Professional Documents
Culture Documents
DC
THE
CO
PY
O
TI
RM
Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name
FO
First Name
MI
IN
Start Here
ACS-1(INFO)(2014)KFI
FORM
(06-06-2013)
.4I/
13194022
Person 1
Person 2
1 What is Person 2s name?
Last Name (Please print)
(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)
First Name
MI
Person 1
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
Male
Day
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Year of birth
Month
Day
Year of birth
Month
Female
Parent-in-law
MI
Other relative
PY
First Name
Son-in-law or daughter-in-law
CO
Husband or wife
TI
RM
Yes, Cuban
FO
Yes, another Hispanic, Latino, or Spanish origin Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
IN
White
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Question 6 about race. For this survey, Hispanic origins are not races.
Question 6 about race. For this survey, Hispanic origins are not races.
.4I7
13194030
Person 3
1 What is Person 4s name?
First Name
MI
Husband or wife
Son-in-law or daughter-in-law
Husband or wife
Son-in-law or daughter-in-law
Other relative
Other relative
Roomer or boarder
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
Female
Male
Month
Day
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Year of birth
Month
Day
Year of birth
Female
CO
MI
Parent-in-law
First Name
PY
Person 4
TI
RM
Yes, Cuban
FO
Yes, another Hispanic, Latino, or Spanish origin Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
IN
Question 6 about race. For this survey, Hispanic origins are not races.
Question 6 about race. For this survey, Hispanic origins are not races.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
.4I?
13194048
Person 5
1
First Name
MI
Person 6
Last Name (Please print)
First Name
MI
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
Male
Sex
Female
Person 8
Day
Year of birth
Sex
Question 6 about race. For this survey, Hispanic origins are not races.
RM
Yes, Cuban
FO
Yes, another Hispanic, Latino, or Spanish origin Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
White
Sex
First Name
MI
Male
Female
Person 10
Last Name (Please print)
Sex
First Name
Male
Female
MI
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Person 11
Last Name (Please print)
Sex
Male
First Name
Female
Person 12
Last Name (Please print)
Sex
.4IQ
MI
First Name
MI
IN
First Name
TI
Female
Person 9
Male
Female
CO
Male
PY
Male
Female
MI
13194055
Housing
home have
b. a flush toilet?
c. a bathtub or shower?
d. a sink with a faucet?
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
1 to 9.9 acres
e. a stove or range?
10 or more acres
f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more
PY
CO
None
b. Handheld computer,
smart mobile phone, or other
handheld wireless computer
TI
Yes
No
1990 to 1999
FO
1960 to 1969
1950 to 1959
IN
1940 to 1949
Year
RM
1970 to 1979
1980 to 1989
1939 or earlier
No
Yes
a. Dial-up service?
b. DSL service?
c. Cable modem service?
d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite Internet service?
g. Some other service?
Specify service
.4IX
13194063
Housing (continued)
.00
None
OR
Yes
No
4
5
part of a condominium?
.00
OR
Coal or coke
Wood
Solar energy
No fuel used
.00
TI
Other fuel
OR
RM
FO
IN
,
OR
.4I
.00
,
OR
None
No
CO
PY
6 or more
13194071
Housing (continued)
B
Yes
.00
No
OR
CO
Amount Dollars
FO
.00
,
OR
IN
None
RM
OR
.00
.00
TI
PY
.00
.00
,
OR
None
.4Ih
13194089
Person 1
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
English at home?
Kindergarten
Yes
CO
Well
Not well
Not at all
TI
F
person attended school or college? Include
IN
FO
RM
Very well
PY
.4Iz
ZIP Code
13194097
Person 1 (continued)
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Now married
Separated
Widowed
PY
Divorced
No
CO
a. Married?
b. Widowed?
c. Divorced?
Once
Two times
No
TI
Yes
RM
No
IN
FO
Yes
Yes
No
Yes
30 or 40 percent
No SKIP to question 26
50 or 60 percent
Yes
Yes
No
No SKIP to question 26
.4I
70 percent or higher
13194105
Person 1 (continued)
No SKIP to question 38
Yes
Minute
days?
a.m.
p.m.
CO
PY
TI
Yes
d. Name of county
RM
a job?
10
IN
14 to 26 weeks
Motorcycle
Bicycle
Walked
No
Subway or elevated
Railroad
Worked at
home SKIP
to question 39a
Ferryboat
Other method
.4J&
27 to 39 weeks
No SKIP to question 36
Taxicab
No
40 to 47 weeks
f. ZIP Code
FO
13 weeks or less
13194113
Person 1 (continued)
L
Yes
No
Yes
No
Yes
CO
PY
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
todays date one year ago up through today.)
Yes
TI
RM
Yes $
No
.00
Yes
FO
IN
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
.00
Yes $
No
.00
Loss
OR $
.00
Loss
.00
Loss
.4J.
.00
None
manufacturing?
No
.00
No
No
.00
.00
11
13194121
Person 2
IN
FO
RM
TI
CO
PY
12
.4J6
13194279
.4Kp
27
13194287
Mailing
Instructions
Please make sure you have...
PY
CO
Then...
IN
FO
RM
TI
EDIT
EDIT CLERK
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
28
.4Kx