General Income Amount Section, Part 2

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-FSAMT15- What was the amount of Food Stamps [fill TEMPNAME+]

received in:

ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT

[fill TEMP3++]

@41 @42 @43 @44 @45

[fill TEMP4++]

@31 @32 @33 @34 @35

[fill TEMP5++]

@21 @22 @23 @24 @25

[fill TEMP6++]

@11 @12 @13 @14 @15

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

-BIGFS4-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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-BIGFS3-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGFS2-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGFS1-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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-FSPER- Who [fill TEMP2++] [fill PTEMPNAME+] [fill TEMP3++]

Food Stamps cover?

ENTER LINE NUMBER OF PERSON COVERED

ENTER (N) FOR NO ONE/NO MORE. ENTER (A) FOR ALL

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

@11 @12 @13 @14 @15 @16 @17 @18 @19 @20

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-CSMTH-

[fill C_HAVHAS+] [fill TEMPNAME+] received any

Child Support payments in

[fill MONTH5++][fill TEMP2++] [fill BIGTEMP]

(1) Yes

(2) No

In [fill MONTH4++]? @4

In [fill MONTH3++]? @3

In [fill MONTH2++]? @2

In [fill MONTH1++]? @1

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-CSAMT15- [fill TEMP7++]

[fill TEMP8++]

What was the amount of child support [fill TEMPNAME+] received:

ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT.

[fill TEMP3++]

@41 @42 @43 @44 @45

[fill TEMP4++]

@31 @32 @33 @34 @35

[fill TEMP5++]

@21 @22 @23 @24 @25

[fill TEMP6++]

@11 @12 @13 @14 @15

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

-BIGCS4-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGCS3-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGCS2-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGCS1-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-MNTHYN-

[fill C_HAVHAS+] [fill TEMPNAME+] received any

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH5++]?

(1) Yes

(2) No

In [fill MONTH4++]? @4

In [fill MONTH3++]? @3

In [fill MONTH2++]? @2

In [fill MONTH1++]? @1

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-MYSTOP21-

What set of circumstances caused [fill TEMPNAME+]

to stop receiving

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH4++]?

(1) Became ineligible because of increased income

(2) Became ineligible because of family changes

(family member left, over age limit, etc.)

(3) Still eligible but could not/chose not to collect

(4) Other, specify

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-OTHSMS21-

What reason was that?

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-MYBEG21L- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH4++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Pregnancy/birth of child

(3) Began receiving for another dependent (e.g. grandchild)

(4) Separated or divorced from spouse/partner

(5) Loss of job/wages/other income (own or partner's)

(6) Loss of other support income

(7) Just learned about the program

(8) Just got around to applying

(9) Became disabled

(10) Other, specify

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

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

-MYBEG21S- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH4++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Became disabled/blind

(3) Over 65

(4) Other, specify

@1 @2 @3 @4

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

-OTHSMB21-

What reason was that?

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

-MYSTOP22-

What set of circumstances caused [fill TEMPNAME+]

to stop receiving

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH3++]?

(1) Became ineligible because of increased income

(2) Became ineligible because of family changes

(family member left, over age limit, etc.)

(3) Still eligible but could not/chose not to collect

(4) Other, specify

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

-OTHSMS22-

What reason was that?

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

-MYBEG22L- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH3++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Pregnancy/birth of child

(3) Began receiving for another dependent (e.g. grandchild)

(4) Separated or divorced from spouse/partner

(5) Loss of job/wages/other income (own or partner's)

(6) Loss of other support income

(7) Just learned about the program

(8) Just got around to applying

(9) Became disabled

(10) Other, specify

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

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

-MYBEG22S- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH3++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Became disabled/blind

(3) Over 65

(4) Other, specify

@1 @2 @3 @4

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

-OTHSMB22-

What reason was that?

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

-MYSTOP23-

What set of circumstances caused [fill TEMPNAME+]

to stop receiving

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH2++]?

(1) Became ineligible because of increased income

(2) Became ineligible because of family changes

(family member left, over age limit, etc.)

(3) Still eligible but could not/chose not to collect

(4) Other, specify

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

-OTHSMS23-

What reason was that?

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

-MYBEG23L- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH2++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Pregnancy/birth of child

(3) Began receiving for another dependent (e.g. grandchild)

(4) Separated or divorced from spouse/partner

(5) Loss of job/wages/other income (own or partner's)

(6) Loss of other support income

(7) Just learned about the program

(8) Just got around to applying

(9) Became disabled

(10) Other, specify

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

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

-MYBEG23S- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH2++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Became disabled/blind

(3) Over 65

(4) Other, specify

@1 @2 @3 @4

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

-OTHSMB23-

What reason was that?

