 35 hours in the months 0 (Read each month)? 1



W

1 1234



x5



q All weeks



0 last month Weeks 0 2 months ago Weeks

Weeks 3 months ago Weeks 4 months ago



d. What was the main rea ion . . . worked fewer

than 35 hours in those weeks? Mark (XI only one.



I



I 1238

I



1 2



q Could not find a full-time job

Wanted to work part time

[7 Health condition or disability



II

I



I I



3

4



I



q Normal workina hours are fewer than 35 hours

or Gaterial shortaae " Other - Specify3



I

I



5 q Slack work



I



s



I

I

I



Refer to item 5a, page 2. (Absent without 3ay any full weeks.) The response to item 5a is:

I



1 I

I



1239



1



I



2



q Yes (or blank) q No - SKIP to Check Item R5

Yes - Mark "5" on ISS No - SKIP to Check Item R5 Yes - Mark "6" on ISS



9a. During this 4-month p&iod, did.



receive any State unemploymeit compensation payments? Supplemental



..



'm 1

I



I



I



1



I I



2



b. During this period,



..also receive any



I



Benefits (SUB)?

I

I



ed" (cod? 170) marked on



1 I



1244



/



I 2



yes



I



q No - SKlP to Check ltem R6

[7 Yes - Mark "10" on ISS



10. During this 4-month p iod, did . . . receive



any money from work rs' compensation for any kind of job-related illness or injury? Refer to cc item 44-47. Was an intervie obtained for reference period



I



t 4



I

I



. . . last



1



OY~S



I



2



q No - SKIP to Check Item R I I, page 6



I



I

NOTES



Refer to item 11 page 5. Are anv income lpes listed in the lncome Roster?



'p 1 U Y e s l 0

I 2



q No - SKIP to 12a



Page 4



FORM SIPP-I3800 (12-22-941



Section I LABOR FORCE AND REClPlENCY (Continued)

Il a . According to the information we obtained last time,



-



. . . had received (Read income types in item I column (2)) during (8 months ago) through Ib, (5months ago). At any time during the past 4 months, that is ,and ,did get income from (Read income lb, types in item I column (2))?



C. I "No" in column (4) f



. ..



I



MARK (X) APPROPRIATE BOX IN ITEM I COLUMN (4) FOR EACH INCOME lb, TYPE LISTED.



b. INCOME ROSTER (ISS CODES 1-56)

I



Line No.

(1)



Income type

(2)



I I



Income code



This reference period

(4)



- In which month did . last receive (Read income type)? Note - The month entered in 1I c must be within the previous reference period, Otherwise, i f last received in a month within the reference period, change the entry in column (4) to "Yes" and mark ISS.



..



I

I



(3)



(5)



I



1



i q

I



1

2



Yes - Mark ISS 1255 Month last rec'd q No - Fill col. (5). x3 q Never received

Yes - Mark ISS Month last recld 1259 No - Fill col. (5). x3 qNever received No Fill col. (5).

1263



I



2



-,

I



1258



I

2 2



1



r l



3

4



6 7 llnYes-MarklSS [7 I2G2

I

I



lmMOnthlastrecrd x3 Never received



1266



(lnYes-MarklSS 2 No - Fill col. (5). (lnYes-MarklSS 2 1 No - Fill col. (5). 7



1267 i ~ I M o n t h l a s t r e c 1 d x3 q Never received

1271



5



6Tl - I



I



1270



I~~Monthlastrecld x3 q Never received



6



-1272

I



I



I n *

2



1



q Yes - Mark ISS

No - Fill col. (5).



1275



J



r



x3



Month last ,-ecrd Never received



l



I



7



1278(lnYe~-MarkISS 1279J~~M0nthlastrec'd 2 q NO- Fill COI. (5). x3 Never received

-



8



1282 )lOYes-MarklSS 2 q No - Fill col. (5). period, did . . . get any income from the Federal Government (that we haven't talked about)?



1283 ( ~ l M o n t h l a s t r e c r ~ x3 17Never received



12a. At any time during this 4-month



I



1284



I I I



1



I

2



q Yes



17 No - SKlP to



13a



I



b. What was it called?

Anything else? Mark (X) all that apply.



Social Security - Mark " I " o n ISS 2 q Federal Supplemental Security Income (Federal SSI) Mark "3" o n ISS 3 A serviceman's or widow's pension from the Department of Veterans Affairs (VA) - Mark "8" on ISS I q Anything else - Mark appropriate code o n ISS a n d specify

I



I



k



q

I



13a. At any time during this 4-month

period, did receive any (other) pension, disability, retirement, or survivor income (that we haven't talked about)?



.. .



Yes



,

I



2

i



q No - SKIP to Check ltem R8



b. What was the source of this

income? Anything else? Mark (X) all that apply.



q U.S. Government Railroad Retirement - Mark "2" o n ISS Black Lung payments - Mark "9" o n ISS 3 q Workers' Compensation - Mark "10" o n ISS

I

2



1



9

1- '

I 1320



' 9



Payments from a sickness, accident or disability insurance policy purchased on your own - Mark "13" o n ISS 1 q Pension from company or union (including income from profit-sharing plans) - Mark "30" o n ISS plans 6 q Federal Civil Service or other Federal civilian employee pension - Mark "31" on ISS r 3? U.S. Military retirement pay (exclude payments from the Department of Veterans Affairs (VA)) - Mark "32" on ISS 8 q National Guard or Reserve Forces retirement - Mark "33" on ISS 9 State government pension - Mark "34" o n ISS 10 q Local government pension - Mark "35" o n ISS 11 Income from paid-up life insurance policies or annuities Mark "36" o n ISS 12 q Other or DK - Specify and enter code from income source list. I f income type is not listed or "DL" enter code 1138"i - Mark ISS

4



1



1322



1-1

I



; Ly



- Mark " 172" o n ISS a n d SKlP to Check ltem R23, page 8



FORM SIPP-13800 (12-22-94)



Page !



Sectior 1



- LABOR FORCE AND REClPlENCY (Continued)

I 1326 I



Is "Disabled" (coce 171) marked f o r . . .? Refer to cc item 2 4. years of age or older? Refer to cc items 32a and 32c. Is . . . a veteran o ' the U.S. Armed Forces? (Mark "No" if currlently in Armed Forces.)



13281 '

I

I



I



I Yes - Mark "171" on ISS and SKlP to 23a. page 8 20No I



q Yes - SKIP to 23a. page 8

No - SKIP to Check Item R23, page 8 No - SKIP to Check Item R12



2

I



1 qyes

,

2



14a. How long d i d . . . serve n active duty in the

Armed Forces?



' 3q Less than 6 months

I

I I I I I 2 3

4



q 6 to 23 months



xi

I



2 to 19 years 20 or more years DK Yes 14d



b. Does . . . have a service connected disability;



that is, a health conditi n or impairment caused, or made worse by m i l i t r y service?

I



C. What i s



. ..'s V A perce Use the following probe 20,30,40,50,60, 70,



t

I

I



,13311

xi



"No ) SKlP to DK

c



disability rating? (Such as 0, 10,

I



I

I I I



0% x i DK x2 q Ref.

x3

101



Mark .z(roM ISS if on rating is 100%; otherwise, mark "20 I "



I



No rating



d. During this 4-month pe od, did . . . receive any

payments from the De Affairs (VA)? (Exclude pay, insurance procee



rtment o f Veterans I ular military retirement I nd GI Bill benefits.)

I



/ 1338 1



I Yes - Mark "8" on ISS 20No



Refer to cc item ; 4. Is . . . 18 years of age or older?



1

I



1



I



OYBS

No - SKIP to 18a Yes - Mark " I " on ISS No - SKIP to Check Item R14



2

I



15a. During this 4-month pel iod, did . . . receive any

Social Security paymen s? is it because. . is (Reac categories) Mark (X) only one.



1-'

I



2 I 2



b. What is the reason . . . i getting Social Security, 1-;



.



-



I I I I



q Retired? q Disabled? 3 q Widowed or surviving child?

4



I

I

I



5



XI

i 2



Spouse or dependent child? Some other reason DK



C. Sometimes people get iocial Security f o r more



than one reason. Is the e another reason receives Social Securil



...



I I I



17 Disabled



Retired



I

I I



Widowed or surviving child 4 [7 Spouse or dependent child 5 No other reason xi DK

3

I



and 15c above. Is "Disabled" (bo: 2) marked in either item?



q Yes

No - SKIP to 16a ~ g in years e



2



15d. A t what age did . . .

Security because o f

I

I I



/

xi

x2

1



DK Ref. Yes No - SKIP to 16a



SKlP to 16a



I



Refer to cc item 2 7. Is . . . the design d parent or guardian of children under 1 ears old who live in this household? I



1I



2



-



I



15e. During the 4-month per od, did . . . receive any

Social Security paymenS:s especially f o r . children (under IS)?



. .'s



I I

I



I q Yes - Mark " I " on ISS 20No



16a. During this 4-month pe od, did . . . (or any

o f . . .'s children under (Supplemental Securit the U.S. Government? Income) payment? Mark (X) only one.

C. Did



I



1354



receive any SSI come) payments from



I

I



1



I 2



q No - SKIP to Check Item R15

Adult(s)



Yes - Mark "3" on ISS



b. Who received the SSI (S ~pplemental Security



11 I I



I



I 2



q Child(ren1 3 q Both adult(s1 and child(ren)

I q Yes - Mark "4" on ISS 20No



also receive a S PARATE SSI payment from the State or local elfare office during these months? I s . . . 40 years of age or older?



. ..



t



' F i

I



I

I



2



q No - SKlP to 18a

I

FORM SIPP-13800 (12-22-94)



I



Page 6



I



Section I - LABOR FORCE AND REClPlENCY (Continued) 17a. Has . . . ever retired from a job or business? iI Yes

(Include retirement from the military.)



3

I I

I



I



2



No - SKlP to Check ltem R16 Yes No - SKIP to 17d



b. During the 4-month period, did . . . receive any

C. What kind o f retirement income?



1 1362 I



I



retirement income other than Social Security?



2 I



1 1364 (

I I



Anything else? Mark (XI all that apply.



1

'3

I



1

I



1- '

1374

I 1378

I I



U.S. Government Railroad Retirement - Mark "2" on ISS 2 36 Pension from company or union (including income from profit sharing plans) - Mark "30" on ISS - 1 3 Federal Civil Service or other Federal civilian employee pension - Mark "31" o n ISS 4 U.S. Military retirement pay (exclude payments from the Department of Veterans Affairs (VA))Mark "32" on ISS s National Guard or Reserve Forces retirement Mark "33" on ISS 6 State government pension - Mark "34" on ISS 7 0Local government pension - Mark "35" on ISS 8 Other or DK - Specify and enter code from income source list. If income type not listed or "OK, " enter code "38"3 - Mark ISS



d.



During the 4-month period, did . . receive any regular income from a paid-up life insurance policy or any other annuities? Refer to cc item 24. years of age or older?



.



11 7

1 I



Yes - Mark "36" on ISS



2uNo



I



;; ;

2



- SKIP to Check Item R 17



I



18a. Does.



. have a physical, mental, or other health condition which limits the kind or amount of work.. . can do?

income because o f . .'s health condition or disability? (Other than Social Security, SSI, or VA?)



.



7 I Yes - Mark "171" on ISS '1



,



No - SKIP to Check Item R17



I



b. During this 4-month period, did . . . receive any



.



i 10yes q

1



I I



XI



"No) DK

I



SKIP to Check Item R17



I



C. What kind o f income?



'3

I



Anything else? Mark (X) all that apply.



'(3981

I



IF^

I

I



U.S. Government Railroad Retirement - Mark "2" on ISS 2 Black Lung payments - Mark "9" on ISS 3 Workers' Compensation - Mark "10" on ISS 4 Payments from a sickness, accident, or disability insurance policy purchased on your own - Mark "13" on ISS 5 Pension from company or union (including income from profit-sharing plans) - Mark "30" on ISS 6 6 Federal Civil Service or other Federal civilian employee pension - Mark "31" on ISS 7 U.S. Military retirement pay (exclude payments from the Department of Veterans Affairs (VA)) Mark "32" on ISS 8 State government pension - Mark "34" on ISS 9 Local government pension - Mark "35" on ISS 10 Other or DK - Specify and enter code from income source list. If income type not listed or "OK," enter code "38" - Mark ISS



I



Refer to cc item 26a. What is . . .'s marital status?



'3

I I 2 3

4



I



Married - SKIP to 20



6Widowed - SKIP to 22a

[7 Divorced



I

I



I



5



Separated Never married - SKIP to Check Item R18 Yes - Mark '29" on ISS and SKIP to Check Item R18 SKIP to Check Item R18



19. Did . . . receive any alimony (or support



payments other than child support) during the 4-month period?



; T I

I I



I



I



x2

1



Ref. Widowed - SKlP to 22a Divorced Both widowed and divorced No - SKIP to Check Item R21 Page 7

I



20. (People who have been widowed or divorced

sometimes receive income because of their former marriage.) Has. . .ever been widowed or divorced? If "Yes," mark previous marital status.

I



2



I

I



3

4



I



I



FORM SIPP-13800 (12-22-94)



Sectior 1 - LABOR FORCE AND REClPlENCY (Continued)

27a. Was..



1



. covered by a any time during the p (Include CHAMPUS, coverage.) (Exclude Medicaid, benefits only for ac diseases.)



2 I



No - SKIP to Check Item R30



ASK OR VERIFY b. Was.. covered by a health insurance plan during the entire 4-mon;h period?



.



-;



I



I I



Yes - SKIP to 27d 20No

I



C. In which months was.



. .covered?



Mark (X) all that apply.



Last month 2 months ago 3 months ago [7 4 months ago

I 2 3



d. Was . . .'s health



coverage from a plan holder), or was, on someone

I

I I



Plan in own name - SKIP to 27f Someone else's plan Both - SKlP to 27f



e. Whose plan covered . . .



Household member

Person No. Name



I

SKlP



I I I



x [7 Not a Household member 4 employer or union Former employer 3 [7 CHAMPUS 4 CHAMPVA 5 Military SKIP to 27h 6 Other XI 17 DK

2 I

I[7 Current



f. Was . . .'s policy obtained through . . .'a current



employer or union, thro ~ g a former employer, I h through the CHAMPUS or CHAMPVA programs, ] or in some other way?

I I I I I



I 1549 I



I



g. Did . . .'s employer or u

pay all, part, or none this plan? plan?



(former employer) premium (cost) of

I



2 3



1All Part 0None

Individual - SKlP to Check Item R30 Family All persons

Name



h. Was . . .Is plan an indivi ual plan or a family i. Other than . .., which p rsons in this household

were covered by . . .'s p n? (Include children as we1 as adults.)



f



1- '

I



7 2



t

I

I



x5



Person No.

I



x3



None



j. Did . . .'s plan cover anybne who did not live in

this household during tke past 4 months? Mark (X) all that apply. If "Yes," "Who did the pla 1 cover?"



9

I



I



I 1569



Yes, spouse Yes, child(ren) 3 Yes, someone else 4uNo

2



I



Page 10



FORM SIPP-13800 112-22-94)



I



Section I LABOR FORCE AND REClPlENCY (Continued)

Are any assets listed in the Asset Roster?



