MEPS Income Section - P18R5P19R3P20R1

For the next questions, it might be useful to have out some of the
family’s financial records, such as a copy of the family’s tax forms
or materials used to complete the tax form, such as year end bank
statements, financial summaries, pay stubs, W-2 forms, and the like.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

NOTE: FOR ALL DOLLAR AMOUNT RANGE CHECKS, ALLOW
THE ENTRY OF WHOLE DOLLAR AMOUNTS ONLY; DO NOT
COLLECT CENTS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN01 - END_LP01

LOOP DEFINITION: LOOP_01 DETERMINES WHICH RU
MEMBERS HAVE FILED OR WILL FILE A FEDERAL INCOME
TAX FORM FOR THE CALENDAR YEAR. IF A JOINT RETURN
WAS OR WILL BE FILED, THE LOOP DETERMINES WHO IS
THE SECONDARY FILER. THIS LOOP CYCLES ON PERSONS
WHO MEET THE FOLLOWING CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

NAVIGATOR DETAILS: LOOP_01 USES NAV_IN01 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Filing Federal Income Tax Return? (e.g., filed yet, filing
status, who filing with, which 1040 form, type of deductions?)

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS INCLUDING DECEASED AND
INSTITUTIONALIZED RU MEMBERS

CONTINUE WITH BOX_00 FOR SELECTED RU MEMBER.

IF PERSON BEING LOOPED ON IS FLAGGED AS
‘SECONDARY FILER ON JOINT FEDERAL TAX RETURN’, GO
TO END_LP01

OTHERWISE, CONTINUE WITH IN02

{PERSON'S FIRST MIDDLE AND LAST NAME}

{Have/Has} {you/{PERSON}} filed a {YEAR} Federal income tax return?

YES .................................... 1 {IN04}
NO ..................................... 2 {IN03}
REF ................................... -7 {IN03}
DK .................................... -8 {IN03}

HELP AVAILABLE FOR DEFINITION OF TAX RETURN.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME}

Will {you/{PERSON}} file a {YEAR} Federal income tax return?

YES .................................... 1 {IN04}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

HELP AVAILABLE FOR DEFINITION OF TAX RETURN.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME}

What {was/will be} {your/{PERSON}’s} filing status ...

single; ................................ 1 {IN06}
married filing joint return; ........... 2 {IN05}
married filing separately; ............. 3 {IN06}
head of household with qualifying
person; or ........................... 4 {IN06}
qualifying widow(er) with dependent
children? ............................ 5 {IN06}
REF ................................... -7 {IN06}
DK .................................... -8 {IN06}

[Code One]

HELP AVAILABLE FOR DEFINITION OF RESPONSE CATEGORIES.

DISPLAY ‘was’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘will be’ IF IN03 IS CODED ‘1’ (YES).

FLAG PERSON BEING LOOPED ON AS ‘PRIMARY FILER ON
FEDERAL TAX RETURN’.

{PERSON'S FIRST MIDDLE AND LAST NAME}

Who is the other taxpayer that {you/{PERSON}} {are/is} filing jointly
with?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code One]

HELP AVAILABLE FOR DEFINITION OF ‘FILING JOINTLY’.

FLAG PERSON SELECTED AT IN05 AS ‘SECONDARY FILER
ON JOINT FEDERAL TAX RETURN’.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

3. DISPLAY ‘PERSON NOT IN RU’ AS THE LAST ENTRY
ON THE ROSTER.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON IS NOT ALREADY FLAGGED AS A ‘PRIMARY
FILER ON FEDERAL TAX RETURN’
- PERSON IS NOT ALREADY FLAGGED AS A ‘SECONDARY
FILER ON FEDERAL TAX RETURN’

{PERSON'S FIRST MIDDLE AND LAST NAME}

{Did/Will} {you/{PERSON}} claim any dependents on {your/his/her} Federal
tax return?

YES .................................... 1 {IN07}
NO ..................................... 2 {IN09}
REF ................................... -7 {IN09}
DK .................................... -8 {IN09}

HELP AVAILABLE FOR DEFINITION OF DEPENDENTS.

DISPLAY ‘Did’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘Will’ IF IN03 IS CODED ‘1’ (YES).

{PERSON'S FIRST MIDDLE AND LAST NAME}

Who {is/will be} listed as {your/{PERSON}’s} dependents?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

DISPLAY ‘is’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘will be’ IF IN03 IS CODED ‘1’ (YES).

CONTINUE WITH BOX_IN07

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

3. DISPLAY ‘PERSON(S) NOT IN RU’ AS THE LAST ENTRY
ON THE ROSTER.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON IS NOT A JOINT FILER (I.E., PERSON WAS
NOT SELECTED AT IN05)
- PERSON IS NOT CURRENTLY BEING LOOPED ON.

IF ‘PERSON(S) NOT IN RU’ SELECTED AT IN07,
CONTINUE WITH IN08

OTHERWISE, GO TO IN09

{PERSON'S FIRST MIDDLE AND LAST NAME}

How many of the dependents that are being claimed on {your/{PERSON}’s}
Federal income tax return live outside of this household?

[Enter Number of Dependents] ........... {IN09}
REF .................................... -7 {IN09}
DK ..................................... -8 {IN09}

HELP AVAILABLE FOR DEFINITION OF HOUSEHOLD.

SOFT CHECK:
SOFT RANGE CHECK: 1-10

{PERSON'S FIRST MIDDLE AND LAST NAME}

{Did/Will} {you/{PERSON}} file on the long form 1040, the short form
1040A, or the short form 1040EZ?

Long form 1040 ......................... 1 {IN15}
Short form 1040A ....................... 2 {IN17}
Short form 1040EZ ...................... 3 {END_LP01}
OTHER .................................. 91 {IN15}
REF .................................... -7 {END_LP01}
DK ..................................... -8 {END_LP01}

[Code One]

DISPLAY ‘Did’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘Will’ IF IN03 IS CODED ‘1’ (YES).

{PERSON'S FIRST MIDDLE AND LAST NAME}

{Did/Will} {you/{PERSON}} claim a deduction for health insurance
premiums?

YES .................................... 1 {IN17}
NO ..................................... 2 {IN17}
NOT APPLICABLE ......................... 3 {IN17}
REF ................................... -7 {IN17}
DK .................................... -8 {IN17}

[Code One]

HELP AVAILABLE FOR DEFINITION OF HEALTH INSURANCE
DEDUCTION.

DISPLAY ‘Did’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘Will’ IF IN03 IS CODED ‘1’ (YES).

{PERSON'S FIRST MIDDLE AND LAST NAME}

{Did/Will} {you/{PERSON}} receive earned income credits?

YES .................................... 1 {END_LP01}
NO ..................................... 2 {END_LP01}
NOT APPLICABLE ......................... 3 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

HELP AVAILABLE FOR DEFINITION OF EARNED INCOME CREDITS.

DISPLAY ‘Did’ IF IN02 IS CODED ‘1’ (YES). DISPLAY
‘Will’ IF IN03 IS CODED ‘1’ (YES).

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH IN17A

TAXABLE INCOME QUESTIONS ARE NEXT.