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

-MYBEG220L- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH1++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Pregnancy/birth of child

(3) Began receiving for another dependent (e.g. grandchild)

(4) Separated or divorced from spouse/partner

(5) Loss of job/wages/other income (own or partner's)

(6) Loss of other support income

(7) Just learned about the program

(8) Just got around to applying

(9) Became disabled

(10) Other, specify

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

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

-MYBEG220S- What set of circumstances led [fill TEMPNAME+] to apply for

[fill INCTYP1]

[fill INCTYP2]

in [fill MONTH1++]? Anything else?

MARK ALL THAT APPLY; ENTER "N" AFTER LAST RESPONSE

NOTE TO FR: THE FIRST RESPONSE "NEEDED THE MONEY" IS NOT

ACCEPTABLE AS THE ONLY RESPONSE, YOU MUST PROBE FOR A SECOND REASON

(1) Needed the money

(2) Became disabled/blind

(3) Over 65

(4) Other, specify

@1 @2 @3 @4

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

-OTSPM220-

What reason was that?

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-MNTHAMT15- For each payment, please report the total amount

[fill TEMP7++].

How much [fill INCTYP1]

[fill INCTYP2] did [fill TEMPNAME+] receive?

[fill TEMP8++]

ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT.

[fill TEMP3++]

@41 @42 @43 @44 @45

[fill TEMP4++]

@31 @32 @33 @34 @35

[fill TEMP5++]

@21 @22 @23 @24 @25

[fill TEMP6++]

@11 @12 @13 @14 @15

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

-BIGAMT4-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGAMT3-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGAMT2-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGAMT1-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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-ROLLOVR1-

Did [fill TEMPNAME+] re-invest or "roll over" any of the

money into an IRA or some other kind of retirement plan?

(1) Yes

(2) No

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-ROLLOVR2-

[fill C_DODOES+] [fill TEMPNAME+] plan to re-invest or

"roll over" any of the money?

(1) Yes

(2) No

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-ROLLAMT-

How much [fill TEMP2++] "roll over" into an other

RETIREMENT account?

ENTER (A) FOR ALL

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-TMCOV- Who did these [fill INCTYP1]

[fill INCTYP2] payments cover?

ENTER LINE NUMBER OF PERSON COVERED

ENTER (N) FOR NO ONE/NO MORE.

ENTER (A) FOR ALL

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

@11 @12 @13 @14 @15 @16 @17 @18 @19 @20

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

-KDMTHYN-

Were any [fill INCTYP1]

[fill INCTYP2]

payments received for

[fill PTEMPNAME+] children in [fill MONTH5++]?

(1) Yes

(2) No

In [fill MONTH4++]? @4

In [fill MONTH3++]? @3

In [fill MONTH2++]? @2

In [fill MONTH1++]? @1

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

-KIDAMT15- For each payment, please report the total amount

[fill TEMP7++].

How much [fill INCTYP1]

[fill INCTYP2] was received:

ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT.

[fill TEMP3++]

@41 @42 @43 @44 @45

[fill TEMP4++]

@31 @32 @33 @34 @35

[fill TEMP5++]

@21 @22 @23 @24 @25

[fill TEMP6++]

@11 @12 @13 @14 @15

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

-BIGKAMT4-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(P) TO PROCEED.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGKAMT3-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGKAMT2-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-BIGKAMT1-

NOTE TO FR -----

THE AMOUNT ENTERED - [fill INDEX2++:,]

IS UNUSUALLY LARGE.

(1) BACKUP AND CORRECT

(P) Proceed

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

-SSKIDCOV- Who did these [fill INCTYP1]

[fill INCTYP2] payments cover?

ENTER LINE NUMBER OF PERSON COVERED

ENTER (N) FOR NO ONE/NO MORE

ENTER (A) FOR ALL

@1 @2 @3 @4 @5 @6 @7 @8 @9 @10

@11 @12 @13 @14 @15 @16 @17 @18 @19 @20

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

-GINCRECUSE-

** DO NOT READ TO RESPONDENT **

Did respondent use any records when reporting

the amount of income received from:

[fill INCTYP1] [fill TEMP]

[fill INCTYP2] [fill TEMP2]

(1) Yes

(2) No

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Page Last Modified: May 12, 2006

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