-



'1588

I

I I



2



I

we 28a. According to the inforn~ation obtained last time,



n ~ e s No - SKlP to 29a



had (Read asset types in item 28b, column (2)) during (8 months ago) th *ough(5 months ago). 4 t ,and At any time during the ~ ~ a smonths, that is (Exclude IRA, Keogh, ,did . . . st IIown (have) (Read asset types in i t e h 28b, column and 401K accounts.) MARK (X) APPROPRIATE FOX IN ITEM 28b, COLUMN (4) FOR EACH ASSET TYPE LISTED.



...



b))?



b.



ASSET ROSTER (ISS C O ~ E S 100-150,

,et type



174)



Line



I

I



;

I I I



1590



,



Asset code



I



This reference period



;i ,

1596



I



- Mark ES



I



1 I q Yes - Mark ISS

20No



2

1600



3

4



3



3



I q Yes - Mark ISS 20No



-;

I I



I



1604



1 I q Yes - Mark ISS

20No



' 1608



5



:+q

1612



1 I q Yes - Mark ISS

20No



1



I



OYes - Mark ISS



1 6 1



I



20No



; ;y

I



I

- Mark ISS



1620



3



8 (SHOW FLASHCARD N)



29a. (In addition to the asse



we have already mentioned) At any tim during the 4-month period did . . . have any other) kinds of assets which earn interest or ring in money, such as the ones shown on this ard? (Exclude assets held in IRA, Keogh, and 401K accounts.)



b. Which kinds of these a

Any others?



I



I q Yes - Mark ISS 20No



I



x2 q Ref.

I I I I I



ets did



. . . own?



1



1626



1



I

2



Regular or passbook savings accounts ...



Mark "100" nn .- S - . .- . - - - .. I S



(Exclude IRA, Keogh, a



401K accounts.)



I



-;

I



Money market deposit accounts - Mark "701" on ISS 3 Certificates of deposit or other savings certificates - Mark "102" on ISS 4 Interest-earning checking accounts (such as NOW or S u ~ e NOW accounts) - Mark r "103" on ISS 5 Money market funds - Mark "104" on ISS 6 q U.S. Government securities - Mark "105" on ISS 1 q Municipal or corporate bonds - Mark "106" on ISS 8 Mortgages - Mark "130" on ISS 9 q U.S. Saving Bonds (E, EE) - Mark "174" on



IS S .-



10

I I



Other interest-earning assets - Mark "107" on ISS and specifyz



' 7 3

,

I I I



11

12



q Stocks or mutual fund shares - Mark "110"

on ISS



q Rental property - Mark "120" on ISS

Royalties - Mark "140" on ISS



13 14



q Other financial investments - Mark "150"

on ISS and specify



Page 12



FORM SIPP-13800 (12-22-941



Section I - LABOR FORCE AND REClPlENCY (Continued)

30a. Was . . . enrolled i n school, either full time or

part time during any of the past 4 months? (Include any regular school, such as elementary, high school, or college, or any vocational, technical, or business school.)

I



1 17 17

I 2



I

I

I



yes,full time Yes, part time 3 q No - SKIP to Check Item R32

I

2 3



b. During which months was . . . enrolled?

Mark (X) all that apply.



q All months

Last month



q 2 months ago 4 q 3 months ago 5 q 4 months ago



C. A t what level or grade was.



. . enrolled?

I



I

2



Elementary grades 1-8



(If enrolled at more than one level during this period, check most recent level.)



I



I I I I



I



I I I



q High school grades 9-12 3 q College year 1 4 q College year 2 5 q College year 3 6 q College year 4 7 q College year 5 8 q College year 6

9



0Vocational school

q Technical school



I



I



10 11



0Business school



31a. Were any o f . . .'s educational expenses during



the last 4 months paid for by the GI Bill, a PELL (BEOG) Grant, a Guaranteed or National Direct Student Loan, any type of scholarship, grant, or other educational assistance? receive? Anything else? Mark (X) all that apply.



' 10 Yes 5

I

2



I



17 No - SKlP to Check ltem R32



I I

I



b. What kind of educational assistance did . . .



Fi l

7

32.

Refer to cc item 26a. Is code 2 (married, spouse absent) the current entry?



GI Bill - Mark "40" on ISS Other Department of Veterans Affairs (VA) Educational Assistance Programs (Survivors and Dependents; Vocational Rehabilitation; Post-Vietnam Veterans) - Mark "41" on ISS College Work Study - Mark "175" on ISS PELL Grant - Mark "176" on ISS Supplemental Educational Opportunity Grant (SEOG) - Mark "777" on ISS Perkins Loan or National Direct Student Loan (NDSL) - Mark "178" on ISS Stafford Loan or Guaranteed Student Loan Mark "779" on ISS Parent Loan for Undergraduate Students al (PLUS) or S u ~ ~ l e m e n tLoan for Student (SLS) - ~ a r k ' " ' l 8 0 " ISS on 9 q Assistance from . . .'s employer Mark "181" on ISS 10 q Fellowship/Scholarship - Mark "182" on ISS 11 Other financial aid - Mark "183" on ISS



1 No - SKIP to Check Item R33 2 17

I I



ASK OR VERIFY Is . .'s spouse in the Armed Forces?



.



'pi



I ayes 20No

IO Y e s



re any codes (excluding codes 171-173, 200-201) marked on the ISS?



1

I

I



1698



(



2 U



No - SKIP to 34a Yes No - Probe and resolve (Make corrections to ISS if necessary)



33a. You said that during the 4-month period . . .



owned (had) (Read all items marked on the ISS, except codes 171-173,200-20 1). Is that correct?



1 q

I

2



b. Did . . . receive income from any other source



1 1702 1



IU Y e s



such as financial help from someone outside the I I household, payments from the government, or I anvthing else? I

I income from some source we have not covered, I such as financial help from someone outside the I household, payments from the government, or I anything else? 1 I



2



- SKIP to 346 [7 No - SKIP to Check Item E l , page 15



34a. Ihave not recorded any sources of income for



. . .during the 4-month period. Did . . . receive



1-1



I

2



q Yes q No - SKIP to Check Item PI, page 53



I



b. What kind of income did . . . receive?

Anything else?



I

I



i ~ ~ l I I I



Enter codes from income source list and mark ISS.



I

I



I FORM SIPP-13800 (12-22-94)



Page 13



NOTES



-



I



I



~



I



Page 14



I



FORM SlPP 13800 (12 22 94)



-



Section 2



- EARNINGS AND EMPLOYMENT



Is 'Worked" (code 170) marked on ISS?



1 Yes q No

1 1



I I



2



- SKIP to first ISS Code marked or



Check Item PI, page 53

I



la. You said . . . worked during the 4-month



period. Was. working for an employer or was . self-employed?



..



..



I

I



2 3



(Include unpaid worker in family business or farm as working for an employer.)



I I



Worked for employer only Self-employed only - SKlP to Statement B, page 20 Both worked for employer and self-employed

Iemployer 2 employers 3 or more employers



b. How many different employers did. . . work for

during this 4-month period?



7

1 I I

I



2 3



IU Y e s



Is "Both worked for employer and self-employed" (box 3) marked?



I



2



No - SKlP to 2a, page 16



. . .worked for an employer and was also self-employed. The first questions will be about. .'s work for an employer.



.



Page



2a. What is the n



. . .worked d



Employer name



4



Twice a month



4-month period?



-



-



-



Section 2

Part A1



- EMPLOYER IDENTIFICATIONNUMBER 1(Continued)

;

I

I I I



- EARNINGS AND EMPLOYMENT (Continued)

.



8a. READ STATEMENT ONLY ONCE PER RESPONDENT

The next question is about the pay. . received from this job during the 4-month period. We need the most accurate figures you can provide. Please remember that certain months contain 5 paydays for workers paid weekly and 3 paydays for workers paid every 2 weeks. Be sure t o include any tips, bonuses, overtime pay, or commissions. What was the totalamount of pay that. . . received BEFORE deductions on this job in (Read each month)? FOR MEMBERS OF THE ARMED FORCES - (Be sure to include cash housing allowances and any other special types of pay.)



LAST MONTH

x3



FIELD REPRESENTATIVE USE ONLY



I



I

I I



None



I I



xi DK x2 q Ref.

Total $



*



:1



.oo



-



------



--------



I



I



2 MONTHS AGO



I



I

I I I



x3 q None

x i q DK x2 I7 Ref.



$



I



I I C---------------I



I

I



3 MONTHS AGO



t



Total



$



.oo .oo



-------------



I I I



x3 xi



None



DK

$

Total



I x2 Ref. I I C---------------I I 4 MONTHS AGO I



I



$



.oo .oo



I I I

I



x3 xi



None DK



I I I

I

I



x2 q Ref.



I

I



Total



$



.oo



Is "DK' marked i n all parts of item 8a?

I

-



2 q NO -



,10Yes



SKIP to 8c



8b. If Iwere t o call back later, would YOU (or .. .)



-



be able t o provide me w i t h the amounts of pay received i n each of these months? (Information about how much . . received each month i s very important t o the results of this survey.)



...



I I



' 3



.



I



,

I



Yes - Mark Callback Summary and Reminder Card, Item 3a 20No



9a. On this job, was . . . a member of a labor union

or a member o f an employee association similar t o a union during the 4-month period? association contract during the 4-month period? Number of employers in item Ib,



'20411

I



q Yes - SKIP to check item ~5 20No

~ 20No

1~



b. Was. . .covered by a union or employee



1- I

I



e



s



I

I



12048

I



2



1 0 1 employer-SKlPtoCheckltem E8,page 19 17 or more employers 2



1I



NOTES



I



FORM SIPP-I3800 (12-22-94)



Page 17



Retail Trade?



[7 State government? [7 Local government?



Armed Forces?



Mark (X) only one.



3



Discharged



6 [7 Quit



for some other reason



4



[7 Twice a month



4-month period?



Section 2 - EARNINGS AND EMPLOYMENT (Continued)

-



Part A 2



- EMPLOYER IDENTIFICATIONNUMBER 2 (Continued)



-



16a. READ STATEMENT ONLY ONCE PER RESPONDENT

The next question is about the pay. received from this job during the 4-month period. We need the most accurate figures you can provide. Please remember that certain months contain 5 paydays for workers paid weekly and 3 paydays for workers paid every 2 weeks. Be sure t o include any tips, bonuses, overtime pay, or commissions. What was the total amount of pay t h a t . received BEFORE deductions on this job i n (Read each month)? FOR MEMBERS OF THE ARMED FORCES - (Be sure toincludecashhousingallowancesandanyother special types of pay.)



I

I

I



..



FIELD REPRESENTATIVE USE ONLY



LAST MONTH



I

I



$



.OO

.OO



I

I I I I



..



x3 ! None l x i DK x2 fl Ref.



$

$ $

Total $



.oo

.OO



I I

I



.oo .oo



*3

I

I



I



C---------------I I



--------------



2 MONTHS AGO



$



.

None DK Ref.

Total

\



$



I

I I I



x3 xi x2



$

$ $ $



I I I

I



.oo .oo .oo .oo .oo .oo



I



C-----------------------------I I I 3 MONTHS AGO



I



I



l

I I



x3 xi



None DK



I

I I I



x2 0Ref.



I



I



Total



$



.oo



I



I



4 MONTHS AGO



I



x3 xi



None



I

I



DK $

Total



I I

I I

I



x2 !Ref. l

I



$



.oo .oo



Is "DK' marked in all parts of item 16a?

I



,myes

2 I



NO- SKIP to 1 6 ~



16b. I f Iwere t o call back later, would you (or. . -1



be able t o provide me w i t h the amounts of pay . . . received i n each of these months? (Information about how much received each month is very important t o the results of this survey.)



1-'

I I l

I



...



Yes - Mark Callback Summary and Reminder Card, Item 3b 20No



C. Counting all locations where this employer



operates, what is the total number o f persons who work f o r . .'s employer?



.



7;

I



I

I I



(Read categories)



I

I I



Under 10 C] I 0-24 3 25-99 4 100499 5 500-999 6~ IOOO+

2

I Yes - SKIP to Check Item ~8 20No



17a. On this job, war . . . a member of a labor union

or a member o f an employee association similar t o a union during the 4-month period? association contract during the $-month period?

I



b. Was. . . covered by a union or employee

I

I



x 3) marked in item la,

I



I I I

I



2



Yes - Read Statement B, page 20 No - SKlP to first ISS Code or Check Item PI, page 53

I



FORM SIPP-I3800 (12-22-94)



Page 19



lt6-zzzLl 008rr-ddts tAUol



OZo6ed



9S Luail4caq3ol dtxs - oN n,



J sa^n, ly

ONf]Z



sl zqg jo e9 urolrroqlra ul )euerrl,,sa^,,



ffi



so ^n t

oNt]z sa^nr



I ttZZ t



epolred qluour 7 slql6ulrnp sseulsnq eql urorl eruocu! (rsq o l A u e e ^ l e c e , ' ' ' p l o ' q

epoFed qluou ? oqt 6u;rnp sseulsnq e slrll ruo4 fueles r e ; n 6 e r p l e d ' ' ' s e 6 ' g g



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asreqrueurqclqM

I



'q



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assoulsnq slql u! sroulrel ro sreururo ploqesnoq 'e9 slqt lo sreqruoru rarllo Ar r oro^ ' ' ' ruorl eplsv e ro d!qsrolelrdord e;c 2d;qsreuyed e s s e u l s n qs , ' ' ' s P M ' q r u !s s e u l s n q s , ' ' ' s e M ' p t ctu ro 000'L J! 666 raw:l "''opnlcu! rlsnq s!ql ro16u;>;rom ru lElol eql serurlPqM 't



drqs:auye65 z eg ot dtXS - drqsrolaudordalog a r l z z z zt



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I



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zroql rouJploqasnoll sr raqloueAq sseursnq uaaq Apeorleqg-g 'sasuadxe oJo|eq sldtocoJ pue s€le epnpur s6uluJea ssoJg



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)OIrx 0LoldtNS-oNIz sol!, @ )cl ! rx euoNI tx



asqluour z! lxou eq16u;rnp eroul Jo o 'O'l$ eq lllrn sseulsnq slrll to s6uluree ssorc eql teqt {u!qr noA oq



srnoH



lffi

NE



k uu-d;

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-!



{rornA;;ensn"'plp



esseulsnq s!ql lP red srnoq Aueur lt oH '6 - A]A1A AO >tSV seulsnq s!ql le sollnp 'l s,' JSOrfr ' ' eren rPqru



ls y{gd, 8027



ro se!l!A!lce luelrodur slql le 6u;op '



-



|;*:fil€fd



essou!snq l^,r{rorur lo pu!{ teqM 'e



usseulsnq ,o pu!{ reqlo autos ! r .,,,,,::::] aeperlllereurt aeperr etesetoq6n r E-9s;



2ou;rnlcelnuenr r ffit ffi



- AltalA ao xsv



- Alu;eur f! sl 'p



t-q



1,,VQ26.,:',1. wa I I Ulrsd

re



zslql sern seulsnqJo pu!{ reqM'c



6totaUS-oNflz l::,8&.&,:,, lsBd eql6ul np paEueqc sseulsnq plF s a ^ n t i8::nCd, esqluoru S 8!ql rol sellnp ro sell A l l c e u l P u r s , ' ' ' a ^ e H ' q J



cLotdtxs-oNnz

so^E t



W



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!i!r!i!! t



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|



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#Sl|;,jiiil$3 rffi



..