SELECT NEXT PAGE OR PRESS ENTER TO CONTINUE.

CONTINUE WITH LOOP_02

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN02 - END_LP02

LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION
ON TAXABLE INCOME FOR EACH RU MEMBER WHO IS 16
YEARS OF AGE OR OLDER OR HAS FILED OR WILL FILE A
FEDERAL TAX RETURN FOR THIS CALENDAR YEAR. THIS
LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERS-
ROSTER WHO MEETS THE FOLLOWING CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

NAVIGATOR DETAILS: LOOP_02 USES NAV_IN02 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Taxable Income Information for Those Filing or Over 16 (e.g.,
wages, interest, dividends, business or property income or loss, IRAs,
pensions, unemployment?)

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS INCLUDING DECEASED AND
INSTITUTIONALIZED RU MEMBERS

CONTINUE WITH BOX_01A FOR SELECTED RU MEMBER.

IF PERSON BEING LOOPED ON IS FLAGGED AS A ‘PRIMARY
FILER ON FEDERAL TAX RETURN’, GO TO IN18

IF PERSON BEING LOOPED ON IS FLAGGED AS A
‘SECONDARY FILER ON A JOINT FEDERAL TAX RETURN’,
GO TO END_LP02

OTHERWISE (I.E., PERSON IS NOT FLAGGED AS EITHER
‘PRIMARY FILER ON FEDERAL TAX RETURN’ OR A
‘SECONDARY FILER ON A JOINT FEDERAL TAX RETURN’,
THAT IS, IN03 IS CODED ‘2’ (NO), ‘-7’ (REFUSED)
OR ‘-8’ (DON’T KNOW)), CONTINUE WITH BOX_01B

IF PERSON BEING LOOPED ON IS 16 YEARS OF AGE OR
OLDER (OR IN AGE CATEGORIES 4-9), CONTINUE WITH
IN18

OTHERWISE (I.E., PERSON IS LESS THAN 16 YEARS OF
AGE (OR IN AGE CATEGORIES 1-3) AND IN03 IS CODED
‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW)),
GO TO END_LP02

NOTE: THE PURPOSE OF BOX_01A AND BOX_01B IS TO
SKIP OUT PERSONS ALREADY FLAGGED AS SECONDARY
FILERS AND PERSONS YOUNGER THAN 16 YEARS OF AGE
WHO HAVE NOT ALREADY REPORTED THAT THEY HAVE FILED
OR WILL FILE A FEDERAL INCOME TAX RETURN.

NOTE: PERSONS REPORTING THAT THEY HAVE FILED OR
WILL FILE A 1040A SHORT FORM (IN09=2) OR A 1040EZ
FORM (IN09=3) RECEIVE THE WAGES, INTEREST,
DIVIDENDS, IRA, PENSIONS, UNEMPLOYMENT, AND SOCIAL
SECURITY TAXABLE INCOME ITEMS.

PERSONS REPORTING THAT THEY HAVE FILED OR WILL
FILE A 1040 LONG FORM, OTHER TYPE OF FORM, OR
REFUSED OR DON’T KNOW THE TYPE OF FORM (IN09=1,
91, -7, -8) RECEIVE ALL THE TAXABLE INCOME
QUESTIONS.

PERSONS REPORTING THAT THEY HAVE NOT AND WILL NOT
FILE ANY FEDERAL TAX RETURN (IN03=2, -7, -8) AND
ARE 16 YEARS OF AGE OR OLDER ALSO RECEIVE ALL THE
TAXABLE INCOME QUESTIONS.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

{People get money from many different sources, such as wages and
salaries, social security, and interest on savings. The next few
questions ask about different sources of income that {you/{PERSON}} {and
{you/{NAME OF SECONDARY FILER}}} received in {YEAR}. It would be useful
to have out any tax materials that you may have.}

{Now let’s talk about {you/{PERSON}} {and {you/{NAME OF SECONDARY
FILER}}}.}

During {YEAR}, how much money did {they/{you/he/she}} receive from
wages or salary, tips, commissions, or bonuses?

[Enter $ Amount] ....................... {BOX_IN18}
REF .................................... -7 {IN19}
DK ..................................... -8 {IN18A}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

DISPLAY ‘People get money from many different
sources, such as wages and salaries, social
security, and interest on savings. The next few
questions ask about different sources of income
that (READ NAME(S) ABOVE) received in {YEAR}. It
would be useful to have out any tax materials that
you may have.’ IF FIRST CYCLE THROUGH LOOP_02.
OTHERWISE, USE NULL DISPLAY.

DISPLAY ‘Now let’s talk about (READ NAME(S)
ABOVE):’ IF NOT FIRST CYCLE THROUGH LOOP_02. IF
FIRST CYCLE THROUGH LOOP_02, USE A NULL DISPLAY.

DISPLAY ‘{and {you/{NAME OF SECONDARY FILER}}}’ IF
IN04 IS CODED ‘2’ (MARRIED FILING JOINT RETURN).
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘you’ IF THE SECONDARY FILER SELECTED AT
IN05 IS SELECTED AS THE RESPONDENT. OTHERWISE,
DISPLAY ‘{NAME OF SECONDARY FILER}’ SUBSTITUTING
THE PERSON’S NAME SELECTED AT IN05.

DISPLAY ‘they’ IF IN04 IS CODED ‘2’ (MARRIED
FILING JOINT RETURN). OTHERWISE, DISPLAY
‘{you/he/she}’ USING THE PERSON BEING LOOPED ON
TO DETERMINE PRONOUN SUBSTITUTION.

FOR ‘NAME OF SECONDARY FILER’, DISPLAY THE
PERSON’S NAME SELECTED AT IN05 DURING LOOP_01 FOR
THE PRIMARY FILER CURRENTLY BEING ASKED ABOUT. IF
IN05 WAS NOT ASKED IN LOOP_01 FOR THIS PERSON, USE
A NULL DISPLAY.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-300,000

IF AMOUNT OTHER THAN ZERO ENTERED AT IN18 AND IN04
IS CODED ‘2’ (MARRIED FILING JOINT RETURN),
CONTINUE WITH IN18OV

OTHERWISE, GO TO IN19

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

What percentage of this amount was received by {you/{PERSON}}?

[Enter Percent] ........................ {IN19}
REF .................................... -7 {IN19}
DK ..................................... -8 {IN19}

HARD CHECK:
RANGE CHECK: 0-100

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-1.

Which of the ranges on this card is the best estimate of how much
money was received [from wages or salary, tips, commissions, or
bonuses in {YEAR}]?

1 - 5,000 ............................... 1 {IN19}
5,001 - 10,000 .......................... 2 {IN19}
10,001 - 15,000 ......................... 3 {IN19}
15,001 - 25,000 ......................... 4 {IN19}
25,001 - 50,000 ......................... 5 {IN19}
50,001 - 100,000 ........................ 6 {IN19}
100,001 OR MORE ......................... 7 {IN19}
REF .................................... -7 {IN19}
DK ..................................... -8 {IN19}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much did {you/{PERSON}} {and {you/{NAME OF SECONDARY
FILER}}} receive in taxable interest from savings accounts, bonds, NOW
accounts, money market accounts, or similar types of investments?

