Assets Income Questionnaire

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ASSTINTRO1

Now I am going to ask about any interest earned

from assets from [MONTH1] 1st to the end of [MONTH4].

(Exclude any assets he/she holds as part of his/her

IRA/Keough/401K/Thrift savings Plan)

PRESS "ENTER" TO CONTINUE

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Did he/she own his/her

[TYPE OF ASSET]

jointly with his/her wife/husband?

(1) Yes

(2) No

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JTINT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

What is the total amount of interest earned on this/these

jointly held [TYPE OF ASSET].

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

Total: [TOTAL]

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AJTINT

ENTER THE INTEREST AMOUNT EARNED PER YEAR

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JTAMT

What is the average amount that he/she and his/her wife/husband had

in this/these jointly held [TYPE OF ASSET]?

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JCAT1B FR NOTE: ASSET IS [TYPE OF ASSET].

Is it:

(1) Less than $ 500

(2) $ 500 to $1,000

(3) $1,001 to $5,000

(4) More than $5,000

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JCAT2B FR NOTE: ASSET IS [TYPE OF ASSET].

Is it:

(1) Less than $ 1,000

(2) $1,000 to $ 5,000

(3) $5,001 to $10,000

(4) More than $10,000

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OAST

Besides any [TYPE OF ASSET]

owned jointly with his/her wife/husband, did he/she have

any in his/her own name?

(1) Yes

(2) No

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OINT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

What is the total amount of interest he/she earned

on his/her [TYPE OF ASSET]?

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

Total: [TOTAL]

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AOINT

ENTER THE INTEREST AMOUNT EARNED PER YEAR

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OAMT

What is the average amount that he/she had in this/these

[TYPE OF ASSET]?

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OCAT1B FR NOTE: ASSET IS [TYPE OF ASSET].

Is it:

(1) Less than $ 500

(2) $ 500 to $1,000

(3) $1,001 to $5,000

(4) More than $5,000

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OCAT2B FR NOTE: ASSET IS [TYPE OF ASSET].

Is it:

(1) Less than $ 1000

(2) $1,000 to $ 5,000

(3) $5,001 to $10,000

(4) More than $10,000

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CBINT

If I were to call back later would you be able to

provide me with the INTEREST amount earned from:

[TYPE OF ASSET]

(1) Yes

(2) No

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ANYCHK

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Earlier you told me he/she owned [TYPE OF ASSET].

Did he/she receive any dividend checks?

(INCLUDE ANY CHECKS MADE OUT JOINTLY WITH A SPOUSE)

(1) Yes

(2) No

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JTDIV

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much was received in dividend checks made out

jointly to [FIRST NAME] [LAST NAME] and his/her wife/husband?

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

Total: [TOTAL]

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AJTDIV

ENTER THE DIVIDEND AMOUNT EARNED PER YEAR

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ODIV

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much did he/she receive in dividend checks

in his/her name only?

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

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AODIV

ENTER THE DIVIDEND AMOUNT EARNED PER YEAR

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OTHDIV

Did he/she earn any dividends that were

credited against a margin account or automatically

reinvested?

(1) Yes

(2) No

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JAMTDV

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much of these kinds of dividends did he/she

earn jointly with his/her wife/husband?

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

Total: [TOTAL]

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AJAMTDV

ENTER THE DIVIDEND AMOUNT EARNED PER YEAR

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OAMTDV

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much of these kinds of dividends did he/she

earn in his/her name only?

ENTER (A) FOR ALTERNATIVE ANNUAL REPORTING

ENTER (N) FOR NONE/NO MORE

@ @ @

Total: [TOTAL]

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AOAMTDV

ENTER THE DIVIDEND AMOUNT EARNED PER YEAR

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CBDIV

If I were to call back later would you be able

to provide me with the DIVIDEND amount earned from

[TYPE OF ASSET]

(1) Yes

(2) No

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JNTRNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Earlier you told me that he/she owned some rental property.

Did he/she receive any rental income from property

owned jointly by him/her and his/her wife/husband?

(1) Yes

(2) No

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JARNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much was received in gross rent from this property?

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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JACLR

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

What was his/her net income or loss after expenses?

(ENTER LOSS AS A NEGATIVE AMOUNT)

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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OWNRNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

(Earlier you told me that [FIRST NAME] [LAST NAME] owned rental property)

Did he/she receive rental income from property

owned entirely in his/her own name?

(1) Yes

(2) No

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OARNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much was received in gross rent from all properties?

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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OACLR

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

What was his/her net income or loss after expenses?

(ENTER LOSS AS A NEGATIVE AMOUNT)

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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JRNT2

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Did he/she receive any rental income from property

owned jointly with others (excluding property owned

jointly with a spouse)

(1) Yes

(2) No

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JACLR2

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

What was his/her share of the net income

or loss after expenses on this property?

(ENTER LOSS AS A NEGATIVE AMOUNT)

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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MRTJNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Earlier you said he/she held a mortgage.

Did he/she own this jointly with his/her wife/husband?

(1) Yes

(2) No

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MIJNT

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

How much interest was paid to him/her and his/her

wife/husband by the borrower?

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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MRTOWN

(Besides any jointly held mortages)

Did he/she hold any mortgages in his/her own name?

(1) Yes

(2) No

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MIOWN

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

(Earlier you said that [FIRST NAME] [LAST NAME] held a mortgage)

How much interest was paid to him/her by the borrower?

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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RNDUP1

(REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Earlier you said he/she had income from royalties.

How much did he/she receive from these royalties?

If income is shared, count only his/her share.

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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RNDUP2 (REFERENCE PERIOD = [MONTH1] 1ST TO THE END OF [MONTH4])

Earlier he/she said that he/she had this/these investment(s):

[TYPE OF ASSET]

How much did he/she receive from this/these investment(s)?

If income shared, count only his/her share.

(ENTER LOSS AS A NEGATIVE AMOUNT)

ENTER (N) FOR NONE/NO MORE

Total: [TOTAL]

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ASTRECUSE

** DO NOT READ TO RESPONDENT **

Did respondent use any records

to answer any Asset questions?

(1) Yes

(2) No

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Page Last Modified: May 12, 2006

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