.:.....: .....



I



aulPu ssoulsng l8 ill5dl -



-!.



ssotb 1's6ututee paq61t1 dunnpord s. tsaulsnq aql zg pue Lg aqt z . ut Joluo'sassoulsnqaJoLu tgupeAoldua-lpsseM ' ' 'il'ZZ a6ed'79 yed u1rct p aql pue aJeLl ssaulsnq seM' ' ']t) ouo Jalue'sessauBnqz u! rcAoldtua-11as aurrPJ acglcerd ;euogsse;ord 'Pl ' ' , r erueu eql serurreqrn / s s e u l s n qs , '



'polred qluour-? slqloulrnp



paAoldure-fles (osle) serur' ' ' pl



sno^ @



I UfgnnN NotlvSHllNfot



rNftN^o]dnf-l]3s



- tg r, td



(panulluoc) INilN^o]dwf



oNV s9NtNUVa - z ul !lces



Section 2 - EARNINGS AND EMPLOYMENT con tin^

Part B1 - SELF-EMPLOYMENT IDENTIFICATIONNUMBER 1 (Con1



7. READ STATEMENT ONLY ONCE PER RESPONDENT.

The next question is about the income. . . received from this business during the 4-month period. We need the most accurate figures you can provide. What was the total amount o f income t h a t . received from this business i n (Read each month)? NOTE - Include total gross earnings before any deductions.

I



FIELD REPRESENTATIVE USE ONLY



I

I



LAST MONTH



..

I I I I



x3

XI



None



*



q DK

Ref.

Total $



x 2



.oo



L---------------I

I I



2 MONTHS AGO



I I



x 0 None 3

XI



I

I I



0DK

Ref.

Total



I

I I



x 2



$



.oo



r----------------.



3 MONTHS AGO



I



x 3

XI



None



I

I I I I



DK

Ref.

Total



x 2



$



.oo



I

I



4 MONTHS AGO



I I



x3

XI



None



I

I I



0DK

Ref.

Total



I

I



x 2

I

2



$



.oo



I

ayes No - SKIP to Check Item S5



Is "DK" marked in all parts of item 7?



kF ! )

I

I



8. If1 Were t o call back later, would you (or . . -1



be able t o provide me w i t h the amounts o f income. . . received i n each o f these months? (Information about how much received each month is very important t o the results of this survey.)



' F

I



...



I I I I

I



yes - Mark Reminder Card and Callback Summary, ltem 4a 20No



Refer to item 4a, page 20.

Is this business incorporated? Has information about the net profit (or loss) for this business already been obtained from another household member?



22501

I

I



10Yes-SKlPto I1 20No ;:is-SKlPto 11



I I I



9a. Can you give me an estimate o f the net profit

or loss, that is, the difference between gross receipts and expenses for this business, during the 4-month period?



'

I

I



~



0yes 2 m N o - S K l P t o 11



1



b. What was the net profit or loss?

If "broke even," enter $1 in box,



I



14

I



")sK/pto



Loss in amount box



10. About how much did . . . earn from this



I



business after expenses during the 4-month period?



1 7

I



I



I

I I



x3 None xi [7 DK x 2 Ref.



11. Was . . .self-employed i n any other business

(professional practicelfarm) during the 4-month period?

:ORM SIPP-13800 (12-22-94)



I I

I



q yes

2



No - SKlP to first ISS Code or Check ltem PI, page 53 Page 21



Sectijn 2



- EARNINGS AND EMPLOYMENT (Continued)

Business name



r more businesses,



usiness I.D. No.



I



I



U None x i q DK

x3



13. Do you think that the gross earnings of this

business w i l l be $1'0 0 or more during the next 12 months? Gross earnings include ;ales and receipts before expenses. 14-16b already been is business by another household mer iber?



t



1-;



,



q Yes

2 XI 0



I



N O - SKlPt021 DK



I

I



' , 3 q Yes - SKIP to 17a

I



20No



I



14. What was the total n

working for this include .



o f employees



. ..



Enter 999 if 7,000 or more employees.



15a. Was . . .'s business i n orporated?



t



1 211811 a

I I



Employees



XI



DK



I

I



1



I



q Yes - SKlP to 16a

Sole proprietorship - SKIP to 17a Partnership



I



20No



b. Was . . .'s business a ole proprietorship or a

partnership?



1-b

I



2



16a. Aside from . . .were

household owners



other members o f this i n this business?



,

I



,q yes

2 0



No - SKlPto 17a

Name



b. Which members?



I



I



Person No.



I



17a. Was . . . paid a regula~ salary f r o m this

business during the 4 month period?

I



b. Did ...receive any (o.:her) income from the

business during this 4 -month period? Is 'Yes' markec in either item 17a or 1 7 b l

I



,w* yes

I



I

I I



20No



,23361 nyeS

I 2



q No - SKlP to Check Item S11

I



Page 22



FORM SIPP-13800 (12-22-94)



Section 2

Part B2



- EARNINGS AND EMPLOYMENT (Continued)



18.



- SELF-EMPLOYMENT IDENTIFICATIONNUMBER 2 (Continued) READ STATEMENT ONLY ONCE PER RESPONDENT. I FIELD REPRESENTATIVE USE ONLY I The next question is about the income. . . I

received from this business during the 4-month period. We need the most accurate figures you can provide.

I I



LAST MONTH



What was the total amount of income that. received from this business i n (Read each month)?

NOTE - Include total gross earnings before any deductions.



..



'msl

I I I



x3

XI



None



*



DK

Ref.



I

I I I



x 2



L----------------



2 MONTHS AGO



1



Total $



.oo



I I I I I I I

I



x3 [7 None

XI



x 2



DK Ref.



Total



$



.OO



r----------------



3 MONTHS AGO



I



x 3 xi



None DK

Total



I

I I I I I



$ $



x q Ref. 2

4 MONTHS AGO



.oo .oo



k--------------



I I I



x3

XI



None

Total



I

I



I



DK x [7 Ref. 2 I ~ Y L

2



$



.oo



Is " D K marked in all parts of item 18?



1 1

1



I

I



No - SKlP to Check ltem S I 1

i



I

~



19. If Iwere t o call back later, would you (or . . .) be



able t o provide me w i t h the amounts of income received i n each o f these months? I (Information about how much received I each month is very important t o the results of I this survey.) I



'3,



...



,



...



yes- ~~~k ~ ~card and ~ Callback Summary, ltem 4b 20No



I



I



Has information about the net profit (or loss) for this business already been obtained from another household

mnmhnr7



I I I



----



, ,nv,,

'

Y



'



V Y



-K I P



'..'.



tn f i r r t K C f iV l o n r rVU L " Y

IVY " I



Check ltem PI, page 53



"."'



20N0



20a. Can you give me an estimate of the net profit

or loss, that is, the difference between gross receipts and expenses for this business, during the 4-month period?



-; ,

I I



2



yes No - SKIP to first ISS Code or Check ltem PI, page 53



b. What was the net profit or loss?

If "broke even," enter $1 in box.



I



1 7 ' ~ x r O3 LOSSin amount box

I



SKlP to first ISS Code or Check ltem PI, page 53



1 21.



I

1



About how much did . . earn from this business after expenses during the 4-month period?



.



I



I

I



x3

XI



I



x 2



None DK Ref.



1 1



SKIP to first ISS Code or Check ltem PI, page 53



I



I

I



FORM SIPP-I3800 (12-22-94)



Page 23



Section 3 - AMOUNTS

Part A



- GENERAL AMOUNTS (ISS Codes 1-56)

I



1. You said ... received (was authorized t o



I



Income code



Name of income type



receive) (Read name oi'income type) during the 4-month period.

(Read "was authorized to receive" if asking about

I



I

I I I I I 2

3

4



10 ISS Code 1 or 2 (SS or RR)

q ISS Code 25 (WIC) - SKIP to 13a, page 27 q ISS Code 27 (Food Stamps) - SKlP to I la,

page 26



I

I I

I



q ISS Codes 37, 50, 51, 52, 53, or 56 - SKIP to

Check Item A4



5



q Other ISS Codes - SKIP to Check Item A4. I

yes



ID



Is . . . a design: ted parent or guardian of children under sge 18?



I I



2



q No - SKIP to Check Item A3

yes



I



2. During this 4-month period, were any separate

payments from (Socia ISecurity1Railroad Retirement) received ?speciallyfor .. .'s children?

I I I 2



No - SKIP to Check Item A3



separate payment for

I 2



No - SKIP to 9a, page 26



Is . . . married?



I

I



2



No - SKIP to Check Item A4.1



4. Did ... receive (Socia Security/Railroad

Retirement) jointly w i :h



.. . ' s



spouse?



7

I 2



i U ~ e s No - SKIP to Check Item A4. I Check ltem PI, page 53



received b y .



. . from the income source



'30151

Is this income source listed on the income roster?

I

I I



I q Yes - ASK 56 2ONo-ASK5a



5a. I n which month, during the 4-month reference

period, did ... begin t o receive (Read name of income type)?

I



5 ~ Some persons receive more .



than one payment per month for certain income types.

read I or 2 (SS or RR)



Mark "Yes" in item 5b fo the first month received and mark "No" for the p~evious months. Then ask if it was received in each c f the remaining months of the reference period anc mark item 5b.



/

I I



b For ISS codes



b. Did ... receive any (Rt!ad name of income type)

i n (Read each month)?

NOTE - Social Security 2nd SSI payments may be adjusted for inflation each January.



I



How much did ... receive in (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.



I I I I



b For all other ISS codes read How much did ... receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month BEFORE any deductions.

IU Y e s



I I

I I



I



(Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



9

I I I I



XI



20No q DK



XI q DK x2 q Ref.



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .



1- '

I

I I I I



I Yes 20No xi DK



x i q DK x2 q Ref.



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .



1'



I



q Yes



3026



I I I I



XI



20No q DK



. I7 1

XI q DK x2 q Ref.



(4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .



13028

I

I



I

I



I Yes 20No x i DK



3030



I



DK x2 q Ref.

xi



7 1

.

FORM SIPP-13800 (12-22-94)



Page 24



I



I



Section 3 - AMOUNTS (Continued)

Part A



I



I



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)



Mark (X) income type code.



7

1



I



I



3032



2



I



r

(



I

-



ISS Code 1 or 2 - SKIP to Check Item A6.1 ISS Code 8 or 20 through 24 3 q All other income codes-- SKIP to next ISS Code o r Check Item PI, page 53

I

-



1

I



6a. Were all the people living here covered by . .

payments?



. S I



yes- S I to Check /tern A 6 KP

2UNo

Person No.

1 ,

I



I

I



b. Which persons were covered?



I



Name

I



I



1 I

--



2U NO



-



U Yes -.



- SKIP t o next ISS Code or - - - -- - .



- .-.-



Check Item PI, page 53



,



7a. What type of Veterans' payments did .

receive?



-



..

I



I



Service-connected disability compensation



I

I

I

-



2 3



q Veterans' pension 4 q Other Veterans' payments

DK

SKIP to next ISS Code o r Check Item PI, page 53



• Survivor benefits



b. Is . ..required t o fill out an annual income



questionnaire i n order t o receive a VA pension? I

I

I



XI



Refer to cc item 45. Was Social SecurityIRailroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period?



I C]Yes - SKIP t o Check Item A 7 1 2 i Z I N o



I



(SHOW FLASHCARD O)



8a. (Social Security/Railroad Retirement) sends out

checks i n two different colored envelopes. Please look at this flashcard and tell me which color envelope .'s check comes in. (Remember, we are interested i n the color of the envelope, not the color of the check.)



; & ; I ;

I



..



/



3

4



Direct deposit



I I

I



q Other



x i • DK

3066



b. Do . . .'s payments usually come on the first of

the month or the third?



I

I



1



I

2



I I

I

I



q First 171Third

Other DK O ~ e s C No - SKIP t o next ISS Code o r ] Check Item PI, page 53



xi



3



Refer to item 2, page 24. Were (Social Security/Railroad Retirement) payments received especially for . . .'s children? NOTES

I I I



I

2



FORM SlPP 13800 (12-22-94)



Page 25



I



Section 3

Refer to item 1Ib, page 5.



- AMOUNTS (Continued)

I



I



Part A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

Is "Food Stamps" (code 27) listed on the income roster?



I



,

I I I I I I I I

I



I[7 Yes - ASK 12b 2 0 N 0 - A S K 12a



I



12a. In which month, during the 4 month reference

begin to receive food stamps? period, did Was it in (Read each month)?

Mark "Yes" in item 12b for the first month received and mark "No" for the previous months. Then ask if it was received in each remaining month of the reference period.



...



b. Did ... receive food stamps in (Read each

month)? NOTE - Food stamp benefits may be adjusted for inflation in July and October. (Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



I I I



1 2 ~ If "Yesr' in item .

I q Yes 2ONo x i q DK



I

I



12b, ask - What was the total amount?



I

I



I I



XI



DK x2 q Ref.



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I



I

I I



Yes 20No xi DK

I



3128



(



x i q DK x2 Ref.

3 1 3



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I I I



inyes 20No XI q DK



I b l

.

2 1 7 1 .



I



x i q DK x2 q Ref.



(4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



= I

1 3134

I I



I Yes 2UNo x i q DK



I



xi DK x2 q Ref.



SKlP to next ISS Code or Check ltem PI, page 53



13a. Did ... receive any WIC benefits in (Read each

month)? Mark (XI all that apply.



Last month 2 months ago 3 3 months ago 4 q 4 months ago

I



2



b. Which persons were covered?



-:

I

I



Person No.



Name



SKlP to next ISS Code or Check ltem PI, page 53



Section 3 - AMOUNTS Part A - GENERAL AMOUNTS (ISS Codes 1-56)

1. You said . . . received (was authorized t o

I



I



receive) (Read name of income type) during the $-month period. (Read "was authorized to receive" if asking about "Food Stamps" - code 27.1

Mark ( X ) incon; e-type code.



Fm

I I

I



Income code



Name of income type



I

I I I



q ISS Code 1 or 2 (SS or RR) q ISS Code 25 (WIC) - SKIP to 13a, page 31 3 q ISS Code 27 (Food Stamps) - SKIP to I la,

i



2



I

I I

I



4



page 30 C ] ISS Codes 37,50, 51, 52, 53, or 56 - SKIP to Check Item A4 5 17 Other ISS Codes - SKIP to Check Item A4. I

1



Refer to cc iten 27.



Is . . . a designated parent or guardian of children under 3ge 18?



-;

I I I I



yes



2



q No - SKIP to Check Item A3

yes



2. During this 4-month r r i o d , were any separate

payments from (Soci Security1 Railroad Retirement) received c !specially for . ' s children?



,

2



..



