General Income Receipt Questionnaire

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OTHINT

That completes the questions about [FIRST NAME] [LAST NAME] 's

work situation. Next are questions about any other sources

of income [FIRST NAME] [LAST NAME] might have.

Remember we are talking about [MONTH1] 1st

up until today.

PRESS ENTER TO CONTINUE

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LMPNOW

Did [FIRST NAME] [LAST NAME] receive any severance pay or

lump sum payments from a pension or retirement

plan when he/she left his/her job(s)?

(1) Yes

(2) No

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LMPFUTR

Does [FIRST NAME] [LAST NAME] ever expect to receive

any such payments from that job?

(1) Yes

(2) No

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LUMPTYP

What type of payment?

ENTER (N) FOR NONE/NO MORE

(1) Lump sum from pension/retirement plan

(2) Severance pay

(3) Deferred payment(s) payable at some later date

(4) Something else

@ @ @ @

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LMPELSE

What kind of other payment was it?

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VAYN

Exclude regular military retirement pay,

insurance proceeds, and GI Bill benefits.

Did [FIRST NAME] [LAST NAME] receive any payments from the

Department of Veterans Affairs (VA)?

(1) Yes

(2) No

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SSYN

Did [FIRST NAME] [LAST NAME] receive any

Social Security payments?

(1) Yes

(2) No

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SSCLDYN

Did [FIRST NAME] [LAST NAME] receive any Social Security payments

on behalf of: READ NAME(S) OF CHILD(REN)

(1) Yes (2) No @

Did [FIRST NAME] [LAST NAME] receive any Social Security payments

for himself/herself?

(1) Yes (2) No @

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SSIYN

Did [FIRST NAME] [LAST NAME] receive any income from

a program called Supplemental Security Income,

that is SSI?

(1) Yes

(2) No

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SSICLDYN

Did [FIRST NAME] [LAST NAME] receive any Supplemental

Security Income (SSI) on behalf of: READ NAME(S) OF CHILD(REN)

(1) Yes

(2) No

Did [FIRST NAME] [LAST NAME] receive any income from Supplemental

Security Income (SSI) for himself/herself?

(1) Yes

(2) No

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STSSIYN

Did [FIRST NAME] [LAST NAME] also receive a SEPARATE SSI payment

from the State or local welfare office?

(1) Yes

(2) No

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DISYN

Earlier I recorded that [FIRST NAME] [LAST NAME] has

a health condition which limits the kind or amount of

work [FIRST NAME] [LAST NAME] can do. Did [FIRST NAME] [LAST NAME]

receive any income (other than those already reported)

because of [FIRST NAME] [LAST NAME]'s health condition?

(1) Yes

(2) No

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DISTYP What kind of income was that?

Anything else?

ENTER (N) FOR NONE/NO MORE

(1) Workers' Compensation

(2) Payments from a sickness, accident, or disability

insurance policy purchased on your own

(3) Employer disability payments

(4) Pension from company or union including income from profitsharing plans

(5) Federal Civil Service or other Federal civilian employee pension

(6) State government pension

(7) Local government pension

(8) U.S. Military retirement pay exclude payments from the

Department of Veterans Affairs (VA)

(9) U.S. Government Railroad Retirement

(10) Black Lung payments

(11) Other

@ @ @ @ @ @ @ @ @ @ @

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OTHRTYPE

What was the specific "other" source of the income

[FIRST NAME] [LAST NAME] received because of his/her health condition?

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RETYN

Earlier I recorded that [FIRST NAME] [LAST NAME] retired from a

previous job. (Other than income already mentioned,) did

[FIRST NAME] [LAST NAME] receive any retirement income?

(1) Yes

(2) No

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RETTYP

What kind of income was that?

Anything else?

ENTER (N) FOR NONE/NO MORE

(1) Pension from company or union

including income from profitsharing plans

(2) Federal Civil Service or other Federal civilian employee pension

(3) State government pension

(4) Local government pension

(5) U.S. Military retirement pay exclude payments from the

Department of Veterans Affairs (VA)

(6) U.S. Government Railroad Retirement

(7) National Guard or Reserve Forces retirement

(8) Other

@ @ @ @ @ @ @ @

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RETOTHR

What is the specific "other" source of the

retirement income that [FIRST NAME] [LAST NAME] received.