{IF NECESSARY, SAY: If any interest from a joint account, include only
the amount that would be {your/his/her} portion.}

[Enter $ Amount] ....................... {IN20}
REF .................................... -7 {IN20}
DK ..................................... -8 {IN19A}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

DISPLAY ‘IF NECESSARY, SAY ... portion.’ IF IN04
IS NOT CODED ‘2’ (MARRIED, FILING JOINT RETURN)
OR IF IN04 WAS NOT ASKED. IF IN04 IS CODED ‘2’
(MARRIED, FILING JOINT RETURN), USE A NULL
DISPLAY.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [in interest from savings accounts, bonds, NOW
accounts, money market accounts, or similar types of investments in
{YEAR}]?

1 - 100 ................................. 1 {IN20}
101 - 500 ............................... 2 {IN20}
501 - 1,000 ............................. 3 {IN20}
1,001 - 5,000 ........................... 4 {IN20}
5,001 - 15,000 .......................... 5 {IN20}
15,001 OR MORE .......................... 6 {IN20}
REF .................................... -7 {IN20}
DK ..................................... -8 {IN20}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from dividends?

{IF NECESSARY, SAY: If any dividends from a joint source, include
only the amount that would be {your/his/her} portion.}

[Enter $ Amount] ....................... {BOX_02A}
REF .................................... -7 {BOX_02A}
DK ..................................... -8 {IN20A}

HELP AVAILABLE FOR DEFINITION OF DIVIDENDS.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: $0-$100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from dividends in {YEAR}]?

1 - 100 ................................. 1 {BOX_02A}
101 - 500 ............................... 2 {BOX_02A}
501 - 1,000 ............................. 3 {BOX_02A}
1,001 - 5,000 ........................... 4 {BOX_02A}
5,001 - 15,000 .......................... 5 {BOX_02A}
15,001 OR MORE .......................... 6 {BOX_02A}
REF .................................... -7 {BOX_02A}
DK ..................................... -8 {BOX_02A}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF IN09 IS CODED ‘2’ (SHORT FORM 1040A), OR ‘3’
(SHORT FORM 1040EZ) GO TO IN25

OTHERWISE, CONTINUE WITH IN22

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from alimony?

[Enter $ Amount] ....................... {IN23}
REF .................................... -7 {IN23}
DK ..................................... -8 {IN22A}

HELP AVAILABLE FOR DEFINITION OF ALIMONY.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from alimony in {YEAR}]?

1 - 100 ................................. 1 {IN23}
101 - 500 ............................... 2 {IN23}
501 - 1,000 ............................. 3 {IN23}
1,001 - 5,000 ........................... 4 {IN23}
5,001 - 15,000 .......................... 5 {IN23}
15,001 OR MORE .......................... 6 {IN23}
REF .................................... -7 {IN23}
DK ..................................... -8 {IN23}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} earn or lose from {their/{your/his/her}} own farm
or non-farm business or practice?

{IF NECESSARY, SAY: If any money from a shared business, include only
the amount that would be {your/his/her} portion.}

[Enter $ Amount] ....................... {BOX_IN23}
REF .................................... -7 {IN24}
DK ..................................... -8 {IN23A}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

DISPLAY ‘{and {you/{NAME OF SECONDARY FILER}}}’ IF
IN04 IS CODED ‘2’ (MARRIED FILING JOINT RETURN).
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘you’ IF THE SECONDARY FILER SELECTED AT
IN05 IS SELECTED AS THE RESPONDENT. OTHERWISE,
DISPLAY ‘{NAME OF SECONDARY FILER}’ SUBSTITUTING
THE PERSON’S NAME SELECTED AT IN05.

DISPLAY ‘their’ IF IN04 IS CODED ‘2’ (MARRIED
FILING JOINT RETURN). OTHERWISE, DISPLAY
‘{your/his/her}’ USING THE PERSON BEING LOOPED ON
TO DETERMINE PRONOUN SUBSTITUTION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-300,000

IF AMOUNT OTHER THAN ZERO ENTERED AT IN23,
CONTINUE WITH IN23OV1

OTHERWISE, GO TO IN24

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

INTERVIEWER: WAS THE AMOUNT ENTERED EARNINGS OR LOSS?

EARNINGS ............................... 1 {BOX_IN23OV1}
LOSS ................................... 2 {BOX_IN23OV1}

[Code One]

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

IF IN04 IS CODED ‘2’ (MARRIED FILING JOINT
RETURN), CONTINUE WITH IN23OV2

OTHERWISE, GO TO IN24

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

What percentage of this amount was {received/lost} by {you/{PRIMARY
FILER}}?

[Enter Percent] ........................ {IN24}
REF .................................... -7 {IN24}
DK ..................................... -8 {IN24}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

IF IN23OV1 IS CODED ‘1’ (EARNINGS), DISPLAY
‘received’. IF IN23OV1 IS CODED ‘2’ (LOSS),
DISPLAY ‘lost’.

HARD CHECK:
RANGE CHECK: 0-100

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was earned or lost [from {their/{your/his/her}} own farm or
non-farm business or practice in {YEAR}]?

1 - 100 ................................. 1 {IN23AOV}
101 - 500 ............................... 2 {IN23AOV}
501 - 1,000 ............................. 3 {IN23AOV}
1,001 - 5,000 ........................... 4 {IN23AOV}
5,001 - 15,000 .......................... 5 {IN23AOV}
15,001 OR MORE .......................... 6 {IN23AOV}
REF .................................... -7 {IN24}
DK ..................................... -8 {IN24}

[Code One]

DISPLAY ‘their’ IF IN04 IS CODED ‘2’ (MARRIED
FILING JOINT RETURN). OTHERWISE, DISPLAY
‘{your/his/her}’ USING THE PERSON BEING LOOPED ON
TO DETERMINE PRONOUN SUBSTITUTION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

INTERVIEWER: DOES THE RANGE SELECTED REPRESENT
EARNINGS OR LOSS?

EARNINGS ............................... 1 {IN24}
LOSS ................................... 2 {IN24}

[Code One]

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money was {your/{PERSON}’s} {and {your/{NAME OF
SECONDARY FILER}’s}} net gain or net loss from the sale of property or
other assets, including the sale of {their/{your/his/her}} home, if it
was taxable?

{IF NECESSARY, SAY: If any money from a shared property or other
asset, include only the amount that would be {your/his/her} portion.}

[Enter $ Amount] ....................... {BOX_IN24}
REF .................................... -7 {IN25}
DK ..................................... -8 {IN24A}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

DISPLAY ‘{and {your/{NAME OF SECONDARY FILER}’s}}’
IF IN04 IS CODED ‘2’ (MARRIED FILING JOINT RETURN)
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘your’ IF THE SECONDARY FILER SELECTED AT
IN05 IS SELECTED AS THE RESPONDENT. OTHERWISE,
DISPLAY ‘{NAME OF SECONDARY FILER}’s}’ SUBSTITUTING
THE PERSON’S NAME SELECTED AT IN05.