I

I



q No - SKlP to Check ltem A3



3. Did . . . also receive

(himself/herself)



payment for these months?



I

I



2



i U ~ e s q No - SKIP to 9a, page 30

I



I



2



rO Yes q No - SKIP to Check Item A4.1



4. Did.



. . receive (Socia Security/Railroad Retirement) jointly with . . .'s spouse?

Has informatior about the amount received b y . . . from the income source entered in item 1 already been recorded during an interyiew f o r . . .'s spouse?

Refer to item I ' b, page 5.



1I



I



2



10 yes q No - SKIP to Check Item A4. I

1 C ] Yes



1

I

I

I



- SKlP to next ISS Code or



Check Item PI, page 53



20No

Iq Yes - ASK 5b 2ONo-ASK5a



' 7 1

I



I



Is this income slource listed on the income roster? 1



I



I

I or 2 (SS or RR)



5a. In which month, duri

period, did income type)?



.. . begin



the 4-month reference receive (Read name of



5 ~ Some persons receive more .

b For ISS codes



than one payment per month for certain income types.

read -



and mark "No" for the it was received in the reference



vious months. Then ask if the remaining months of



b. Did .. .receive any (R ad name of income type)

i n (Read each month)? NOTE - Social Security and SSI payments may be adjusted for inflation each January.



t



How much did . . receive in (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.



.



b For all other ISS codes read How much did receive in (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month BEFORE any deductions.



...



1I



I

I



i Yes 20No xi q DK



xi 0DK x2 0Ref.



I

I

I



nDK



/

1



xi



DK



x 2 U Ref.



I

I I



XI



DK



x i 0DK x2 Ref.



I



I I

I



X~ODK



x i q DK x2 Ref.

FORM SIPP-I3800 (12-22-94)



Page 28



I

Part A



Section 3

Mark (X) income type code.



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



- AMOUNTS (Continued)

I



I



3232



1



ISS Code 1 or 2 - SKIP to Check Item A6. I Code or Check Item PI, page 53



I

I I



q ISS Code 8 or 20 through 24 3 q All other income codes - SKIP to next ISS

2



I



6a. Were all the people living here covered by . . .'s

payments?



1- :

I

I



.,q Yes - SKIP to Check /tern ~6

20No



b. Which persons were covered?



3



rT-/l

Person No.



Name



n7 T



I



Is this ISS Code "8"?



'7' ~ e s O

i



I

I



2



No - SKIP to next ISS Code or Check Item PI, page 53



7a. What type of Veterans' payments did ..

receive?



.



' 7 1

I



I

b. Is. . . required t o fill out an annual income

Refer to cc item 45. Was Social Securitv/Railroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period? (SHOW FLASHCARD 0)



1 2



q Survivor benefits



Service-connected disability compensation



I



3 4



I

I



questionnaire i n order t o receive a VA pension? I

I

I



2UN0 SKlP to next ISS Code or x i q DK Check Item PI, page 53

1



']

Yes



Veterans' ensi ion Other veterans' payments



I



Yes - SKIP to Check Item A7



.



I

I



8a. (Social Security/Railroad Retirement) sends out

checks in two different colored envelopes. Please look at this flashcard and tell me which color envelope .'s check comes in. (Remember, we are interested in the color of the envelope, not the color of the check.)



I



..



I

I



q Direct deposit q Other x i q DK

3 4



I



b. Do. . . payments usually come on the first of ' s

the month or the third?

I I I I

I



3266



(



1



q First

Third Other DK yes



2



3



xi

1



Refer to item 2 page 28. , Were (Social SecurityIRailroad Retirement) payments received especially f o r . . .'s children?



8 6 2 3 1

I I I



2 C] No



- SKIP to next ISS Code or

Check Item PI, page 53



FORM SIPP-13800 (12-22.94)



Page 29



Section 3 - AMOUNTS (Continued)



I



I



Part A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued)



Is "Food Stam~s" (code 27) listed on the income roster?



,

I



2



No - ASK 12a



I2a. In which month, during the 4 month reference

period, did ... begin to receive food stamps? Was it in (Read each month)?

Mark "Yes" in item 126 for the first month received and mark "No" for the previous months. Then ask if it was received in each remaining month of the reference period.



I

I

I

1



I

I



I

I I



b. Did ... receive food stamps in (Read each

month)?



I

I I I



1

1 2 ~If "Yesi1in item .

I[7 Yes 20No x i DK



NOTE - Food stamp benefits may be adjusted for inflation in July and October. (Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



12b, ask - What was the total amount?



I



I



3324



1



I

I

I



DK x2 [7 Ref.

XI



1 . $ 1

1



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



,33261 q.Yes -i

I I



138 321



xiODK



I



x i q DK x2 Ref.



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



'3

I



I I

I



I Yes 2ONo x i C ] DK



x i DK x2 q Ref.



(4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

I I

-



xi



DK



xi x2



DK Ref.



SKIP to next ISS Code or Check Item P I , page 53



13a. Did ... receive any WIC benefits in (Read each

month)? Mark (XI all that apply.



1 2 3 4



I

b. Which persons were covered?



! 3344 1



Last month 2 months ago 3 months aao 4 months ago

Name



-:

I



Person No.



7 r/-/l

'uwl



( ( r l



pqrl--l-l



rl--l-l



SKIP to next ISS Code or Check Item P I , page 53



NOTES



I

FORM SIPP-13800 (12-22-941



Page 3



Section 3 AMOUNTS Part A - GENERAL AMOUNTS (ISS Codes 1-56)

-



-



1. You said ... received was authorized t o



I



receive) (Read name 01 income type) during the 4-month period. if (Read "was authorized to -eceivem asking about "Food Stamps" - code 27 I

?



1 1

I



Income code



Name of income type



I

I



type code.

I



2



q ISS Code 1 or 2 (SS or R R ) ISS Code 25 (WIC)- SKIP to 13a, page 35



I

I I I



3



I

I

-



ISS Code 27 (Food Stamps) - SKlP to I la, page 34 4 ISS Codes 37, 50, 51, 52, 53, or 56 - SKIP to Check Item A4 5 q Other ISS Codes - SKIP to Check Item A4. I yes No - SKIP to Check Item A3



Refer to cc iten 27. Is . . . a design; :ed parent or guardian of children under Ige 18?



'3U)II I

I

I



2



I



4-month riod, were any separate payments from (Socia Security1Railroad Retirement) received specially for .'s children?



3. Did ...also receive a

(himselfherself)



t



' q yes- SKlP to Check ltem A3 q [7 No

I 2



..



I

I



payment for these months?



1

I

t



1



2



Yes No - SKIP to 9a, page 34 No - SKIP to Check Item A4. I



Refer to cc item 26a. Is



1U Y ~ S I

I

2



. . . married?



4.



Did receive (Socia Security/Railroad Retirement) jointly w i .. .'s spouse?

Has informatior about the amount received by. . . 'rom the income source entered in item I already been recorded during an inter~iew o r . . .'s spouse? f Refer to item I i b, page 5. Is this income s ~ u r c e listed on the income roster?



...



13412

I



113Yes 2 [7 NO - SKlP to Check ltem A4. I

I



1- '

I

I

I



q Yes - SKlP to next ISS Code or

Check Item PI, page 53



20No

I Yes - ASK 56 zONo-ASK5a



' 7 1

I I



I

I



5a. I n which month, durin 0 the 4-month reference

period, did income type)?



... begin



5 ~ Some persons receive more .



t i



3



receive (Read name of



Mark "Yes" in item 5b fo and mark "No" for the p it was received in each the reference period an



b. Did ... receive any (R ad name of income type)

i n (Read each month)?

NOTE - Social Security nd SSI payments may be adjusted for inflation ea n January.



f



the first month received vious months. Then ask if the remaining months of mark item 5b.



I I



,

I

I



than one payment per month for certain income types. b For ISS codes I or 2 (SS or RR) read How much did ... receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.



I

I



I

I



b For all other ISS codes read How much did ... receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month BEFORE any deductions.



(Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I



I I



XI



q DK



xi x 2



DK Ref.



(2 months ago) . . . . . . xi x 2



DK Ref



(3 months ago) . . . . .



( 4 months ago)



......



I



I



Page 32



I FORM SIPP-I3800 (12-22-94)



I

I

Part A



Section 3

Mark (X) income type code.



- AMOUNTS (Continued)

I



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

3432

I I



I



I 2



10ISS Code 1 or 2 - SKIP to Check Item A6. I

q ISS Code 8 or 20 through 24

other income c o d e s - SKIP t o next ISS Code or Check Item PI, page 53



3 q All



I



I



6a. Were all the people living here covered by . . .'s

payments?

I



1

2



q Yes - SKlP to Check ltem A6

No

Name



b. Which persons were covered?



Person No.



I



Is this ISS Code "8"?



i q

I I



IO



~ e s



2



q No - SKIP to next ISS Code or

Check Item PI, page 53



7a. What type of Veterans' payments did . . .

receive?



' 7 1

I

I



I 2 3



q Service-connected disability compensation



I

I



Survivor benefits Veterans' pension 4 10 Other Veterans' payments

1 XI



b.



. . . required t o fill out an annual income questionnaire i n order t o receive a VA pension? I

I S

I

I



1 yes 0

q DK No



)



SKIP to next Code or Check Item PI, page 53



Refer to cc item 45.

Was Social SecurityIRailroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period?



,

I



I



Yes - SKlP to Check ltem A7



(SHDW FLASHCARD 0)



8a. (Social Security/Railroad Retirement) sends out

checks i n two different colored envelopes. Please look at this flashcard and tell me which color envelope .'s check comes in. (Remember, we are interested i n the color of the envelope, not the color of the check.)



I



Blue Direct deposit Other DK First Third Other DK



..



I

\



I



2 3 4



q Buff



I I



xi



b. Do. . .'a payments usually come on the first of

the month or the third?



1 3466 1

I

I I

I



I 2 3



xi



Refer to item 2, page 32.

Were (Social SecurityIRailroad Retirement) payments received especially f o r . . .'s children?

I

I I



2



10Yes 17No - SKIP to next ISS Code or Check Item PI, page 53



I



I



FORM SIPP-13800 (12-22-941



Page 33



Section 3 - AMOUNTS (Continued)

Par: A payments received f o each month)?



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



9a. Were (Social Securityl3ailroad Retirement)



.. .'s



I



children in (Read



I

I I I I



NOTE - Social Security ~layments may be adjusted for inflation each January. (Lastmonth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



9b. If nYeslfin item 9a - How much

was received?

4

XI



110 i n y e s 971

I I



I

I



20No x i DK

IU Y e s



3



7



2



)



1



$



.



F l b]



DK x2 q Ref.

3476



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .

,



1I I



20No x i DK



I1$)

x i q DK x2 Ref.



.



I I



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .



'31781 0 Y e s

I



I I

I I



20No XI q DK

I0 Y e s 20No XI q DK



3480



I1$)

XI



I



.



( 4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . .



31821

I I

I

I



q DK x2 q Ref.



3484



I



/$ 1

. .

q DK

Ref.



X I



x2



VERIFY IF ONLY ONE CkILD OR ASK 10a. Were a l l children livin! here covered b y these

payments?



1

1

I

I



Yes - SKlP to next ISS Code or Check ltem PI, page 53 20No

I



b. Which children were c ~ v e r e d ?



Person No.



Name



SKlP to next ISS Code or Check ltem P I , page 53



I a. Were a l l the people l i v g here covered under 1



I



.. .'s



food stamp allot

I I



I



Yes - SKIP to Check Item A7. I

Name



b.



Which persons were c vered?



Person No.



/



NOTES



Page 34



FORM SIPP-13800 (12-22-94)



.



Part A



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



Section 3 - AMOUNTS (Continued)



fer to item I page 5. lb, Is "Food Stamps" (code 27) listed on the income roster?



,

I



I Yes - ASK 12b 2mN0-ASK12a



I I I I

I



12a. In which month, during the 4 month reference

period, did begin to receive food stamps? Was it in (Read each month)?

Mark "Yes" in item 12b for the first month received and mark "No" for the previous months. Then ask if it was received in each remaining month of the reference period.



...



I

I I I

I



b. Did ... receive food stamps in (Read each

month)? NOTE - Food stamp benefits may be adjusted for inflation in July and October. (Last month) . . . . . . . .



I

I

I



I

I



/ 12~.

I



If "Yesi1in item Izb, ask - What was the total amount?



I



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I I I



Yes



3



5



20No xi DK

I Yes 20No x i DK



7

.

xi x2 DK Ref.

XI



I



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



1- '

I I



I

I



DK x2 El Ref.



( 4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



1 3534



I

I I



I Yes 20No xi DK



xi x2



DK Ref.



SKIP to next ISS Code or Check Item P I , page 53



13a. Did ... receive any WIC benefits in (Read each

month)?

2 3

4



Mark (X) all that apply.



L~~~month 2 months ago 3 months ago 4 months ago

Name



b. Which persons were covered?



,

I



Person No.



SKIP to next ISS Code or Check Item P I , page 53 NOTES



=ORM SIPP-I3800 (12-22-94)



Page 3!



-



-



Part A - GENERAL AMOUNTS (ISS Codes 1-56)

I



Income code



Name of income type



receive) (Read name 4-month period.



income type) during the



r l

I I I I



(Read "was authorized "Food Stamps" - code



q ISS Code 1 or 2 (SS or RR) q ISS Code 25 (WIC) - SKIP to 13a, page 39 3 q ISS Code 27 (Food Stamps) - SKlP to 1la,

i



2



page 38

4



I

I I

I



q ISS Codes 37, 50, 51, 52, 53, or 56 - SKIP to q Other ISS Codes - SKIP to Check Item A4. I

Check Item A4



5



2



q No - SKlP to Check ltem A3



2

I



No - SKlP to Check ltem A3



3. Did. ..

I



payment for these months?



1q Yes 3 8 0

I I

I



2



q No - SKIP to 9a, page 38

No - SKIP to Check Item A4.1 yes



Refer to cc iten, 26a.



I

I 2



qyes



Is . . . married?



4. Did ... receive (Soci Security/Railroad

Retirement) jointly w h



t ..

I



.'s spouse?



'

I



~



1a 2 i



q No - SKIP to Check Item A4. I q Yes - SKIP to next ISS Code or

Check ltem PI, page 53



1



1



I



Has informatio received b y . . entered in item during an inter



about the amount from the income source 1 already been recorded riew for . . .Is spouse?



T 'I

I I



20No

I Yes - ASK 5b zONo-ASK5a



Refer to item I Ib, page 5.



Is this income aource listed on the income roster?



I

I I



5a. In which month, duri g the 4-month reference

period, did income type)?



... begin



Mark "Yes" in item 5b f and mark "No" for the p it was received in each the reference period an

in (Read each month)?



b. Did ... receive any (R ad name of income type)

d NOTE - Social Security ~ n SSI payments may be adjusted for inflation ez :h January.



f



t



I



5 ~ Some persons receive more .

b For ISS codes

read -



receive (Read name of

I



than one payment per month for certain income types.



the first month received evious months. Then ask if f the remaining months of mark item 5b.



,,

I

I



1 or 2 (SS or RR)



I



,



I



I

I



How much did ... receive in (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.



b For all other ISS codes read How much did receive in (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month BEFORE any deductions.



(Last month) . . . . . . .



:

I



...



i



CI Yes

DK



xi:o N .



I



7b 1 l )

3618



.



xi x 2



DK Ref.



(2 months ago) . . . . .

I

I

I



ODK



I

I



xi x 2



DK q Ref.



(3 months ago) . . . . .

xi x 2 (4 months ago) . . . . . .

I



DK Ref.



,

Page 36



I



XIUDK



xi

x2



DK



q Ref.

FORM SIPP-13800 (12-22-9



I I



Section 3 AMOUNTS (Continued)

Part A



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



-



I I



Mark (X) income type code.

I



3632

I

I



q ISS Code 1 or 2 - SKIP to Check Item A6.7 q ISS Code 8 or 20 throuah 24 3 q All other income codes- SKIP to next ISS

I 2



Code or Check Item PI, page 53



6a. Were all the people living here covered by . . .'s

payments?



7

I



1



q Yes - SKIP to Check /tern ~6 20No

i'ersrn Nr.



b. Which persons were covered?



,



Name



I



1 6 6 IO y e s 361 I 2 No - SKIP to next ISS Code or

I



Check Item PI, page 53



7a. What type of Veterans' payments did . . .

receive?



7 1

I



I

b. Is . . . required t o f i l l out an annual income



I



2 3



I



I I



I



questionnaire i n order t o receive a VA pension? I

I

I



3660



1x i



:8

4

I



Service-connected disability compensation Survivor benefits Veterans' ensi ion Other veterans' payments



DK



~ ~ 1



SKIP to next ISS Code or Check Item PI, page 53



Refer to cc item 45.

Was Social SecurityIRailroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period?



Yes - SKlP to Check ltem A7



I



(SHOW FLASHCARD 0 )



8a. (Social SecurityIRailroad Retirement) sends out

checks i n t w o different colored envelopes. Please look at this flashcard and tell me which color envelope ...'s check comes in. (Remember, we are interested i n the color of the envelope, not the color of the check.) the month or the third?

I 3

4



I

I

I



xi



Direct deposit Other DK First Third



b. Do . . .'s payments usually come on the first of



I 3666 I I



1



I 2



I I

I



3 q Other x i q DK

I



8 OYes 6 3 1

Were (Social Security/Railroad Retirement) payments received especially f o r . . .'s children? UOTES

I 2



I

I



No - SKIP to next ISS Code or Check Item PI, page 53



I



I



FORM SIPP-1380011 2-22-94)



Page 37



Section 3 - AMOUNTS (Continued)

pakA payments received f each month)?



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



.. .'s children in (Read

may be adjusted



I

I I I



9b. /f "Yesr1 item 9a - HOW much in

was received?

I q Yes 20No xi DK



I

I



(Last month)

I I I

I



x i q DK x2 Ref.

3676



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



1I I I I



1UYes



20No xi DK



1 $( (

1



.



x i q DK x2 q Ref.



F l



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



'7)e s y

1



3680



I

I I I



20No xi DK



xi DK x2 q Ref.



/I



.



(4 months ago)



............................

I I I XI



q DK

Yes



VERIFY IF ONLY



10a. Were all children

payments?



I ] i



x i q DK x2 q Ref.



I



SKlP to newt ISS Code or Check ltem PI, page 53

Name



I

I



2UNo

Person No.



b. Which children were



3

I



-



--



SKIP to next ISS Code or Check Item P I , page 53



Il a . Were all the people li\ ing here covered under ... food stamp allotment? ' s



I



i

I



q Yes - SKIP to Check Item A7. I

Name



b. Which persons were



1



vered?



Person No.



P P P P P P P



Page 38



FORM SIPP-13800 (12-22-9



Section 3 AMOUNTS



-



I

4-month period.



Part A



- GENERAL AMOUNTS (ISS Codes 1-56)

I



I



+rj

receive" if asking about

I I

I



r



Income code



l



Name of income type



Mark (X) incon e type code.



'71

I I I



q ISS Code 1 or 2 (SS or RRI 2 q ISS Code 25 (WIC) - SKIP to 13a, page 43

I



3



I

I I I



ISS Code 27 (Food Stamps) - SKlP to 1la, page 42 4 q ISS Codes 37, 50, 51, 52, 53, or 56 - SKlP to Check Item A4 5 Other ISS Codes - SKIP to Check Item A4. I

No - SKIP to Check Item A3



Is . . . a designz ted parent or guardian of children under sge 18?



2. During this 4-month eriod, were any separate

payments from (Soci ISecurity1Railroad Retirement) received specially for. .'s children?



.



,,

I I



I



2



I

I



q Yes 2 No - SKlP to Check ltem A3

i ~ ~ e s



3. Did.



..

Refer to cc iten 26a. Is . . . married?



payment for these months?



1

I

I



2



q No - SKIP to 9a, page 42



1 q

I

2



1 0 ~ e s No - SKIP to Check Item A4. I

1



4. Did ... receive (Socia Security/Railroad

Retirement) jointly w i :h



.. .Is spouse?



'I T

I I I

I



q Yes

No - SKIP to Check Item A4.1



2 I



Has informatior about the amount received b y . . . from the income source entered in item 1 already been recorded during an intenriew f o r . . .'s spouse?



q Yes - SKlP to newt ISS Code or

Check ltem PI, page 53



20No

I Yes - ASK 56 2ONo-ASK5a



Is this income saurce listed on the income roster?



I

I I



5a. In which month, duri

period, did ... income type)?



the 4-month reference receive (Read name of



5 ~ Some persons receive more .

b For ISS codes

read -



Mark "Yes" in item 5b fo the first month received and mark "No" for the p vious months. Then ask if it was received in each f the remaining months of the reference period an mark item 5b.



b. Did ... receive any (R ad name of income type)

in (Read each month)?

NOTE - Social Security z nd SSI payments may be adjusted for inflation each January.



ft



than one payment per month for certain income types.

I or 2 (SS or RR)



How much did receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.



...



I



b For all other ISS codes read How much did receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month BEFORE any deductions.



...



(Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I



I



I



XIUDK



I



I



xi DK x q Ref. 2



months ago) . . . . . . . . . . . . . . .

I



I

I



XI



DK



X I q DK



x 2



q Ref.



months ago) . . . . . . . . . . . . . . .

xi DK x q Ref. 2



months ago) . . . . . . . . . . . . . . .

I

I



I I



xi



q DK



XI



DK

FORM SIPP-13800 (12-22-94)



x q Ref. 2



Page 40



Section 3 - AMOUNTS (Continued)

Part A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

Mark (X) income type code.

I



1



3832



I 2



ISS Code 1 or 2 - SKIP to Check Item A6.1



I

I I



C ISS Code 8 or 20 through 24 ] 3 All other income codes - SKIP to next ISS

Code or Check Item PI, page 53

yes - SKIP to Check /tern ~6 20No

Person No. Name



6a. Were all the people living here covered by . .'s

payments?

I I



-



b. Which persons were covered?



I



Is this ISS Code "8"?



'3 U ~ e s

I I I 2



No - SKIP to next ISS Code or Check Item PI, page 53



7a. What type of Veterans' payments did.

receive?



..



' 8 8 q Service-connected disability compensation 351

I

I



I



2 3 4



C Survivor benefits ]



I



I

I I



C Other Veterans' payments ]

SKIP to next ISS Code or Check Item PI, page 53



Veteransf pension



b. Is . . .required t o fill out an annual income



questionnaire i n order t o receive a VA pension? I

I

I



A

,



Yes 2i3N0 xi DK



1



I



Refer to cc item 45.

Was Social SecuritvJRailroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period?



SKlP to Check ltem A7



I

I



(SHOW FLASHCARD 0)



8a. (Social Security/Railroad Retirement) sends out

checks i n two different colored envelopes. Please look at this flashcard and tell me which color envelope .'s check comes in. (Remember, we are interested i n the color of the envelope, not the color of the check.)



..



/

I I



q Direct deposit q Other x i C DK ]

3 4

1 2



b. Do . . .'s payments usually come on the first of

the month or the third?



I 3866 1

I

I I I

I



First Third Other DK yes No - SKIP to next ISS Code or Check Item PI, page 53



3



xi



Refer to item 2, page 40. Were (Social SecurityJRailroad Retirement) payments received especially for . . .'s children?



1

I I I



1



i 2



I

FORM SIPP-13800 (12-22-94)



Page 41



I



I



I Section 3 - AMOUNTS (Continued) ~ a A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued) b

Were (Social Security ailroad Retirement) payments received f .'s children in(Read each month)?



I



I



NOTE - Social Security jayments may be adjusted for inflation each Janua TY.

(Last month) . . . . . . .



f

I



..



I

I I

I



9b. If "Yes" in item 9a - How much

was received?



I I



XI



x2



DK Ref.



(2 months ago) . . . . . . . . . . . . . . . .



=($).M

xi x2 DK Ref.



(3 months ago) . . . . .



I

( 4 months ago) . . . . .

I



x i [7 DK x2 Ref.



1

I



I



x2



U Ref.



payments? Which children were overed?



I I



Yes - SKlP to next ISS Code or Check Item PI, page 53 20No



Person No.



Name



SKlP to next ISS Code or Check ltem P I , page 53



Il a . Were all the people



.. .'s food stamp al



n g here covered under nent?

I



I



10Yes - SKlP to Check ltem A7. I

Name



20No

Person No.



b. Which persons wer



P P P P P P P



I I



Section 3 - AMOUNTS (Continued)

Part A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

Refer to item 1Ib, page 5. Is "Food Stamps" (code 27) listed on the income roster?

I



I I



I



I1 Yes - ASK 12b 7 zaNo-ASK12a



I



128. In which month, during the 4-month reference

period, did begin to receive food stamps? Was it in (Read each month)?

Mark "Yes" in item 12b for the first month received and mark "No" for the previous months. Then ask if it was received in each remaining month of the reference period.



...



I

I I

I



I I I

I



I



I



b. Did ... receive food stamps in (Read each

month)? NOTE - Food stamp benefits may be adjusted for inflation in July and October. (Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



I I I



I

1 2 ~If "Yes" in item .

I1 Y e s 20N0



1

12b, ask -What was the total amount?



I

I



13922

I I I

I



DK x2 q Ref.

XI

11 Yes 2UNo XI DK



(2 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



(3 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



"

I

I I



'3926



XI



x2



DK Ref.



I

I I

I



inyes 2UNo XI q DK

Iq Yes 2UNo XI DK



XI



(4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .



/

I I I



x2



DK Ref.



XI



q DK

Ref.



x2



SKIP to next ISS Code or Check ltem P I , page 53



13a. Did ... receive any WIC benefits in (Read each

month)?

2



I



L~~~month



q 2 months ago

U 4 months ago

- 3 months ago



Mark (X) all that apply.



1 3944 1

I I



3

4



I



b. Which persons were covered?



Person No.



Name



SKIP to next ISS Code or Check ltem P I , page 53

NOTES



FORM SIPP-13800(12-22-94)



Page 43



Section 3 - AMOUNTS

Part A



- GENERAL AMOUNTS (ISS Codes 1-56)

I



4-month period.

"Food Stamps" - code 27.) Mark (X) income type code.



IlW0lrT-l

I

I

I



I



Income code



Name of income type



' T I

I I I I I I I



q ISS Code 1 or 2 (SS or RR) q ISS Code 25 (WIC) - SKIP to 13a, page 47 3 ISS Code 27 (Food Stamps) - SK;P 6 l l a ,

I 2

4



5



Refer to cc item .?7. Is . . . a designat d parent or guardian of children under a



-;



I



page 46 ISS Codes 37, 50, 51, 52, 53, or 56 - SKIP to Check Item A4 Other ISS Codes - SKIP to Check Item A4.1



I



q yes

No - SKIP to Check Item A3



I



2



I



2. During this 4-month p iod, were any separate

payments from (Social ecurityl Railroad Retirement) received e pecially for .'s children?

I 2



3. Did.



..also receive a (himselfherself)

Is . . . married?



t

t

I



q yes

I

I



No - SKlP to Check ltem A3



..



parate payment for of these months?



' 7 1

I

I



i



yes



2 1



q No - SKIP to 9a, page 46

1



I



2

i



O ~ e s No - SKIP to Check Item A4.1



4. Did ... receive (Social ecurity/Railroad

Retirement) jointly w i t



.. .'s



spouse?



1-'

I



2

I



OY~S No - SKIP to Check Item A4. I



Has information )bout the amount received b y . . . f o m the income source entered in item 1 already been recorded during an intervi !w f o r . . .'s spouse? Refer to item 1I t , page 5. Is this income so=~rce listed on the income roster?



I I

1



Yes - SKIP to next ISS Code or Check ltem PI, page 53 20No

I



7 Yes - ASK 5b '1

I

I I



2ONo-ASK5a



I



5a. In which month, during the 4-month reference

period, did income type)?



...begin t o receive (Read name of



5 ~ Some persons receive more .

b For ISS codes

read -



I



than one payment per month for certain income types.

I or 2 (SS or RR)



it was received in the reference



months of name of income type) SSI payments may be



b. Did ... receive any (Re

i n (Read each month)? NOTE - Social Security a adiusted for inflation eac



How much did ... receive i n (Read each month marked "Yes" in item 5b)? Please answer by giving the total amount each month AFTER any deductions such as Medicare premiums.

I



I



I



] b For all other ISS codes read How much did ... receive i n (Read each month marked "Yes" in item 5b)? Please answer bv giving the total amount each month BEFORE any deductions.



(Last month) . . . . . . . . . xi x 2 DK Ref.



(2 months ago) . . . . . . .



.



4022



1



xi q DK x q Ref. 2



) .

DK Ref.



(3 months ago) . . . . . . .

xi x2

(4 months ago) . . . . . . .

I

I

I



XIODK



I

I



XI



q DK

Ref.

FORM SIPP-13800 (12-22-9



x 2



'age 44



Section 3 - AMOUNTS (Continued)



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued) Mark (X) income type code. 1I q ISS Code 1 or 2 - SKIP to Check Item A6.1

Part A

I

I



2



0ISS Code 8 or 20 through 24

All other income codes-- SKIP to next ISS Code or Check Item PI, page 53



I I



3



6a. Were all the people living here covered by . . . ' I

payments?

I

I



(O Yes - SKIP to Check /tern ~6 20No

Person NO. Name



b. Which persons were covered?



I



Is this ISS Code "8"?



'10561

I I



O ~ e s 2 No - SKIP to next ISS Code or Check Item PI, page 53

I I



7a. What type of Veterans' payments did . .

receive?



.



! q Service-connected disability compensation q

I



I

I

I



2 3

4



b. Is. . . required t o f i l l out an annual income



questionnaire i n order t o receive a VA pension? I

I

I



21JN0) to next ISS Code or I Yes SKIP

XI



•



'



Survivor benefits Veterans' pension Other Veterans' payments

--



DK



Check Item PI, page 53



r to cc item 45.

Was Social SecuritvIRailroad Retirement (code 1 or code 2) marked f o r . . . in the previous reference period?



I



(O Yes - SKlP to Check ltem A7



,



I



I



(SHOW FLASHCARD 0)



8a. (Social Security/Railroad Retirement) sends out

checks in two different colored envelopes. Please look at this flashcard and tell me which color envelope .Is check comes in. (Remember, we are interested in the color of the envelope, not the color of the check.)

I



3

4



..



I I



XI



Direct deposit Other DK



b. Do . . .'a payments usually come on the first of

the month or the third?



I I

I



1 4066 1



I

I



First Third 3 q Other XI DK

I



2



Refer to item 2, page 44.

Were (Social SecurityJRailroad Retirement) payments received especially for . . .'s children?

I I



I

2



Yes No - SKIP to next ISS Code or Check Item PI, page 53



I



Section 3



- AMOUNTS (Continued)

I



Par A - GENERAL AMOUNTS (ISS Codes 1-56) (Continued)



9a. Were (Social Security ailroad Retirement)

payments received for each month)?

NOTE - Social Security (Last month)



. 1



.'s children in (Read



yments may be adjusted



I I I I I I

1 Yes 20No



9b. If ''Yesnin item 9a - How much



xi x2

months ago)



DK Ref.



;

I I I



4



r



1



p



1



.



xi



DK



xi x2



DK Ref.



F l



months ago)



DK

months ago)

I I I

I



xi x2



DK Ref.



xi



DK

I



xi x2



DK Ref.



VERIFY IF ONLY ONE CHILD OR ASK 10a. Were all children living here covered by these payments?



f 1Yes - SKlP to next ISS Code or F

1



I

I

I



Check ltem P7, page 53

Name



20No

Person No.



I



SKIP to next ISS Code or Check Item P I , page 53



1 l a . Were all the people I .. . food stamp all( ' s



FJ here covered under ent?

I



i



Yes - SKIP to Check Item A7.7

Name



20No

Person No.



b. Which persons were



NOTES



FORM SIPP-13800 (12-22-94



Section 3

Part A



- AMOUNTS (Continued)

I



- GENERAL AMOUNTS (ISS Codes 1-56) (Continued)

I



Is "Food Stamps" (code 27) listed on the income roster!



12a. In which month, during the 4-month reference

period, did begin to receive food stamps? Was it in (Read each month)?

Mark "Yes" in item 126 for the first month received and mark "No" for the previous months. Then ask if it was received in each remaining month of the reference period.



...



I

I

I

I



I I I I I I I I I I



b. Did ... receive food stamps in (Read each

month)? NOTE - Food stamp benefits may be adjusted for inflation in July and October. (Last month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



1 2 ~ If "Yesein item .

I Yes 20No x i DK



IZb, ask - What was the total amount?



I-I

I



4124



I I

I



1 1(



rn



XI

x2



DK Ref.



(2 months ago) . .

I

- -



- -



I I



xiUDK



I



x i DK x2 C] Ref.



(3 months ago) . . . . . . . . . . .

I

I

I



I

xi DK



xi x2



DK Ref.



( 4 months ago) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

I I

-



xi x2



DK Ref.

-



SKIP to next ISS Code or Check Item P I , page 53



13a. Did ... receive any WIC benefits in (Read each

month)? Mark (X) all that apply.

2



q L~~~month q 2 months ago

C] 3 months ago C] 4 months ago

Name



3 4



b. Which persons were covered?



I I



Person No.



SKIP to next ISS Code or Check Item P I , Page 53 NOTES



=ORM SIPP-13800 (12-22-94)



Page 4'



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gt a6ed



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' e s n o d s , " ' l c snlels ,v\orNalul s



'slunocce ))|lot pue'q6oey'VUl popnl: xo qclqrn (si€sse pau/ao ' ' leql pgesnoA rellref Jo saueu peau pe.l'

I (slunooce ro slunocce MON-ladnS MON se qons) - t0L 0urlceqc 6ururea-1se;alul opo3 SSIn t | 90er : solecrl!uocs6urnes reqlo ro tlsodeplo selecryua3- Zgt opo3 SSIIe I tO€i 1 I slunocce llsodap lolreur Aeuo61 LOt opo3 SSta z I zotl ' slunosce s6ulnes)ooqssedleln6ag - 0O! epoC SSIn r lioer-"]



'L



'A1ddeptfi ile x)\rew lassv 'p€ rnnosedAl



(to1 puP'zoL'LoJ 'oot sopoc gNl)c3Hc 9NlNUvl-IsfufrNt oNV 'llsodllo Jo sflvcHtlult3'slNnocSv sst) srNnocsv llsod3o lit)tuvw A:tNot l'sINr o ccvsS NlAv s - gued



(panulluoc)slNnowv - t uollcas



Section 3

Asset types owned.



- AMOUNTS (Continued)

and 107

I



Part C - OTHER INTEREST-EARNING ASSETS (ISS Codes 104,105,106,



Mark (X) all that apply.



3

2 I 4404



I



q ISS Code 104 - Money market funds ISS Code 105 - U.S. Government securities

ISS Code 106 - Municipal or corporate bonds



3

4



I 4406



q ISS Code 107 - Other interest-earning assets Specifyz



I



3



q Interview for spouse already conducted SKIP to 3a

Yes No - SKIPto 3b



2a. D i d .



o w n any o f these jointly w i t h . (husbandlwife)?



..



. .'s

I



I



In



2



0



b. What is your best estimate o f the total amount

o f interest earned on these jointly held (Read asset types) during the 4-month period (including even small amounts credited t o .'s account(s))?



1- ' ..



.



a



- SKIP to 3a



I I I I



I



x3 q None - SKlP to 3a x i DK x2 q Ref. - SKIP to next ISS Code or Check Item PI, page 53

-



C. What is your best estimate of the average



amount t h a t . . . and. .'s (husbandhife) had i n I these jointly held (Read asset types) during the 4-month period? I



.



I



*



f

4414

XI

1 I I



.

x2



- SKIP to 3a



DK Ref. - SKlP to next ISS Code or Check ltem PI, page 53



I

I



d. If 1 were t o call back later, would you be able t o

provide me w i t h an estimate o f the average amount? (This information is especially important for the purposes o f this survey.)

I I



[7 Yes - Mark Reminder Card and Callback Summary, ltem 7



2UNo



3a. Besides any (Read asset types) owned jointly

w i t h . .Is (husbandlwife), did other (Read asset types)?



.



. . . own any



7

I I

I



1

4420



2



1UYes q No - SKlP to next ISS Code or Check Item PI, page 53



b.



What is your best estimate o f the total amount I o f interest. . .earned on these (Read asset types) 1 during the 4-month period (including even small amounts credited t o . .'s account(s))?



.



' 7

I I



- SKIP to next ISS Code or



I

I



Check Item PI, page 53 x3 [7 None - SKIP to next ISS Code or Check ltem PI, page 53 XI DK x2 [7 Ref. - SKIP to next ISS Code or Check Item PI, page 53



C. What i s the best estimate o f the average



amount t h a t . . had i n these (Read asset types) during the 4-month period?

1 I I



.



*



- SKIP to next ISS Code or

Check Item PI, page 53



q DK x2 0Ref. - SKlP to next ISS Code or Check ltem PI, page 53

XI



d. If Iwere t o call back later, would you be able t o

provide me w i t h an estimate o f the average amount? (This information is especially important for the purposes o f this survey.) NOTES



'

I

I



SKlP to next

2UNo



I

FORM SIPP-13800 (12-22-94)



Page 49



I



Section 3

Part 1



- AMOUNTS (Continued)

I



- STOCKS AND MUTUAL FUND SHARES (ISS Code 110) l a . Earlier you told me that . . . owned stocks or 1yes ,

mutual fund shares w ich excluded IRA, b . Keogh, and 401 K acco ~ n t sDid . . .receive any dividend checks d ring these 4 months? (Include checks made ~ ujointly to t and



...



I I

I I



x i I1 I DK



$



SKlP to 3a



I



Interview status o f . . .'s spouse.



-1

I



1



I

I I



2 3



No spouse in household - SKIP to 2a Interview for spouse not yet conducted Interview for spouse already conducted SKIP to 2a



Callback Summary, ltem 9



- SKlP to 3a

~ 3



None - SKlPto 3a 0



0 Callback Summary, ltem I



2



lnterview for spouse not yet conducted



FORM SlPP 13800 (12 22 94)



-



-



-



-



Section 3



- AMOUNTS (Continued)



Part E - RENTAL INCOME (ISS Code 120)



I I I



3



q Interview for spouse already conducted SKlP to 3a

Y~S No - SKlP to 3a



2a. Did . . . receive any rental income from



property owned jointly by.. and. ..'s (husbandlwife) during the last 4 months? Include only property owned entirely by couple. from this property during the 4-month period?



.



iO



I I



2



I

I



b. About how much was received i n gross rent



,

I

I I



17 T . Il b

4604



xi x2



I

I



DK Ref. - SKIP to next ISS Code or Check Item PI, page 53



c. What is your best estimate o f the amount that

was cleared after expenses?



I



I I I I



I

x4



x3 xi x2



None DK Ref. - SKlP to next ISS Code or Check ltem PI, page 53 Lost money - Enter amount of loss in box



3a. Did . . . receive rental income from property



I



owned entirely i n . .'s o w n name during the last 4 months? from this property during the 4-month period?



.



1 Yes 0

I



2



NO - SKlP to 4a



b. About how much was received i n gross rent



I I I I



x i q DK x2 [7 Ref. - SKIP to next ISS Code or Check Item PI, page 53



I $

.



C. What is your best estimate o f the amount that



I



was cleared after expenses?

I I

I I I



4a. Did . . . receive any rental income from



property owned jointly w i t h others during the last 4 months? (Not including property owned entirely b y . and . ."s spouse)



'A :46181

I



x3 None x i q DK x2 Ref. - SKIP to next ISS Code or Check Item PI, page 53 x4 Lost money - Enter amount of loss in box

ia



..



.



,



I I



2



yes N o - SKIP to next ISS Code or Check ltem PI, page 53



b. What is your best estimate o f . . .'s share

o f the amount cleared on this property during the last 4 months?

I I



5

1 4622

I



x3 q None x i DK x2 Ref. x4 Lost money - Enter amount of loss in box



SKIP to next ISS Code or Check ltem PI, page 53



NOTES



FORM SIPP-13800 (12-22-94)



Page 51



008tt-ddts uoj tn6-zz-zlt t



Zg a6ed



S:IION xoq u! ssollo lunoue Jalu:l - Aeuou lsol a ,* @,



'lau zx n )cnrx auoN rx n



'aJeqs ' ' Aluolun 0'paleqs selA euocut s,' Jl



lffi



m

g



' zgedLl tassepeoa) eso ll uorl e^lecer " plp ourocu! qcnul n orl 'srll rout ? lsed oql6u;rnq '(sedAlpsse peail ] rq ' ' ' ples no^ rellrP3



't



Ld Luolt \caq? ol dlxs - oN fl z



s a ^ n r l€r,-]

I t



091 zpoueLu ro )?! apoSssl sl '9LVual \caq3 01roJaa



'Jau zx n )Oatx auoN ex n

|91r'I



arornoiloq lsejolu! rlcnru n oq'stll 1'e6e6your E pleq "

I



Dql Aq ' ' ' ol pled sean roru ? lsed aql6u;rnq leql ples noA rellref) 'q



gLV Luoll4ceqJ ot dDts - oN Ll z



sa ^n r Fil;;:

I I



' ' rgse6e6your Aue ploq aau|Bu urulo s,' p;p 1'se6e6uour pl rq A11u;o! Aue sepgsegl 'e7



'Jou zx n )Catx ouoN flrx



ffi

qz ot dtxs - oNfl z solnr@ ez ot dt>s

- polcnpuocApearle asnodslol ^ alN alul n r palcnpuoc geA1ou asnods Jol n ornlelul l-l z qz ot dt>ts - ptoqosnoq ur esnods oN - r ho-'tt-



I I



ere/l oiloq oql Aq esnods s,' " pue " 'ol pged sern 'q lserelu! qcnru ,t oq'sql roru ? lsed eql6u;rng ' qllrn A;1u;o! slrll uA tr. 4esnods s,' "'plg'e6e6your e p l r r l ' ' ' p g e sn o A r o l t r e f ' E l



'asnods ,' ' ']o s



nlels ,v\orNalul



toldtxs-oNflz sa^n t



@



zpa)retu)tt opocsst sl '9LV uJol ot ralaa



\ceqJ



sluau,rlsanu! roqlo - 0gLopoo SSln t, lffi lercueurl serlleAog 0?t apo3SSt- , lffi _ se6e6yo61 ott apoc ssr -, @



'A1dde;?q ile x) \rew lassv ' p a r nno sedfi



(o9t pue'ot!'ot! sepocssl) slN!il tISfANt]V|CNVNH U3HIOONV SfttlVAOU'S39V9IUr DUI I rred



(panutluoc)slNnowv



- t uollces



Section 4

Refer to cc item 19b.



- PROGRAM QUESTIONS



I



Is this the reference oerson's questionnaire? Refer to cc items 16a and 16b. Is this residence owned by the local housing authority OR does the government pay part of the rent? ("Yes" marked in cc item 16a or 16b)



15

i

I



I



2



O ~ e s NO- SKIP to Check Item T I , . - 54 page



I

I



I



1

I I I



1



I



2



U ~ e s No - SKIP to 2a



I



l a . What is your monthly rent?

Include only the amount the respondent pays for rent. Exclude any subsidized amount.

I



x 3



None



I I

I



DK x q Ref. 2



)SKIP



to



b. (In addition t o rent,) do you pay for any

Exclude telephone.



utilities such as water, electricity, gas, or oil?



'48061 2 00N~o e s 1

I I

I



xi



DK



2a. The government has an energy assistance

program which helps pay heating and cooling costs. This assistance can be received directly by the household or it can be paid directly t o the electric or gas company, fuel dealer, or landlord. Has this household received assistance o f this type during the past 4 months?



;q~ e s i u

q

I

I I I I

1



XI



DK



SKIP to Check ltem P3



b. Was this assistance received i n the form o f

checks, coupons or vouchers sent t o this household, or were the payments sent directly t o a utility company, fuel dealer, or landlord? Mark (X) all that apply.

C. What was the total amount o f the energy

1 4820



2



3

I



Checks sent to household Coupons or vouchers sent to household Payments sent directly to utility company, fuel dealer, or landlord



I I I



assistance received by this household during the past 4 months? Are there any children 5 to 18 years old who live in this household?



,

I I



xi q DK



nyes

q No - SKlP to Check ltem T I , page 54



2



3a. Do any o f the children i n this household

usually eat a complete hot lunch offered a t school?



'88 n ~ e s 12

I



2 I

I



q No - SKlP to Check ltem T I , page 54

Children Number of lunches



b. How many children?

C. How many complete school lunches do all o f



"301

I



the children eat per week? xi



DK



d. Did you (or another person) apply for the

children t o receive free or reduced-price lunches under the Federal School Lunch Program during this school year?

I I I 2



5 NO- SKlP to 3f

q Free lunch - SKIP to 3g q Reduced-price lunch

Full-price lunch



e. I n the past 4 months, were the lunches free,

reduced price, or were they f u l l price? Mark (XI only one.

