Household Income Survey Questionnaire
Please complete the Household Income Survey Questionnaire to provide information about your household’s composition and general income sources. Do not include any sensitive personal or financial information.
How many people live in your household?
*
What is the age range of the head of household?
*
Please Select
18-24
25-34
35-44
45-54
55-64
65 or older
What is the relationship of each household member to the head of household?
Rows
Relationship
Member 1
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-relative
Member 2
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-relative
Member 3
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-relative
Member 4
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-relative
Member 5
Spouse/Partner
Child
Parent
Sibling
Other Relative
Non-relative
What is your household's main source(s) of income?
*
Wages/Salary
Self-employment
Pension/Retirement
Government Assistance
Investment Income
Other
What is your household’s total monthly income (before taxes)?
*
Please Select
Less than $1,000
$1,000–$2,499
$2,500–$4,999
$5,000–$7,499
$7,500–$9,999
$10,000 or more
Does anyone in your household have more than one job?
*
Yes
No
What is the highest level of education completed by any household member?
*
Please Select
No formal education
Primary school
High school diploma or equivalent
Some college or vocational training
Bachelor’s degree
Graduate or professional degree
What is your household’s primary type of housing?
*
Owned home
Rented home/apartment
Public/subsidized housing
Other
How many people in your household are currently employed?
*
Please provide any additional comments about your household’s income situation (optional).
Submit
Should be Empty: