Wave 4 Topical Mod Wave 4 Topical Modules Items Booklet

Items Booklet for
Specification:
Section: Assets and Liabilities

AL01A

Mark One Only
As of [fill LDORP], did anyone outside of this
household owe money to [fill TEMPNAME] as the
result of the sale of a business or property?
(Exclude mortgages owed to [fill TEMPNAME] which
have already been reported.)
(1)
(2)

Yes
No

@

AL01B

Enter Number
How much was owed to [fill TEMPNAME]?
If shared, count only [fill PTEMPNAME] share.
$@

AL02A

Mark One Only
I recorded earlier that [fill TEMPNAME] owned Series E or EE
U.S. Savings Bonds.
Did [fill HESHE] own them as of [fill LDORP]?
[r]H[n]
(1)
(2)

Yes
No

@

AL02B

Enter Number
What was the FACE VALUE of the U.S. Savings Bonds that
[fill TEMPNAME] owned?
If ownership was shared, count only [fill PTEMPNAME] share.
[r]H[n]
$@
Mark One Only

AL02D

As of [fill LDORP], did [fill TEMPNAME] own jointly with
[fill HISHER] [fill SPOUSE] any checking accounts which did
not earn interest?
[if MS eq <1> and JTCI1_ARR(<1>,<1>) eq <1> and AST2A eq <1>]
(Do not include any jointly owned interest-earning checking
accounts reported earlier.)
[endif]
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 1 of 120

Survey:
Section: Assets and Liabilities

Items Booklet

AL02E

Enter Number
What is your best estimate of the amount of money
[fill TEMPNAME] and [fill HISHER] [fill SPOUSE] had in those
checking accounts as of [fill LDORP]?
ENTER (N) FOR NONE
$@

AL02F

Multiple Entry
As of [fill LDORP], did [fill TEMPNAME] and
[fill HISHER] [fill SPOUSE] together owe any money for (1)
(2)

Yes
No

Store bills or credit card bills?

@B

Loans obtained through a bank or credit union,
other than car loans or home equity loans?

@L

Any other debt we have not yet mentioned, including
medical bills not covered by insurance, money owed
to private individuals, educational loans, or any
other debt not covered and excluding mortgages,
home equity loans, and car loans?

@O

AL03A

Multiple Entry
How much was owed as of [fill LDORP] for [if AL02F@B eq <1>]
Store bills or credit card bills?
[endif]
[if AL02F@L eq <1>]
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
[endif]

$@B

$@L

[if AL02F@O eq <1>]
Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any other
debt not covered and excluding mortgages,
home equity loans, and car loans?
$@O
[endif]

Page 2 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Assets and Liabilities

AL04A

Mark One Only
[if MS eq <1> and AL02D eq <1>]
Beside any checking accounts owned jointly with [fill HISHER]
[fill SPOUSE], as of [fill LDORP], did [fill TEMPNAME] own any
[fill TEMP1] checking accounts in [fill HISHER] OWN name which did
NOT earn interest?
[fill TEMP5]
[fill TEMP6]
[else]
As of [fill LDORP], did [fill TEMPNAME] own any [fill TEMP1]
checking accounts in [fill HISHER] OWN name which did NOT earn
interest?
[fill TEMP5]
[fill TEMP6]
[endif]
(1)
(2)

Yes
No

@

AL04B

Enter Number
What is your best estimate of the amount of money
[fill TEMPNAME] had in those checking accounts as of
[fill LDORP]?
ENTER (N) FOR NONE
$@

AL04C

Mark One Only
Did [fill TEMPNAME] have any debts in [fill HISHER] own name,
such as credit card bills, loans from a financial institution,
or educational loans?
(1)
(2)

Yes
No

@

AL04D

Multiple Entry
As of [fill LDORP], did [fill TEMPNAME] owe any money in
[fill HISHER] own name for (1)
(2)

Yes
No

Store bills or credit card bills?

@B

Loans obtained through a bank or credit union,
other than car loans or home equity loans?

@L

Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any
other debt not covered and excluding mortgages, home
equity loans, and car loans?

@O

Thursday, March 05, 2009

Page 3 of 120

Survey:
Section: Assets and Liabilities

Items Booklet

AL05A

Multiple Entry
How much was owed as of [fill LDORP] for [if AL04D@B eq <1>]
Store bills or credit card bills?
[endif]
[if AL04D@L eq <1>]
Loans obtained through a bank or credit union,
other than car loans or home equity loans?
[endif]
[if AL04D@O eq <1>]
Any other debt we have not yet mentioned including
medical bills not covered by insurance, money owed
to private individuals, educational loans, and any
other debt not covered and excluding mortgages,
home equity loans, and car loans?
[endif]

$@B

$@L

$@O

AL06A

Mark One Only
I recorded earlier that [fill TEMPNAME] owned an
IRA or KEOGH account.
As of [fill LDORP], did [fill HESHE] have any Individual
Retirement Accounts - any IRAs?
[r]H[n]
[if MS eq <1> or MS eq <2>]
[fill TEMP1]
[fill TEMP2]
[endif]
(1)
(2)

Yes
No

@

AL06B

Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME]
contributed to [fill HISHER] IRA accounts?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@ Years
Enter Number

AL06C

As of [fill LDORP], what was the total balance or
market value (including interest earned) of the
IRA accounts in [fill HISHER] own name?
ENTER (N) FOR NONE
$@

Page 4 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Assets and Liabilities

AL06D

Mark One Only
Was the total (1)
(2)
(3)
(4)

Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?

@

AL06E

Multiple Entry
As of [fill LDORP], which kinds of
assets did [fill TEMPNAME] hold in [fill HISHER] IRA accounts?
Was [fill HISHER] IRA account invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1

Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
@2

@3

@4

AL06F

Multiple Entry
Please specify the Other Assets.
(1)
(2)

@1
@2

AL06G

Mark One Only
As of [fill LDORP], did [fill TEMPNAME] have a KEOGH account
in [fill HISHER] OWN name?
[r]H[n]
(1)
(2)

Yes
No

@

AL06H

Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] contributed
to [fill HISHER] KEOGH account?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@ Years
Enter Number

AL06I

As of [fill LDORP], what was the total balance or market value of
assets in [fill PTEMPNAME] KEOGH account(s)?
ENTER (N) FOR NONE
$@

Thursday, March 05, 2009

Page 5 of 120

Survey:
Section: Assets and Liabilities

Items Booklet

AL06J

Mark One Only
Was the total (1)
(2)
(3)
(4)

Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?

@

AL06K

Multiple Entry
As of [fill LDORP], which kinds of
assets did [fill TEMPNAME] hold in [fill HISHER] KEOGH
account(s)?
Was [fill HISHER] KEOGH account invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1

Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings bonds
Stocks or mutual fund shares
Other assets
@2

@3

@4

AL06L

Multiple Entry
Please specify the other assets held.
(1)
(2)

@1
@2

AL07A

Mark One Only
I recorded earlier that [fill TEMPNAME] participated in a
401k, 403b, or thrift plan.
Did [fill HESHE] have that account as of [fill LDORP]?
[r]H[n]
(1)
(2)

Yes
No

@

AL07B

Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] contributed
to [fill HISHER] 401k, 403b, or thrift plans?
[r]H[n]
ENTER (L) FOR LESS THAN 1 YEAR
@

Page 6 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Assets and Liabilities

AL07C

Enter Number
As of [fill LDORP], what was the total balance or market
value (including interest earned) of any 401k, 403b, or
thrift plans held in [fill PTEMPNAME] own name?
ENTER (N) FOR NONE
$@

AL07D

Mark One Only
Was the total (1)
(2)
(3)
(4)

Less than $5,000
$5,000 to $25,000
$25,001 to $50,000
More than $50,000?

@

AL07E

Multiple Entry
As of [fill LDORP], which kinds of assets did [fill TEMPNAME]
hold in [fill HISHER] 401k, 403b, or thrift plans?
Was [fill HISHER] 401k/403b/thrift plan invested in (READ CATEGORIES) MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1

Certificates of deposit or other saving
certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
@2

@3

@4

AL07F

Multiple Entry
Please specify the Other Assets.
(1)
(2)

@1
@2

AL07G

Mark One Only
As of [fill LDORP], did [fill TEMPNAME] have any life insurance?
INCLUDE GROUP POLICES PROVIDED BY EMPLOYERS
[r]H[n]
(1)
(2)

Yes
No

@

AL07H

Enter Number
What is the CURRENT CASH VALUE of ALL life insurance
policies that [fill TEMPNAME] [fill HAVHAS]?
[r]H[n]
$@

Thursday, March 05, 2009

Page 7 of 120

Survey:
Section: Assets and Liabilities

Items Booklet

AL07I

Mark One Only
What types of life insurance [fill DODOES] [fill TEMPNAME] have is it "term insurance", "whole life", or [fill DODOES]
[fill HESHE] have both of these types?
[r]H[n]
(1) Term only
(2) Whole life only
(3) Both types
@