I I 2

3



f. What was the average price paid by all o f the

children for a complete school lunch?

I



XI



DK



g. Do any o f the children usually eat breakfast a t

school under the Federal School Breakfast Program?

I I 2



q Yes

No - SKlP to Check ltem T I , page 54



h. How many children? i. How many complete school breakfasts do all

o f the children eat per week?



''8U

I



Children Number of breakfasts



xi

I



DK



j. I n the past 4 months, were the breakfasts free,

reduced price, or were they f u l l price?

I



'3 5 Free breakfast

I

I

I



Mark (X) only one.



2 3



Reduced-price breakfast Full-price breakfast

I



FORM SIPP-I3800 (12-22-94)



Page 53



0 l n 6 - z z ' z L l0 8 e r - d d t s U o J W



?g a6ed



oslooraqMauos n z ouroqui\Aonr @



asloeloqMeLuosnz



eLuoqu/v\onr @



I



OIOqnratu( pelPool AllrE



easlo i ro eruoq urulos,' ' ' ul ulrd ssoulsnq slql seM 'q



)CI3 Lx uorlerod:o3 e a d r q s ; a u p ea z _ 4 d rqsrolar:dold elog - r hso-;'



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pJeclorluoc uo palsrl loN n rx UO | |



preclorluoc uo polsrl loN E rx

| |



uor

F



I



lee08



lelosl I I



JOqUrnu



cl ssoursn8



raqurnu cl ssautsng



ol dtxs



99 e6ed 'O LJ*ell 4caq3



@

loq|unu uoslad



ot dt>ts



99 a6ed '61 Luau ryaq3



I trog t

laqulnu uoslod



uolleulrolul a ol ssoursnq rau^ o Jaqlo pue 'Ji



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oureN



aureN



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I r Lloquaul Plt qasnoqloqloue Jol lv\alnJol r ue ur pourelqo

svvy



ez ot dt>ts - oN fl z sa1nt @



e z o l d t x s - o N n z l-t s o ^ n t l-4



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seH srqltnoqeJOrleuiloJur



prec lojluoc uo polsll loN n rx



UO 'oNct ssaursng n @



uo 'oN ot ssaursn8 [_l l.6i6tt



preclolluos uo palsrlloN n ex



@



-



t-



lfidt



('pots!l s! ssaulsnq tr tocas e ! 6b€J sLuol!ll!] uaLl 'pelsil ssau/sng $ru eql roJ ;J-tJ sLuail ilu) tt urol! cc) prec lorluoc a l txorl ssaursnq srql rol rsqu ru cl oqucsueJl



'



oureu sseursnS lg

t8 l tcd



- " ou,leu ssaursng | 8008 lg m9d

E



t



t'tttt"tt'



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79 e6ed



'o weualels ol dtxs - auoNn ex UO sessoursng



I I I I



| 9008 |



6u1r p e l e r e d o p u e u r u r o ' ' ' p!p sesseu!s rq luerelllp Aueur ^ oH 'q

- A]A3A AO >lSV



e?661 reeA repue;ec



'suJeJapnlcul

'O 79 abed waLuapts oi dtXS - oN n, sa1- r [g



iv6,6L reeArepu r;ecEugrnpaurll Aue le ssaulsnq e e: e r e d op u e u r u r o '' ' p l q ' B !



ONNZ 'O tuaLuateJs ot dtXS- so^ n r l.g99g. 79 a6ed



suroucc) sar'? ^ q l z c N V ' q l g ' ' q l g ' q ] ?a l lo qcea loJ " / roJpaurelqo ,arnrolur seM ue



iu t pue'gf'gl'il



r



qL



ONL]Z r-r ol dlxs - se^ n r L g



(t? r.r]au i prec lolluoc oql 3c) u o ' ' ' l o l I alsrlsassaulsnq A u e ;) seLueu erv oql



'rurelnrelureql lo Ued slql Eulrnp sprocer ol rotor ol ;n;d1eq Aran eq plnorn 1; '?661 reeA repuelec 6u;rnp solllure, pue suosred ;o uo;1en1; I eql lo elq;ssod ernlcgd elpJncce lsour eq11a6 ol s! ,ne!^relu! rno ;o yed s;qg;o esod nd eq1



'lvnNNV - v I ted srNnoScv rNf tNfulrfu oNV f t^locNl



sf]noow'tvcldol



- I uollces



I I I



Section 5 - TOPICAL MODULES (Continued)



-



Part A

I - I



- ANNUAL INCOME AND RETIREMENT ACCOUNTS (Continued)



I I



Is "Sole ~ro~rietorshio" marked in i t e h 2a?



F - Yes - SKlP to Zh 1

I



1 1



2UNo



I I



2 ~ Were any other members .

o f this household part owners of this (businesslpractice)?



I I I



,8106

x :

I

I



I



I - Yes - SKIP to Zh 2UNo



I



yes



Ei)

Person

NO.



8156



(

x:



I



yes SKIP to 2g



SKIP to Zg



d. Which other household



I



members were owners?

I I I



Person No.



Name



I



Name



Person No.



Person No.



I I I I



Name



Name



e. Was this



(businesslpractice) owned entirely by members o f this household?



I



Yes - SKIP to Zg



p; i i ;

OR x i q DK



- SKlP to 2g



I

I I



f. What percentage of this

(business/practicel was owned by members of this household?



I



; percent

I I



I



OR x i DK



UI



Percent



9. What percentage of this



(businesslpractice) did own i n . .'s own name?



.



.. . 1= I8116

I



IIU

OR



Percent



U J



Percent



h. What were the gross

RECEIPTS of this (businesslpractice) i n 19941 Please use records if they are available.

Obtain estimate, if necessary.



I

I -I



* *



I

I



I



I

I I



x i q DK x2 Ref.



I

I



i. What were the total



EXPENSES of this (businesslpractice) i n 19941 Please use records if they are available.

Obtain estimate, if necessary.



ii I v . T

I I I 1 I I



xi x2



DK Ref.



x i q DK x2 CI Ref.



I



either item 2h or 2i?

I 2



NO- SKlP to Check Item T7



I



2j. If Iwere t o call back

later, could you provide me w i t h an estimate of (receiptslexpenses)? (This information is especially important for this survey)?



I



-1 I I



I



10Yes - Mark Callback



Summary and Reminder Card, items 1l a and/or I l b



Reminder Card, items I l a and/or I l b



20N0

I



2UNo



I



I



I



I



I



I



I



FORM SIPP-13800 (12-22-94)



Page 55



008er-ddts WUoJ $6 ZZ-ZL't



99 o6ed



S]ION



xoq ut ssollotunoue rawJ - Aeuou lsol E o" @



'Jau zx n )Oatx auoN tx n



I I I I



r-1

l-J



E

o11uail 4caq3ot o9

xoq ut ssol lo



'olqPl!e^P ere Aeql l! sproceJ esn eseold at66l u! sossoulsnq rllo s,' ' ' ulorl eruocu! lou s,'''sEnAlpqM

l( zaJotrj



't



o ruaualels ol dtys - oN fl z so^n r



r



@ p"r

', ss



B',"i'ji'""s'tJ HH

;,tfr"lilif.iJ"Ji ffi



o lua.uolels ol dlxs - oN n, ssou$nq#au ro] tl J Luail\caqJ e1e1duo3 sa1 ! , Lg



xoq ur ssol lo _J lunoue rau:l - Aeuou lsol n r*lg 'lou l-l zx



I



)o-rx



tunouerawJ - Abubur ri61O ,*@ 'Jau zx E )cl n rx auoN rx n



ouoN ! ex



i

I



g



@

'oN uosJod



@



m

g



li-tzq

'oN uosrod



urNMo-o3 0Nocts

xoq ur ssol lo tunoue ratul - Abubur16o1a o" @



urNMo-oc cNoSls

xoq u! ssol Jo _.,j tunoue ralui - Aeuou lso-14 ?xl-g!4



'lou zx n



'lau Tt zx



I

I



)C fltx auoN n ry



g



t:



)Clnrx auoNn rx



I I

I tLzS I



trc

I zszs

'oN uosrod



'fuessaceu g 'ateultsa ulelqo



'oN uosJod



2F' urAoploqasnoq Ja.4loJo _J l z n e t s weu peeA) Aq pen;ecer se^ leql eurocu! leu JunourE aql sprn lpqM



'u



I



(sti



ot oll tualt4ro'Jot dr*S{)o n l* 6! uratt4rat4J dtxs{lg -l:-''" loNftz loNnz so^l-l r | 0rz8 so^ l-l r. | 0ez8



s ,.ueu peoA) plp '' ' 'Jol p( lroder Apeerle eruocu!

lou eql urorl yedy zssoulsnq



a(ec!lcerd/sseu!snq) slql urorl ?661 u! ruocu! 1eu Aue enlocoJ ulAo plotlosnoq JaLlp Jo 'ur7



o11 tuoll \cotl) ot dlxs - oN fl z



ped s l 1;o s:aunno sJo( uaur ploqosnoq



sal-'



@



61tuail 4caLnol dlxs - oN n, _ so^n r | 8028



::Y:,;";::i# ffi

'fuessecau 4 'apunsa u1e$o



ONL]Z Luol! 'pre3 zL roputuaa pue fueuutng _ 4ceqileJ 4rew - sa^,n r Lg:gL



o Nf ] z zL ual! 'pre3 raputuaa pue fueutung 4ceqileJryew-so1Et @

Bl Luail 4caq3 ol dlys - xoq u! ssol ]o tunoue retul - Aeuouulsol a tx lg, ;



'Jol



(',t rnJnsslql 1o sesodrnd aql rol luelrodurg Att rrcedsest uolleruJolu! s q1) 4eleurllse ue qllrn aur epgnord noA p;noc 'l l{ceq llBc ol erern I ll



8l Luau4caqJ ol dlrs - xoq ut ssol]o _ tunoue ralu1 - Aeuou lsol fr o" E:gg



)onrx

(""



" 'Jau zx ' auoNl ex n



S t u r a u1 . . . 4ceqJt _ oj ll 00 |



?l Luatl 43otlJ ol



" "



auoNlex



)cnrx "lau n zx



t

I



d/)s ll



I



dt>ts



fffil



-elqel!e^p ere Aeqt l! )cor osn oseold av66L u! (ecllcerd/sseu;snq) slql uro4 elr|ocu! ' ' se^A rEqM '{z leu s,'



(ponulluoc)srNnoccv rNsl^tfutrfu oNV fl loSNl'IVnNN - v u e d



(penulluoc)sf]noon



lvcldol



- I uollce!



Section 5

Part A



- TOPICAL MODULES (Continued)



- ANNUAL INCOME AND RETIREMENT ACCOUNTS (Continued)



I



The next few questions are about personal retirement plans.



4a. Does. . . have an Individual Retirement



Account - an IRA - in . .Is OWN name? I f . . . is only included in . . .'s (husbandfs/wife's) IRA accounts, mark the "No" box.



.



'93301 i n y e s

I I I I



xi



DK N O ) ~ K I Pto 4h



b. Did . . . make any tax-deductible contributions

to IRA accounts which applied to tax return?



. . .'s



1994



C ] yes

I



(Contributions which were deducted from gross income.)

C. How much were



xi



NO q DK ) ~ K I Pt o 4d



I I

I



tax-deductible contributions to IRA accounts which applied .Is 1994 tax return? to



. . .'s



..



I



(Form 1040, line 24a) (Form 1040A, line 15a)



I

I I



xi x2



m.

DK Ref.

yes



I



d. Did. . . make any withdrawals from. . .'s IRA

accounts during 19941 Mark "No" if funds were "rolled over" within 60 days of the withdrawal.



,93361

I

I I

1

-'



x i q DK ) ~ K I Pto 4f NO



e. How much did . . . withdraw from IRA accounts I

during 19941

3



I

I I



xi x2



DK Ref.



f. Including ALL IRA accounts in . . .'s OWN name,

how much did . . .'s IRA accounts earn during 19941



1I

I I



I



x3 17 None x i 17DK x2 Ref.



9. What types of assets did . . - have in - - -'s IRA

accounts? Mark (XI all that apply. Anything else?



1



1



1 2



q savinas certificates or other Certificatesof deposit



~ o n emarket funds i U.S. Government securities 4 Municipal or corporate bonds 5 [7 U.S. Savings Bonds 6 q Stocks or mutual fund shares 7 Other assets - Specifyz

3



h. Does . . . have a Keogh account in . . .'a OWN

name?

I

I I

I



q yes

xi



DK " ) ~ to Check Itern T I I N ~ l ~



i. Did . . . make any tax-deductible contributions

to a Keogh account which applied to. 1994 tax return?



..Is



I I I

I



j. How much were . . .'s tax-deductible

(Form 1040, line 27)



contributions to Keogh accounts which a- ~ ~ l i to d . .'s 1994 tax return? e . -



I I



1I I I



xi x2



DK Ref.



k. Did . . . make any withdrawals from . . .Is

Keogh accounts during 19941



1- '

I I I



inyes

xi



DK N O ) ~ K I Pto 4m

I



I FORM SIPP-13800 (12-22-94)



,

Page 57



lPlCAL MODULES (Continued)

Part A - ~ N N U A L INCOME AND RETIREMENT ACCOUNTS (Continued)



4 . How much did . . . wi hdraw from Keogh 1

accounts during 199 ?

I I I



m. Including ALL Keogh

name, how much did earn during 19941



i



xi x2



DK Ref.



ccounts in . ..'s OWN .'s Keogh accounts



.



x3

XI



x2



None DK Ref.



n. What types of assets

Keogh accounts? Mark ( X ) all that apply. Anything else?



Certificates of deposit or other savings certificates 2 Money market funds 3 1 U.S. Government securities 7 4 Municipal or corporate bonds 5 [7 U.S. Savings Bonds 6 Stocks or mutual fund shares 7 Other assets - Specify3

I



I



Are the names of any employers listed f o r . . . on the qontrol card?



40. During 1994, did . . . articipate in an employee

thrift plan such as a I plan? Such a plan k allows employees to efer part of their salary and not have to pay t xes on their deferred salary until they retir or make a withdrawal. during 19941



p. How much did . . . ca tribute to this plan

x3 [7 None DK x2 Ref.



t



1 ,

yes

1 1



I



2



No - SKIP to Check ltem T I 2



I



xi



N Oto Check ~ l I 2 ) ~ ltem T ~ DK



XI



'age 58



FORM SIPP-13800 112-



Section 5



- TOPICAL MODULES (Continued)

Part B - TAXES

I



I

la. D i d .

19941



Has tax information f o r . . . already been obtained in an interview for a s~ouse with whom . . . filed a ioint return?



1 I I I



I Yes - SKIP to Check ltem T19, page 61 20No



I



. .file a Federal income tax return for

. . filed alone or jointly.



1- '

I I I



2



10Yes No - SKlP to Check ltem T19, page 61



Mark "Yes" i f .



b. Do you have a copy o f the tax form or a

worksheet that you could refer t o for the next f e w questions?



