Literal question
41. Income in the past 12 months.
Mark (X) the "Yes" box for each type of income this person received, and give your best estimate of the total amount during the past 12 months. (Note: The "past 12 months" is the period from today's date one year ago up through today.)
Mark (X) the "No" box to show types of income not received.
If net income was a loss, mark the "Loss" box to the right of the dollar amount.
For income received jointly, report the appropriate share for each person, or, if that's not possible, report the whole amount for only one person and mark the "No" box for the other person.
a) Wages, salary, commissions, bonuses, or tips from all jobs.
Report amount before deductions for taxes, bonds, dues, or other items
[] Yes, $____.00 (total amount for past 12 months)
[] No
b) Self-employment income from own non-farm businesses or farm businesses, including proprietorships and partnerships.
Report net income after business expenses.
[] Yes, $____.00 (total amount for past 12 months)
[] No
[] Loss
c) Interest, dividends, net rental income, royalty income, or income from estates and trusts.
Report even small amounts credited to an account
[] Yes, $____.00 (total amount for past 12 months)
[] No
[] Loss
d) Social Security or Railroad Retirement
[] Yes, $____.00 (total amount for past 12 months)
[] No
e) Supplemental Security Income (SSI)
[] Yes, $____.00 (total amount for past 12 months)
[] No
f) Any public assistance or welfare payments from the state or local welfare office.
[] Yes, $____.00 (total amount for past 12 months)
[] No
g) Retirement, survivor, or disability pensions. Do not include Social Security.
[] Yes, $____.00 (total amount for past 12 months)
[] No
h) Any such other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony. Do not include lump sum payments such as money from an inheritance or the sale of a home
[] Yes, $____.00 (total amount for past 12 months)
[] No
42. What was this person's total income during the past 12 months?
Add entries in questions 40a to 40h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.
[] None
or
$____.00 (total amount for past 12 months)
[] Loss