DISPLAY ‘their’ IF IN04 IS CODED ‘2’ (MARRIED
FILING JOINT RETURN). OTHERWISE, DISPLAY
‘{your/his/her}’ USING THE PERSON BEING LOOPED ON
TO DETERMINE PRONOUN SUBSTITUTION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-300,000

IF AMOUNT OTHER THAN ZERO ENTERED AT IN24,
CONTINUE WITH IN24OV

OTHERWISE, GO TO IN25

INTERVIEWER: WAS THE AMOUNT ENTERED A NET GAIN OR A NET LOSS?

NET GAIN ............................... 1 {IN25}
NET LOSS ............................... 2 {IN25}

[Code One]

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was earned or lost [from the sale of property or other assets,
including the sale of {their/{your/his/her}} home, if it was taxable,
in {YEAR}]?

1 - 100 ................................. 1 {IN24AOV}
101 - 500 ............................... 2 {IN24AOV}
501 - 1,000 ............................. 3 {IN24AOV}
1,001 - 5,000 ........................... 4 {IN24AOV}
5,001 - 15,000 .......................... 5 {IN24AOV}
15,001 OR MORE .......................... 6 {IN24AOV}
REF .................................... -7 {IN25}
DK ..................................... -8 {IN25}

[Code One]

DISPLAY ‘their’ IF IN04 IS CODED ‘2’ (MARRIED
FILING JOINT RETURN). OTHERWISE, DISPLAY
‘{your/his/her}’ USING THE PERSON BEING LOOPED ON
TO DETERMINE PRONOUN SUBSTITUTION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

INTERVIEWER: DOES THE RANGE SELECTED REPRESENT
NET GAIN OR NET LOSS?

NET GAIN ............................... 1 {IN25}
NET LOSS ............................... 2 {IN25}

[Code One]

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from payments from Individual Retirement
Accounts, that is, IRA, Keogh, or 401K accounts?

[Enter $ Amount] ....................... {IN26}
REF .................................... -7 {IN26}
DK ..................................... -8 {IN25A}

HELP AVAILABLE FOR DEFINITION OF IRA.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from payments from IRA, Keogh, and 401K accounts
in {YEAR}]?

1 - 100 ................................. 1 {IN26}
101 - 500 ............................... 2 {IN26}
501 - 1,000 ............................. 3 {IN26}
1,001 - 5,000 ........................... 4 {IN26}
5,001 - 15,000 .......................... 5 {IN26}
15,001 OR MORE .......................... 6 {IN26}
REF .................................... -7 {IN26}
DK ..................................... -8 {IN26}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from private pensions, military retirement,
other Federal government employee pensions, state or local government
employee pensions, or annuities?

[Enter $ Amount] ....................... {BOX_02B}
REF .................................... -7 {BOX_02B}
DK ..................................... -8 {IN27}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-300,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-1.

Which of the ranges on this card is the best estimate of how much
money was received [from private pensions, military retirement,
Other Federal government employee pensions, state or local government
employee pensions, or annuities in {YEAR}]?

1 - 5,000 ............................... 1 {BOX_02B}
5,001 - 10,000 .......................... 2 {BOX_02B}
10,001 - 15,000 ......................... 3 {BOX_02B}
15,001 - 25,000 ......................... 4 {BOX_02B}
25,001 - 50,000 ......................... 5 {BOX_02B}
50,001 - 100,000 ........................ 6 {BOX_02B}
100,001 OR MORE ......................... 7 {BOX_02B}
REF .................................... -7 {BOX_02B}
DK ..................................... -8 {BOX_02B}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF IN09 IS CODED ‘2’ (SHORT FORM 1040A) OR ‘3’
(SHORT FORM 1040EZ), GO TO IN30

OTHERWISE, CONTINUE WITH IN28

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive as a net gain or loss from estates or trusts,
partnerships, S corporations, royalties, or from rental income?

{IF NECESSARY, SAY: If any money from a joint venture, include only
the amount that would be {your/his/her} portion.}

[Enter $ Amount] ....................... {BOX_IN28}
REF .................................... -7 {IN30}
DK ..................................... -8 {IN28A}

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-300,000

IF AMOUNT OTHER THAN ZERO ENTERED AT IN28,
CONTINUE WITH IN28OV

OTHERWISE, GO TO IN30

INTERVIEWER: WAS THE AMOUNT ENTERED A NET GAIN OR A NET LOSS?

NET GAIN ............................... 1 {IN30}
NET LOSS ............................... 2 {IN30}

[Code One]

HELP AVAILABLE FOR DESCRIPTION OF AMOUNTS TO INCLUDE.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was earned or lost [from estates or trusts, partnerships,
S corporations, royalties, or from rental income in {YEAR}]?

1 - 100 ................................. 1 {IN28AOV1}
101 - 500 ............................... 2 {IN28AOV1}
501 - 1,000 ............................. 3 {IN28AOV1}
1,001 - 5,000 ........................... 4 {IN28AOV1}
5,001 - 15,000 .......................... 5 {IN28AOV1}
15,001 OR MORE .......................... 6 {IN28AOV1}
REF .................................... -7 {IN30}
DK ..................................... -8 {IN30}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

INTERVIEWER: DOES THE RANGE SELECTED REPRESENT
NET GAIN OR NET LOSS?

NET GAIN ............................... 1 {IN30}
NET LOSS ............................... 2 {IN30}

[Code One]

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from unemployment compensation?

[Enter $ Amount] ....................... {IN31}
REF .................................... -7 {IN31}
DK ..................................... -8 {IN30A}

HELP AVAILABLE FOR DEFINITION OF UNEMPLOYMENT COMPENSATION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from unemployment compensation in {YEAR}]?

1 - 100 ................................. 1 {IN31}
101 - 500 ............................... 2 {IN31}
501 - 1,000 ............................. 3 {IN31}
1,001 - 5,000 ........................... 4 {IN31}
5,001 - 15,000 .......................... 5 {IN31}
15,001 OR MORE .......................... 6 {IN31}
REF .................................... -7 {IN31}
DK ..................................... -8 {IN31}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

During {YEAR}, how much money did {you/{PERSON}} {and {you/{NAME OF
SECONDARY FILER}}} receive from Social Security and equivalent tier 1
Railroad Retirement benefits?

[Enter $ Amount] ....................... {END_LP02}
REF .................................... -7 {END_LP02}
DK ..................................... -8 {IN32}

HELP AVAILABLE FOR DEFINITION OF SOCIAL SECURITY.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF SECONDARY FILER}

SHOW CARD IN-1.

Which of the ranges on this card is the best estimate of how much
money was received [from Social Security and equivalent tier 1
Railroad Retirement benefits in {YEAR}]?

1 - 5,000 ............................... 1 {END_LP02}
5,001 - 10,000 .......................... 2 {END_LP02}
10,001 - 15,000 ......................... 3 {END_LP02}
15,001 - 25,000 ......................... 4 {END_LP02}
25,001 - 50,000 ......................... 5 {END_LP02}
50,001 - 100,000 ........................ 6 {END_LP02}
100,001 OR MORE ......................... 7 {END_LP02}
REF .................................... -7 {END_LP02}
DK ..................................... -8 {END_LP02}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_02 AND CONTINUE WITH IN34

During {YEAR}, did anyone in the family receive Worker’s Compensation?