,



I I



I Yes - Allow person time to get form 20No



2. What was . . .'s filing status on . . .'s 1994

Federal tax return? Did



. ..file as -



1 9396

I I I I



Read categories - Mark (X1 one.



q A single taxpayer? q Married, filing a joint return? 3 q Married, filing separately?

I



2



I

I I

I



Unmarried head of househoid? Qualifying widow(er) with dependent child? x i q DK

4



5



3a. What were the total number o f exemptions ' s claimed on . . . tax return?

-



Exem~tions If "00" or "01" SKlP to 4 -



3efer to cc item 20.



I I I I 2



I

did



Number of current household members.



q One - SKlP to 3c q Two or more

Name



I



3b. Besides.



. . . claim as an exemption?



. ..which persons i n this household



I



m



Person No.



I

I



q None in household



C. Did



ASK OR VERIFY .. claim exemptions for any persons who lived outside o f . .'s home for the entire year?



.



I



17Yes

q No - SKlP to 4

SECOND DEPENDENT

9418



.



,

I



2



d. What was the relationship o f this (these)

person(s1t o



. . .?



I



FIRST DEPENDENT

I



Record for two persons only.



' fParent Fq

I I I I 2 3



1



q Child q Brotherlsister 4 q Other q F~~~ 1040



~arent Child 3 q Brotherlsister 4 q Other

2



IU



4. D i d .



.file form 1040, the long form or d i d . . . file one o f the short forms, 1040A or 1040EZ1

(Form 1040 is blue) (Form 1040A is pink) (Form 1040EZ is green)



.



[FI

I



I

I I I I



3



xi



Form 1040EZ DK



SKlP to Check Item T14,



5. 1 am going t o mention t w o forms that people

are sometimes required t o attach t o their tax return. Please tell me if these were included w i t h . .'s 1994 tax return. (1) Schedule A, Itemized Deductions . . . . . . . . .



I

I



.



I '

I I I I



I



I0 Y e s 20N0 xi DK



(2) Schedule D, Capital Gains and Losses . . . . .



9

I I I



10Yes 20No XI q DK Page 59



FORM SIPP-13800 (12-22-94)



Section 5



- TOPICAL MODULES (Continued)

Part B - TAXES (Continued)



I



I



I

I



dent have a copy of . . .'s Federal inc ,me tax form or a worksheet to re ?r to?



F (

I



IO Y e s 2ONo



6a. How much were.. . . a I-IIU... a were . .'s ( nd . . .'s

(Schedule A, line 291



husband'slwife's) item ed deductions for 19941



b. On . . .'s Form 1040, d i

husbandhnrife) claim -



t



I



-1

I



I

I

I



DK x2 q Ref. - SKIP to Check Item T I 7

XI



T. b - Il

I I I I



-.-



. . . (and . ..'s



I



I



(Ask for each credit claimed.)



6 ~ What was the .

amount o f the (Read name o f credit) claimed? (1) A child and depend ~t care expense credit . . . .

(Form 1040, line 4 1)



I



xi x2



DK Ref.



--



(2) A credit for the elde rly or the disabled. . . .

(Form 1040, line 42)

I



I I

I



x2 inyes q NO - SKIP to 8a



Ref.



Is "Schedule D, Capital Gains and Losses" marked ' Yes"?



I I I I



2



7. How much were . . .'s



( nd



husband'slwife's) capit Igains or losses from the sale or exchange of personal assets for 19941 (Form 1040, line 13)



8a. Adjusted gross



1



...'s



+T . , IKl

I

I I



x3 xi



'

I

I



~



:



None DK

:zit



1



money - Enter amount o f ~ o s s box in



total income less and exclusions.



;=, I T

1

I

I



(Form 1040, line 31) (Form 1040A, line 16) ) (Form 1040EZ, line 5



9463

I



x3 q None xi q DK x2 q Ref. x4 Lost money - Enter amount of /ass in box



SKIP to 9a



b. Federal income tax liab lity is the total tax as



I



or determined by the tax t ~ b l e schedule plus or minus certain adjustme rts. What was . . .'s (and . . .'s husband'shi e's) net tax liability i n 19941

(Form 1040, line 53) (Form 1040A, line 27) (Form 1040EZ line 9 )



i T x I

I I



I

I I



x3 q None x i DK x2 q Ref.



I

I

I



I



$23,050 or more - SKIP to Check ltem T I 9



What is the amo i t of adjusted gross income reported



I



2



q Less than $23,050



FORM SIPP-13800 (12-22-94)



Section 5 - TOPICAL MODULES (Continued)



- TAXES (Continued) 9a. D i d . . . claim an earned income credit on . . . i ' s l OyeS

Part B

I



Federal income tax return?



I I I



XI



'



DK ) ~ ~ toP NO l Check Item T I 9



b. What was the amount o f earned income credit

claimed? (Form 1040, line 56) (Form 7040A, line 28c)



557

~



I



I



x i q DK x2 Ref.

Owned or being bought?



Tenure of reference person. Are



. . .'s living quarters -



I I I I



3



for cash? Occupied without cash payment?



SKIP to Statement E,



erview status of



. . .'s spouse



' 7 1

I I I



I 2



No spouse in household



q Interview for spouse not yet conducted

Interview for spouse already conducted SKIP to Statement E, page 62 ayes No - SKIP to Statement E, page 62

yes NO- SKlP to IOd

Name



3



10a. Did . . . pay any property taxes on . .'s

residenceb) i n 1994?



.



1- '

I I



1 2



b. D i d .



pay these jointly w i t h someone else living here?



..



2



c. Who made these joint payments w i t h . . .?



1- '

I



Person No.



I



Person NO.

I I



Name



d. What was (your share of) the property tax bill

for



'



. . .'s



residence(s1 i n 19941



Obtain estimate, if necessary. (Schedule A, line 6)



,Fi

I I

I



XI



[ i

.

DK

Ref.



x2



I



FORM SIPP-I3800 (12-22-94)



Page 61



I,6-ZZ-ZL\ 008et-ddls l tuol



zg s6ed



S:lLON



)Catx auoN rx I



g



ITafi,

e9 ol dtxs - oN fl z I s a ^ E r I zzset



atlqrn pJeoq aloo cs le Aeru\E pue uoor ro|| fsoc lPlol eql se^,r reqM 'p ol!qrn ouro aloorlcs 6ugpue11e u r o r ; iA e r u r e ^ ! l ' ' ' p l q ' C o



)Oatx



ouoN ! ex



I



| 0296 ,

I



PI PT



s{ooq s," 'lo



2se;lddns pue fsoc lelol oql sern leqrn 'q



)O3tx ouoN n rx



lTi56']

oNflz



aseol pue u o l l l n l s , " ' l o tsoc lelol eql sPrnlPqM 'P - srl: four zl lsed eql6u1rnq 'n

1'q1qndseM o ttl Jo lunoue pe1eatb eqy ' rueds " ttclLtlt^., lootlJs aqJj! ,,soL,,4Jew) 'sPM 't alooqcs c!lc rd e ug pelloruo " Areluaue;eu



'LJ Luau fg e0ed 4caL0 ol dlxs - so^ n r



I | | 9196



,otdt>ts-oNnz sa^nt



l-tit6r



q6rq.ro erooqcs E@



ueds sennautl ]o lunouJe u! p^ol \cotlc'stlluotu zL , uelfi oJou le palp)ue il) , eper6 ro lenel leqrn tV 'Z



)c ro raqlo E zr looqcsssaursn8 il n looqcs lecruqcaln 0r looqcs leuorlecon 6 n +9 leaA a6eg;o3 s 3 g r e e Ae 6 a 1 1 o 3 1 r tr rcaAebag;o3 s a g r e e Ae 0 e 1 1 o 3 ;s ( 7 rcaAa6e11o3 3t lseleet6 oLtl ttc!tt^ 1 reeAe6e11o3 e 3 Tsedaql ur latal aL 7 1 - 6 s e p e r Oo o q c sq 6 l H1 z l g-1 sepe-r6A.reluer-ua;3 r l?ir-6a epellorue"'se,



|



Vg a6ed



'LJ Luolt\caLp ot dtXS - oN E z



s sseulsnq ro lecluqcel e ro'e6e;goc Jo'tooqcs I q61q 'Areluourelc se qcns'looqcs re;n6er



'reuo*"fffX



^"''3ll,"r1tlr.;;t; ZL lsed eql 6u;rnp to.il sa^ l'6i66i n, r f c su ! p e l l o r u a ' ' ' s e M

xeueqr @



'L



'6u;cueul; pue lueurllorue looqcs lnoqp orp suollsenb me;



{penulluoc} s3]nooht 'tvctdol - I uo!}c€ t



9NISNVNH ONV INil t't'touNf,]OOHCS - C Ued



Section 5



- TOPICAL MODULES (Continued)

5b. How much did ... receive?

I I I I I I I I



I

I



I

..



Part C



- SCHOOL ENROLLMENT AND FINANCING (Continued)

I



Please look at card DD in your pamphlet and t e l l me i f . received any o f these types o f educational assistance during the past 12 months? Anything else?

(1) The GI Bill? . . . . . . . . . . . . . . . . . . . . . .



SKIP to Check Item C1 Received

XI I



DK



(2) Other Veterans' Educational Assistance Programs? (Include survivors and dependents, vocational rehabilitation and post-Vietnam veterans' assistance.) . . . . . . . . . . . . .



'3 ,



Received

XI



DK



(3) College Work Study Program?. . . . .



7 Received '1

I

I



I,

xi



.



(4) A Pell Grant? . . . . . . . . . . . . . . . . . . .



' 9

I I I



Received



DK



(5) A Supplemental Educational Opportunity Grant (SEOG)? . . . . . . . .



I

I



Received

XI



I



I



(6) A National Direct Student Loan (NDSL) (or Perkins Loan)?. . . . . . . . . .



I I

I



DK



Received 9650



I

I I



, T l . M

XI



DK



(7) A Stafford Loan or Guaranteed Student Loan (GSL)? . . . . . . . . . . . . . .



I

I



=7

1 9652 I



I



Received

XI



DK



(8) A Parent Loan f o r Undergraduate Students (PLUS) or Supplemental Loan f o r Students (SLS)? . . . . . . . . . . (9) Assistance f r o m



'9656)

I

I I I



I



Received

XI



DK



.. .'s



employer? . . .

I



I



Received

9662



(10) A fellowship



0 .



scholarship? . . . . . . .



1I



I



.

I



x i [7 DK



Received

XI



I



DK



( A t u i t i o n reduction? . . . . . . . . . . . . . . I) I



1

I I

I



Received

9670

XI



DK



(1 Anything else (other than assistance 2) f r o m relatives and friends). including the JTPA Training program, Income Contingent Loan, or anything else? . . . . . . . . . . . . . . . . . . . . . . . . . . .



7



I



1



1



Received

9674



,



I

I



,/$.m

xi



DK



NOTES



I FORM SIPP-13800 (12-22-94)



I



Page 63



CALLBACK SUMMARY

Are any lTarked on Reminder Ca .d f o r . . .?

--



I



)-I

I

I



IU Y e s



2



- Mark appropriate itemfs) below, then SKIP to Check Item C2 No - SKIP to Check Item C2



1. Social Security Num er

(Enteiinccitem33a~



~



I



-



m



-



~



x



i



O



x2ORef. x r m N o n e D K



2. Medicare claim num

(Item 23b, page 8)

EMPLOYER Employer #I (Item 8a, page 17) of pay received



bd bd



Last month 2 months ago



x i q DK x2

XI



Ref. x3 q None Ref. x3 Ref. x3 None None



q DK x2



I



3 months ago



x i q DK xs xi xi

XI



i n . . .?



1

(



.

101 51



4 months ago



DK xz DK x2



Ref. x3 q None Ref. x3 q None Ref. x3 None



b. Employer #2



(Item 76a, page 79)



1 $



Last month



2 months ago in



q DK x2



. . .?



P1 I . (./00/

I



4 months ago



XI



q DK x2



Ref. xs q None Ref. x3 None



4. SELF-EMPLOYMENT a. Self-employment #I



(Item 7, page 2 1 1 What was the total a r ount this of income received fn business in . . .?



11-'

I



.



$Last month

2 months ago months ago



XI



q DK xz

DK x2



i - (, s,

.



xi



Ref. x3 q None Ref.

x3



I 3 $ 1 -$ $

DK

x2



q lrlone



4 months ago



xi

XI



DK xt



Ref. xo q None Ref. xs None None



U



I

I



@1 u I What wasinthe.total afrl om nt ht .~ s1- I of income received business . .?

b.

Self-employment #2 (Item 78, page 231



(



$

I

(



I

(



I $bd3 months ago k~ I $ 4 months ago

ii z

I



1 1 00 1 2 months ago



-



Last month



q DK xz



XI



DK xn q Ref. xs DK x2 DK xz through



xi xi



Ref. x 3 O None Ref. xs None



5. What was the averagc

amount in savingsIMc ney market deposit accoul tsl CD1s/lnterest-earning checking accounts iointlv bv husband ?ltern.2c,. page 48)



I I



Amounts for the period of -



T



I



T



I



I

I



1

I



I

I



. kd



xi



DK x 2 U Ref.



6. What was the averag

amount i n savings1M market deposit accou tsl CD1s/lnterest-earning checking accounts in w n name? (Item 3c, page 81



1 7



7. What was the ave

amount in Money funds/securities/bon jointly by husband (Item 2c, page 49)

I



t

I



$

1



XIUDK



x~ORef.



1 9

I



XI



DK x 2 O Ref.



1



8. What was the averagd

amount in Money ma et fundslsecuritieslbondfn own name? (Item 3c, page 491



I



.

I

I I I



xi



DK xn



Ref.



9. What was the amount

received in dividends ~y husband and wife join:ly? (Item 7b, page 50)



as 1 o8

I



.



DK



x2



Ref.



X3



N~~~



10. What was the amount



I



received in dividends k w n $ j q name? (Item 2a, page 0)

I



1 F[ 5



xi



DK xn q Ref. x3



None



I



'age 64



FORM SIPP-13800 (12-22-94)



I



1



CALLBACK SUMMARY (Continued)



I I

I



I Ia . What were the aross l

I



I



I



Business 1



Business 2



receipts of this ibusinessl practice) in 1994? (Item 2h, page 55)



I



I



xi DK x2 El Ref.



XI



I

.



x2



DK Ref.



I 1b. What were the total



expenses of this (business, practice) in 1994? (Item 2i, page 55) What was the net income from this (business/practice) in 1994? (Item Zk, page 56) Has an interview been conducted for all household members 15+?



' y

I



xi x2



DK Ref.



XI



x2



DK Ref.



I I

I I



1 12. 7



,

I

I



xi



DK x2 El Ref.

1



XI



1- '

I



I

I



x2



DK Ref.



2



Yes - Enter finish time on cover page, fill cc items 36 and 39 and END INTERVIEW No - Enter finish time for this household member, THEN interview next 15+ household member



NOTES



FIRE-INTERVIEW TRANSCRIPTION ITEMS



Fill the following items with a red pencil .



Item



Page



I a . Start t i m e (Cover Page) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l



1 1 1

1



2-4.5b.5..



6...............................................



Checklter? N 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



C U S GOVERNMENT PRINTING OFFICE 1995-390-974