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LIFEYN

Did [FIRST NAME] [LAST NAME] receive any REGULAR retirement

income from a paidup life insurance policy

or any other annuities?

(1) Yes

(2) No

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SURYN

(Other than income already mentioned) did [FIRST NAME] [LAST NAME]

receive any income as a result of being a widow(er)?

(1) Yes

(2) No

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SURTYP What kind of income was that? Anything else?

ENTER (N) FOR NONE/NO MORE

(1) Pension from company or union including

income from profitsharing plans

(2) Veterans' compensation or pension

(3) Federal Civil Service or other Federal civilian employee pension

(4) U.S. Government Railroad Retirement

(5) State government pension

(6) Local government pension

(7) Income from paidup life insurance policies or annuities

(8) U.S. Military retirement pay. Exclude payments from the

Department of Veterans Affairs (VA)

(9) Black Lung benefits

(10) Worker's Compensation

(11) Payments from estate or trust

(12) National Guard or Reserve Forces retirement

(13) Other

@ @ @ @ @ @ @ @ @ @ @ @ @

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SUROTH

What was the specific "other" source of income

[FIRST NAME] [LAST NAME] received as a widow(er)?

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FCCYN

Did [FIRST NAME] [LAST NAME] receive any foster child care?

(1) Yes

(2) No

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CSAGREE

Have support payments ever been court ordered or

informally agreed to for [FIRST NAME] [LAST NAME]'s child(ren)?

(1) Yes

(2) No

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CSYN

Did [FIRST NAME] [LAST NAME] receive any kind of financial

support payments from the child(ren)'s other parent?

(1) Yes

(2) No

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ALIYN

Did [FIRST NAME] [LAST NAME] receive any

alimony payments (other than child support)?

(1) Yes

(2) No

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

FSYN

Was [FIRST NAME] [LAST NAME] (or his/her wife/husband)

authorized to receive food stamps?

(1) Yes

(2) No

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WICYN

Is [FIRST NAME] [LAST NAME] on WIC, the Women,

Infants, and Children nutrition program?

(1) Yes

(2) No

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PATYN

Did [FIRST NAME] [LAST NAME] receive any AFDC, welfare, or

public assistance?

(1) Yes

(2) No

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PATYP

Did [FIRST NAME] [LAST NAME] receive:

READ ALL CATEGORIES. ENTER (N) FOR NONE/NO MORE

(1) AFDC

(2) General Assistance or General Relief

(3) Energy Assistance Program

(4) Other

@ @ @ @

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PAOTHR

What was the specific "other" source of public

assistance income?

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

PSSTHRU

Did [FIRST NAME] [LAST NAME] receive ANY

child support as a bonus or pass through from AFDC?

(1) Yes

(2) No

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NOINC

Did [FIRST NAME] [LAST NAME] receive nonjob income from some source

we have not covered, such as financial help from someone

outside this household, payments from the government,

or anything else?

(1) Yes

(2) No

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INCLIST I have recorded that, between [MONTH1] 1st and today,

[FIRST NAME] [LAST NAME] had the following sources of nonjob income:

(READ NAMES OF INCOME SOURCES)

Have I listed anything that SHOULD NOT be there?

(1) Yes

(2) No

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ERRSRC

Which of these?

ENTER (N) FOR NONE/NO MORE

@ @ @ @ @ @

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ANYOTH

Did [FIRST NAME] [LAST NAME] receive nonjob income from any other source,

such as financial help from someone outside the household,

payments from the government, or anything else?

NOTE TO FR: DO NOT ANSWER 'YES' FOR ANY TYPES OF

ASSETBASED INCOME, WHICH WILL BE COVERED IN THE NEXT SECTION.

(1) Yes

(2) No

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OTHSRCE

What kind of income did [FIRST NAME] [LAST NAME] receive?

Anything else?

ENTER NUMERIC CODE OF INCOME SOURCE REPORTED

ENTER (N) FOR NONE/NO MORE

@ @ @ @

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Page Last Modified: May 12, 2006

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