YES .................................... 1
NO ..................................... 2 {IN37}
REF ................................... -7 {IN37}
DK .................................... -8 {IN37}

HELP AVAILABLE FOR DEFINITION OF WORKER’S COMPENSATION.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED WORKER’S
COMPENSATION’ AT IN35 AND GO TO LOOP_03

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN35

Who received Worker’s Compensation in {YEAR}?

PROBE: Anyone else receive Worker’s Compensation in {YEAR}?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CONTINUE WITH LOOP_03

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED MEMBERS)

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN03 - END_LP03

LOOP DEFINITION: LOOP_03 DETERMINES HOW MUCH
MONEY WAS RECEIVED FROM WORKER’S COMPENSATION FOR
RU MEMBERS WHO RECEIVED WORKER’S COMPENSATION IN
THE CALENDAR YEAR. THIS LOOP CYCLES ON EACH
PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE
FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED WORKER’S COMPENSATION IN THE
CALENDAR YEAR (SELECTED AT IN35)

NAVIGATOR DETAILS: LOOP_03 USES NAV_IN03 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Amount Received from Worker’s Compensation

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED WORKER’S COMPENSATION IN THE
CALENDAR YEAR (SELECTED AT IN35)

CONTINUE WITH IN36 FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

How much money did {you/{PERSON}} receive from Worker’s Compensation
[in {YEAR}]?

[Enter $ Amount] ....................... {END_LP03}
REF .................................... -7 {END_LP03}
DK ..................................... -8 {IN36A}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-50,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from Worker’s Compensation in {YEAR}]?

1 - 100 ................................. 1 {END_LP03}
101 - 500 ............................... 2 {END_LP03}
501 - 1,000 ............................. 3 {END_LP03}
1,001 - 5,000 ........................... 4 {END_LP03}
5,001 - 15,000 .......................... 5 {END_LP03}
15,001 OR MORE .......................... 6 {END_LP03}
REF .................................... -7 {END_LP03}
DK ..................................... -8 {END_LP03}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_03 AND CONTINUE WITH IN37

During {YEAR}, did anyone in the family receive Supplemental Security
Income, also known as S.S.I.?

YES .................................... 1
NO ..................................... 2 {IN41}
REF ................................... -7 {IN41}
DK .................................... -8 {IN41}

HELP AVAILABLE FOR DEFINITION OF S.S.I.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED S.S.I.’ AT
IN38 AND GO TO LOOP_04

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN38

Who received Supplemental Security Income in {YEAR}?

PROBE: Anyone else receive S.S.I. in {YEAR}?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CONTINUE WITH LOOP_04

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN04 - END_LP04

LOOP DEFINITION: LOOP_04 DETERMINES HOW MUCH
MONEY WAS RECEIVED FROM SUPPLEMENTAL SECURITY
INCOME (S.S.I) FOR RU MEMBERS WHO RECEIVED S.S.I.
IN THE CALENDAR YEAR. THIS LOOP CYCLES ON EACH
PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE
FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED SUPPLEMENTAL SECURITY INCOME IN
THE CALENDAR YEAR (SELECTED AT IN38)

NAVIGATOR DETAILS: LOOP_04 USES NAV_IN04 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Supplemental Security Income – Number of Months Received
and Amount Received Monthly

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED SUPPLEMENTAL SECURITY INCOME IN
THE CALENDAR YEAR (SELECTED AT IN38)

CONTINUE WITH IN40A FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

For how many months in {YEAR} did {you/{PERSON}} receive money from
Supplemental Security Income?

[Enter Number of Months] ................ {IN40B}
REF .................................... -7 {IN40B}
DK ..................................... -8 {IN40B}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

HARD CHECK:
RANGE CHECK: 1-12

{PERSON'S FIRST MIDDLE AND LAST NAME}

On average, how much money did {you/{PERSON}} get per month [from
Supplemental Security Income in {YEAR}]?

[Enter $ Amount] ........................ {END_LP04}
REF .................................... -7 {END_LP04}
DK ..................................... -8 {IN40C}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-50,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-3.

Which of the ranges on this card is the best estimate of how much money
was received per month [from Supplemental Security Income in {YEAR}]?

1 - 250 ................................. 1 {END_LP04}
251 - 500 ............................... 2 {END_LP04}
501 - 750 ............................... 3 {END_LP04}
751 - 1,000 ............................. 4 {END_LP04}
1,001 OR MORE ........................... 5 {END_LP04}
REF .................................... -7 {END_LP04}
DK ..................................... -8 {END_LP04}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_04 AND CONTINUE WITH IN41

During {YEAR}, did anyone in the family receive any money from
public assistance, such as Temporary Assistance for Needy
Families, also known as TANF{, {STATE TANF NAME 1}}{, {STATE TANF
NAME 2}}{, {STATE TANF NAME 3}}, or general assistance?

YES .................................... 1
NO ..................................... 2 {IN46}
REF ................................... -7 {IN46}
DK .................................... -8 {IN46}

HELP AVAILABLE FOR DEFINITION OF PUBLIC ASSISTANCE.

DISPLAY ‘, {STATE TANF NAME 1}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE TANF PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED HAS ONE OR
MORE TANF NAME(S). OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘, {STATE TANF NAME 2}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE TANF PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED HAS A SECOND
OTHER TANF NAME. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘, {STATE TANF NAME 3}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE TANF PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED HAS A THIRD
OTHER TANF NAME. OTHERWISE, USE A NULL DISPLAY.

FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 36.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED PUBLIC
ASSISTANCE’ AT IN42 AND GO TO LOOP_05

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN42

Whose name was on the checks?

PROBE: Does anyone else receive a check from public assistance in
their name?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

CONTINUE WITH LOOP_05

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN05 - END_LP05

LOOP DEFINITION: LOOP_05 DETERMINES WHO WAS
COVERED BY PUBLIC ASSISTANCE, WHETHER ANY OF THE
CHECKS INCLUDED MONEY FROM TANF AND HOW MUCH WAS
RECEIVED PER MONTH. THIS LOOP CYCLES ON EACH
PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE
FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON’S NAME WAS ON THE PUBLIC ASSISTANCE
CHECKS (SELECTED AT IN42)

NAVIGATOR DETAILS: LOOP_05 USES NAV_IN05 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Public Assistance (who covered, TANF included, number of
months received, amount received monthly)

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON’S NAME WAS ON THE PUBLIC ASSISTANCE
CHECKS (SELECTED AT IN42)

CONTINUE WITH IN43 FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

Sometimes checks from public assistance cover more than one person
in the family, even though only one person’s name is on the check.

Who is covered by {your/{PERSON}’s} checks from public assistance?

PROBE: Did {your/his/her} checks cover anyone else?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

3. DISPLAY ‘PERSON NOT IN RU’ AS THE 2ND TO LAST
ENTRY ON THE ROSTER.

4. DISPLAY ‘CHECK ONLY COVERS (PERSON) IN HEADER’
AS THE LAST ENTRY ON THE ROSTER.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON IS NOT SELECTED AS RECEIVING HIS OWN
PUBLIC ASSISTANCE CHECKS; THAT IS PERSON WAS NOT
SELECTED AT IN42

{PERSON'S FIRST MIDDLE AND LAST NAME}

Did any of {your/{PERSON}’s} checks include money from Temporary
Assistance for Needy Families, also known as TANF{,/ or} {STATE
TANF NAME 1}{,/, or} {STATE TANF NAME 2}{, or STATE TANF NAME 3}?

YES .................................... 1 {IN45A}
NO ..................................... 2 {IN45A}
REF ................................... -7 {IN45A}
DK .................................... -8 {IN45A}

HELP AVAILABLE FOR DEFINITION OF TANF.

DISPLAY ‘,’ IF THE STATE IN WHICH INTERVIEW IS
BEING CONDUCTED HAS AT TWO OR MORE OTHER STATE
SPECIFIC TANF NAMES. DISPLAY ‘or’ IF THE STATE IN
WHICH INTERVIEW IS BEING CONDUCTED HAS ONLY ONE
STATE SPECIFIC TANF NAME. USE A NULL DISPLAY IF
STATE HAS NO STATE SPECIFIC TANF NAMES.

DISPLAY ‘{STATE TANF NAME 1}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE TANF PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED HAS ONE OR
MORE TANF NAME(S). OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘,’ IF THE STATE IN WHICH INTERVIEW IS
BEING CONDUCTED HAS THREE OTHER STATE SPECIFIC
TANF NAMES. DISPLAY ‘, or’ IF THE STATE IN WHICH
INTERVIEW IS BEING CONDUCTED HAS TWO STATE
TANF NAMES. USE A NULL DISPLAY IF STATE HAS ZERO
OR ONLY ONE STATE SPECIFIC TANF NAME.

DISPLAY ‘{STATE TANF NAME 2}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE TANF PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED HAS A SECOND
OTHER TANF NAME. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘, or {STATE TANF NAME 3}’ (SUBSTITUTING
THE REAL STATE NAME FOR THE TANF PROGRAM) IF THE
STATE IN WHICH INTERVIEW IS BEING CONDUCTED HAS A
THIRD OTHER TANF NAME. OTHERWISE, USE A NULL
DISPLAY.

FOR THE SPECIFIC NAME TO USE BY STATE, SEE
ATTACHMENT 36.

{PERSON'S FIRST MIDDLE AND LAST NAME}

For how many months in {YEAR} did {you/{PERSON}} receive checks from
public assistance?

[Enter Number of Months] ................ {IN45B}
REF .................................... -7 {IN45B}
DK ..................................... -8 {IN45B}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

HARD CHECK:
RANGE CHECK: 1-12

{PERSON'S FIRST MIDDLE AND LAST NAME}

On average, how much money did {you/{PERSON}} get per month [from
public assistance in {YEAR}]?

[Enter $ Amount] ........................ {END_LP05}
REF .................................... -7 {END_LP05}
DK ..................................... -8 {IN45C}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-50,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-3.

Which of the ranges on this card is the best estimate of how much money
was received per month [from public assistance in {YEAR}]?

1 - 250 ................................. 1 {END_LP05}
251 - 500 ............................... 2 {END_LP05}
501 - 750 ............................... 3 {END_LP05}
751 - 1,000 ............................. 4 {END_LP05}
1,001 OR MORE ........................... 5 {END_LP05}
REF .................................... -7 {END_LP05}
DK ..................................... -8 {END_LP05}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_05 AND CONTINUE WITH IN46

During {YEAR}, did anyone in the family receive any money from
child support?

YES .................................... 1
NO ..................................... 2 {IN49}
REF ................................... -7 {IN49}
DK .................................... -8 {IN49}

HELP AVAILABLE FOR DEFINITION OF CHILD SUPPORT.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED CHILD
SUPPORT’ AT IN47 AND GO TO LOOP_06

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN47

Who received child support in {YEAR}?

PROBE: Anyone else receive child support in {YEAR}?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

HELP AVAILABLE FOR DESCRIPTION OF WHO TO INCLUDE.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CONTINUE WITH LOOP_06

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN06 - END_LP06

LOOP DEFINITION: LOOP_06 DETERMINES HOW MUCH
MONEY WAS RECEIVED FROM CHILD SUPPORT FOR RU
MEMBERS WHO RECEIVED CHILD SUPPORT IN CALENDAR
YEAR. THIS LOOP CYCLES ON EACH PERSON ON THE RU-
MEMBERS-ROSTER WHO MEETS THE FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED CHILD SUPPORT IN CALENDAR YEAR
(SELECTED AT IN47)

NAVIGATOR DETAILS: LOOP_06 USES NAV_IN06 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Child Support – Number of Months Received and Amount
Received Monthly

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

CONTINUE WITH IN48A FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

For how many months in {YEAR} did {you/{PERSON}} receive money from
child support?

[Enter Number of Months] ................ {IN48B}
REF .................................... -7 {IN48B}
DK ..................................... -8 {IN48B}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

HARD CHECK:
RANGE CHECK: 1-12

{PERSON'S FIRST MIDDLE AND LAST NAME}

On average, how much money did {you/{PERSON}} get per month [from
child support in {YEAR}]?

[Enter $ Amount] ........................ {END_LP06}
REF .................................... -7 {END_LP06}
DK ..................................... -8 {IN48C}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-3.

Which of the ranges on this card is the best estimate of how much
money was received per month [from child support in {YEAR}]?

1 - 250 ................................. 1 {END_LP06}
251 - 500 ............................... 2 {END_LP06}
501 - 750 ............................... 3 {END_LP06}
751 - 1,000 ............................. 4 {END_LP06}
1,001 OR MORE ........................... 5 {END_LP06}
REF .................................... -7 {END_LP06}
DK ..................................... -8 {END_LP06}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_06 AND CONTINUE WITH IN49

Not counting military retirement, during {YEAR}, did anyone in the
family receive any veteran’s payments such as education or disability
benefits?

YES .................................... 1
NO ..................................... 2 {IN52}
REF ................................... -7 {IN52}
DK .................................... -8 {IN52}

HELP AVAILABLE FOR DEFINITION OF VETERAN’S PAYMENTS.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED VETERAN’S
PAYMENTS’ AT IN50 AND GO TO LOOP_07

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN50

Who received veteran’s payments such as education or
disability benefits [in {YEAR}]?

PROBE: Anyone else receive veteran’s payments in {YEAR}?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CONTINUE WITH LOOP_07

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN07 - END_LP07

LOOP DEFINITION: LOOP_07 DETERMINES HOW MUCH
MONEY WAS RECEIVED FROM VETERAN’S PAYMENTS FOR RU
MEMBERS WHO RECEIVED VETERAN’S PAYMENTS IN THE
CALENDAR YEAR. THIS LOOP CYCLES ON EACH PERSON ON
THE RU-MEMBERS-ROSTER WHO MEETS THE FOLLOWING
CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED VETERAN’S PAYMENTS IN THE
CALENDAR YEAR (SELECTED AT IN50)

NAVIGATOR DETAILS: LOOP_07 USES NAV_IN07 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Amount Received from Veteran’s Payments

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED VETERAN’S PAYMENTS IN THE
CALENDAR YEAR (SELECTED AT IN50)

CONTINUE WITH IN51 FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

How much money did {you/{PERSON}} receive from veteran’s payments such
as education or disability benefits in {YEAR}? [Do not include military
retirement.]

[Enter $ Amount] ....................... {END_LP07}
REF .................................... -7 {END_LP07}
DK ..................................... -8 {IN51A}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from veteran’s payments such as education or
disability benefits in {YEAR}]?

1 - 100 ................................. 1 {END_LP07}
101 - 500 ............................... 2 {END_LP07}
501 - 1,000 ............................. 3 {END_LP07}
1,001 - 5,000 ........................... 4 {END_LP07}
5,001 - 15,000 .......................... 5 {END_LP07}
15,001 OR MORE .......................... 6 {END_LP07}
REF .................................... -7 {END_LP07}
DK ..................................... -8 {END_LP07}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_07 AND CONTINUE WITH IN52

Besides what we have already talked about, during {YEAR}, did anyone
in the family receive any money from regular cash contributions from
people who do not live in this household?

YES .................................... 1
NO ..................................... 2 {IN55}
REF ................................... -7 {IN55}
DK .................................... -8 {IN55}

HELP AVAILABLE FOR DESCRIPTION OF REGULAR CASH
CONTRIBUTIONS AND HOUSEHOLD.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVED REGULAR
CASH CONTRIBUTIONS FROM OUTSIDE HOUSEHOLD’ AT
IN53 AND GO TO LOOP_08

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH IN53

Who received regular cash contributions from people who do not live
in this household [in {YEAR}]?

PROBE: Anyone else receive regular cash contributions, in {YEAR},
from people who do not live here?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CONTINUE WITH LOOP_08

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
DISPLAY THE RU-MEMBERS-ROSTER FOR SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, EDIT, AND DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL CURRENT RU MEMBERS (INCLUDING PERSONS
WHO ARE DECEASED AND INSTITUTIONALIZED THIS ROUND
WHO ARE CURRENT ROUND 3 MEMBERS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_IN08 - END_LP08

LOOP DEFINITION: LOOP_08 DETERMINES HOW MUCH
MONEY WAS RECEIVED FROM REGULAR CASH
CONTRIBUTIONS FROM OUTSIDE THE HOUSEHOLD FOR RU
MEMBERS WHO RECEIVED THESE TYPES OF CONTRIBUTIONS
IN THE CALENDAR YEAR. THIS LOOP CYCLES ON EACH
PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE
FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED REGULAR CASH CONTRIBUTIONS
FROM SOMEONE OUTSIDE OF THE HOUSEHOLD IN THE
CALENDAR YEAR (SELECTED AT IN53)

NAVIGATOR DETAILS: LOOP_08 USES NAV_IN08 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Regular Cash Contributions – Number of Months Received
and Amount Received Monthly

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)
- PERSON RECEIVED REGULAR CASH CONTRIBUTIONS
FROM SOMEONE OUTSIDE OF THE HOUSEHOLD IN THE
CALENDAR YEAR (SELECTED AT IN53)

CONTINUE WITH IN54A FOR SELECTED RU MEMBER.

{PERSON'S FIRST MIDDLE AND LAST NAME}

For how many months in {YEAR} did {you/{PERSON}} receive money from
regular cash contributions from people who do not live in this
household?

[Enter Number of Months] ................ {IN54B}
REF .................................... -7 {IN54B}
DK ..................................... -8 {IN54B}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

HARD CHECK:
RANGE CHECK: 1-12

{PERSON'S FIRST MIDDLE AND LAST NAME}

On average, how much money did {you/{PERSON}} get per month [from
regular cash contributions from people who do not live in this
household, in {YEAR}]?

[Enter $ Amount] ........................ {END_LP08}
REF .................................... -7 {END_LP08}
DK ..................................... -8 {IN54C}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

{PERSON'S FIRST MIDDLE AND LAST NAME}

SHOW CARD IN-3.

Which of the ranges on this card is the best estimate of how much
money was received per month [from regular cash contributions from
people who do not live in this household, in {YEAR}]?

1 - 250 ................................. 1 {END_LP08}
251 - 500 ............................... 2 {END_LP08}
501 - 750 ............................... 3 {END_LP08}
751 - 1,000 ............................. 4 {END_LP08}
1,001 OR MORE ........................... 5 {END_LP08}
REF .................................... -7 {END_LP08}
DK ..................................... -8 {END_LP08}

[Code One]

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER
THAT MEETS THE CONDITIONS STATED IN THE LOOP
DEFINITION.

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_08 AND CONTINUE WITH IN55

During {YEAR}, did anyone in the family get benefits from the
Supplemental Nutrition Assistance Program, also known as SNAP {or
{STATE SNAP NAME}}, or food stamps?

YES .................................... 1 {IN56}
NO ..................................... 2 {IN59}
REF ................................... -7 {IN59}
DK .................................... -8 {IN59}

HELP AVAILABLE FOR DEFINITION OF SNAP.

DISPLAY ‘or {STATE SNAP NAME}’ (SUBSTITUTING THE
REAL STATE NAME FOR THE SNAP PROGRAM) IF THE STATE
IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE
THE NAME ‘SNAP.’ FOR THE SPECIFIC NAME TO USE BY
STATE, SEE ATTACHMENT 36.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

For how many months in {YEAR} were SNAP or other food stamp benefits
received?

[Enter Months] ......................... {IN58}
REF ................................... -7 {IN58}
DK .................................... -8 {IN58}

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

HARD CHECK:
RANGE CHECK: 1-12

What was the approximate monthly value of the SNAP or other food
stamp benefits?

[Enter $ Amount] ....................... {IN59}
REF ................................... -7 {IN59}
DK .................................... -8 {IN59}

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-1,000

SHOW CARD IN-4.

This card lists some sources of income. Has anyone in the family
received any income, other than income we have already talked about,
such as income from sources listed on this card?

YES .................................... 1 {LOOP_09}
NO ..................................... 2 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}

HELP AVAILABLE FOR DEFINITIONS OF SHOW CARD CATEGORIES.

FOR EACH OF THE FOLLOWING:

OTHER INCOME SOURCE CATEGORY 1
OTHER INCOME SOURCE CATEGORY 2
OTHER INCOME SOURCE CATEGORY 3
OTHER INCOME SOURCE CATEGORY 4
OTHER INCOME SOURCE CATEGORY 5

ASK IN60 - END_LP09

LOOP DEFINITION: LOOP_09 COLLECTS INFORMATION
ABOUT OTHER SOURCES OF TAXABLE INCOME. THIS LOOP
CYCLES ON SOURCES OF TAXABLE INCOME LISTED AT
IN60. THE first cycle of this loop collects THE
THE FIRST SOURCE OF TAXABLE INCOME. SUBSEQUENT
CYCLES OF THE LOOP ARE DETERMINED BY THE RESPONSE
AT IN63. IF IN63 IS CODED '1' (YES), THE LOOP
CYCLES AGAIN TO COLLECT THE NEXT SOURCE OF TAXABLE
INCOME. IF IN63 IS CODED ‘2’ (NO), ‘-7’
(REFUSED), or ‘-8’ (DON’T KNOW), THE LOOP ENDS.

NAVIGATOR DETAILS: LOOP_09 USES NAV_IN09 TO
CONTROL THE FLOW OF THE LOOP AND THE SOURCES
SELECTED AT IN60.

SHOW CARD IN-4.

From which of the sources on this card did anyone in the family
receive income [that we have not yet talked about]?

WAGES AND SALARY ...................... 1 {NAV_IN09}
FARM INCOME (OR LOSS) ................. 2 {NAV_IN09}
BUSINESS INCOME (OR LOSS) ............. 3 {NAV_IN09}
SOCIAL SECURITY/RAILROAD RETIREMENT ... 4 {NAV_IN09}
PRIVATE, MILITARY, OR GOVERNMENT
PENSIONS ............................ 5 {NAV_IN09}
INTEREST .............................. 6 {NAV_IN09}
DIVIDENDS ............................. 7 {NAV_IN09}
RENTAL INCOME (OR LOSS) ............... 8 {NAV_IN09}
OTHER SOURCE .......................... 91 {IN60OV}
REF ................................... -7 {NAV_IN09}
DK .................................... -8 {NAV_IN09}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

ENTER OTHER INCOME SOURCE:

[Other Specify] ......................... {NAV_IN09}
REF .................................... –7 {NAV_IN09}
DK ..................................... –8 {NAV_IN09}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

{STR-DT}

SERIES: Additional Sources of Income and Amount

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO PAST
THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

Income Source

[1. Income Source Selected at IN60] [Status-25]
[2. Income Source Selected at IN60] [Status-25]
[3. Income Source Selected at IN60] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: INCOME SOURCE
INSTRUCTIONS: DISPLAY THE INCOME SOURCE CATEGORY
SELECTED AT IN60 FOR THIS CYCLE OF THE LOOP.
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
DISPLAY ALL INCOME SOURCES SELECTED AT IN60.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL INCOME SOURCES SELECTED AT IN60.

CONTINUE WITH BOX_03B FOR SELECTED INCOME SOURCE.

IF SINGLE PERSON RU, AUTOMATICALLY CODE PERSON AS
‘RECEIVED INCOME FROM IN60 SOURCE’ AT IN61 AND GO
TO IN62. OTHERWISE, CONTINUE WITH IN61

Who received income from {CATEGORY SELECTED AT IN60} in {YEAR}?

PROBE: Anyone else receive income from (INCOME SOURCE) in {YEAR}?

[1. First Name, [Middle Name], Last name-65]
[2. First Name, [Middle Name], Last name-65]
[3. First Name, [Middle Name], Last name-65]

[Code All That Apply]

FOR ‘CATEGORY SELECTED AT IN60’, DISPLAY THE
RESPONSE CATEGORY NAME SELECTED AT IN60 DURING
THE CURRENT LOOP.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITION:

- PERSON IS A CURRENT RU MEMBER (INCLUDES DECEASED
AND INSTITUTIONALIZED RU MEMBERS)

What is the total amount received from {CATEGORY SELECTED AT IN60},
in {YEAR}, for {all of the people just mentioned/{you/{PERSON}}}?

[Enter $ Amount] ....................... {BOX_IN62}
REF ................................... -7 {IN63}
DK .................................... -8 {IN62A}

FOR ‘CATEGORY SELECTED AT IN60’, DISPLAY THE
RESPONSE CATEGORY NAME SELECTED AT IN60 DURING
THE CURRENT LOOP.

DISPLAY ‘all of the people just mentioned’ IF A
MULTI-PERSON RU. OTHERWISE (I.E., SINGLE-PERSON
RU), DISPLAY ‘{you/{PERSON}}’.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

BEGINNING IN PANEL 12, PRE-FILL CENTS DIGITS
WITH ‘00’ SO THAT FIELD ACCEPTS WHOLE DOLLAR
AMOUNT ONLY.

SOFT CHECK:
SOFT RANGE CHECK: 0-100,000

IF AMOUNT OTHER THAN ZERO ENTERED AT IN62 AND
IN60 IS CODED ‘2’ (FARM INCOME OR LOSS), ‘3’
(BUSINESS INCOME OR LOSS), ‘8’ (RENTAL INCOME OR
LOSS), OR ‘91’ (OTHER SOURCE), CONTINUE WITH
IN62OV

OTHERWISE, GO TO IN63

INCOME SOURCE: {DISPLAY CATEGORY SELECTED AT IN60.........}

INTERVIEWER: WAS THE AMOUNT ENTERED A NET GAIN OR A
NET LOSS?

NET GAIN ............................... 1 {IN63}
NET LOSS ............................... 2 {IN63}

[Code One]

SHOW CARD IN-2.

Which of the ranges on this card is the best estimate of how much
money was received [from {CATEGORY SELECTED AT IN60} in {YEAR}]?

1 - 100 ................................. 1 {BOX_IN62A}
101 - 500 ............................... 2 {BOX_IN62A}
501 - 1,000 ............................. 3 {BOX_IN62A}
1,001 - 5,000 ........................... 4 {BOX_IN62A}
5,001 - 15,000 .......................... 5 {BOX_IN62A}
15,001 OR MORE .......................... 6 {BOX_IN62A}
REF .................................... -7 {BOX_IN62A}
DK ..................................... -8 {BOX_IN62A}

[Code One]

FOR ‘CATEGORY SELECTED AT IN60’, DISPLAY THE
RESPONSE CATEGORY NAME SELECTED AT IN60 DURING
THE CURRENT LOOP.

(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY:) IF ROUND 3, DISPLAY FIRST CALENDAR
YEAR OF PANEL FOR {YEAR}. IF ROUND 5, DISPLAY
SECOND CALENDAR YEAR OF PANEL FOR {YEAR}.

IF ‘-7’ (REFUSED) OR ‘-8’ (DON’T KNOW) IS NOT
CODED AT IN62A AND IN60 IS CODED ‘2’ (FARM INCOME
OR LOSS), ‘3’ (BUSINESS INCOME OR LOSS), ‘8’
(RENTAL INCOME OR LOSS), OR ‘91’ (OTHER SOURCE),
CONTINUE WITH IN62AOV

OTHERWISE, GO TO IN63

INCOME SOURCE: {DISPLAY CATEGORY SELECTED AT IN60.........}

INTERVIEWER: DOES THE RANGE SELECTED REPRESENT NET GAIN OR NET
LOSS?

NET GAIN ............................... 1 {IN63}
NET LOSS ............................... 2 {IN63}

[Code One]

SHOW CARD IN-4.

Aside from what you already told me about, has anyone in the family
received any other income, such as income from another source listed
on this card?

YES .................................... 1 {END_LP09}
NO ..................................... 2 {END_LP09}
REF ................................... -7 {END_LP09}
DK .................................... -8 {END_LP09}

HELP AVAILABLE FOR DEFINITIONS OF SHOW CARD CATEGORIES.

Income (IN) Section