AL08A

Mark One Only
Are any of [fill PTEMPNAME] life insurance policies provided
through [fill HISHER] current employer(s)?
(1)
(2)

Yes
No

@

AL08B

Enter Number
What is the CASH VALUE of the life insurance policies
provided through [fill HISHER] employer(s)?
[r]H[n]
$@

Page 8 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only

RE02

ASK IF NOT APPARENT:
Is this residence a mobile home?
(1)
(2)

Yes
No

@
Multiple Entry

RE03

Which persons in this household are the
owners of this home?
ENTER LINE NUMBER OF PERSON(S) IN
HOUSEHOLD WHO OWN HOME.
ENTER (N) FOR NONE/NO MORE
@1

@2

@3
Multiple Entry

RE04

When was this home purchased?
MONTH:
YEAR:

@MO
@YR
Mark One Only

RE05

Is there a mortgage, home equity loan, or other debt on this
home?
INCLUDE RENTAL PROPERTIES ATTACHED TO OR LOCATED IN THE RESIDENCE
(1)
(2)

Yes
No

@
Enter Number

RE06

Altogether, how many mortgages, home equity loans, or other
debts are there on this home?
@

Number
Mark One Only

RE062BIG

THE NUMBER OF MORTGAGES/LOANS/ETC. ENTERED -- [FILL RE06] -IS VERY LARGE.
IS IT CORRECT?
DOES THE RESPONDENT UNDERSTAND THAT WE ARE ASKING ABOUT THE *NUMBER
OF DIFFERENT LOANS* (*NOT* THE TERM OF THE MORTGAGE -- THE NUMBER
OF YEARS OVER WHICH IT IS TO BE PAID OFF)?
(1) BACK UP AND CORRECT
(P) PROCEED
@

Thursday, March 05, 2009

Page 9 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
Enter Number

Items Booklet

RE07

FIRST MORTGAGE
How much principal is currently owed on the first mortgage
or loan?
If possible, please check any records you may have from the
lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number

RE08

FIRST MORTGAGE
In what year was the first mortgage or loan obtained?
If the mortgage was assumed, report the original date of
the mortgage.
YEAR:

@
Enter Number

RE09

FIRST MORTGAGE
And in which month was the first mortgage or loan obtained?
Month:

@
Enter Number

RE10

FIRST MORTGAGE
What was the amount of the mortgage or loan when it was
obtained or last refinanced?
If the mortgage was assumed, give the original amount of
the mortgage.
$@
Enter Number

RE11

FIRST MORTGAGE
What is the total number of years over which payments are to
be made?
ENTER (N) FOR NOT FIXED
@

Page 10 of 120

Number of Years

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles

RE12

Enter Number
FIRST MORTGAGE
What is the current annual interest rate on this mortgage or
loan?
ENTER PERCENT FROM 00.001% TO 99.999%
1/8
1/4
3/8
1/2

=
=
=
=

.125
.25
.375
.5

5/8 = .625
3/4 = .75
7/8 = .875

@ %
Mark One Only

RE13

FIRST MORTGAGE
Is the interest rate variable or fixed?
VARIABLE INTEREST RATES CAN CHANGE OVER THE TERM OF THE MORTGAGE
OR LOAN
(1)
(2)

Variable interest rate
Fixed interest rate

@
Mark One Only

RE14

FIRST MORTGAGE
Was this mortgage obtained through an FHA or VA mortgage
program?
(1) Yes - FHA LOAN
(2) Yes - VA LOAN
(3) No
@
Enter Number

RE15

SECOND MORTGAGE
How much principal is currently owed on the second mortgage
or loan?
If possible, please check any records you may have from the
lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number

RE16

SECOND MORTGAGE
In what year was the second mortgage or loan obtained?
If the mortgage was assumed, report the original date of
the mortgage.
ENTER 4 DIGIT YEAR: @
Thursday, March 05, 2009

Page 11 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

RE17

Enter Number
SECOND MORTGAGE
And in which month was the second mortgage or loan obtained?
Month: @

RE18

Enter Number
SECOND MORTGAGE
What was the amount of the mortgage or loan when it was
obtained or last refinanced?
If the mortgage was assumed, give the original amount of
the mortgage.
$@

RE19

Enter Number
SECOND MORTGAGE
What is the total number of years over which payments are to
be made?
ENTER (N) FOR NOT FIXED
@ Number of years

RE20

Enter Number
SECOND MORTGAGE
What is the current annual interest rate on this mortgage
or loan?
ENTER PERCENT FROM 00.001% TO 99.999%
1/8
1/4
3/8
1/2

=
=
=
=

.125
.25
.375
.5

5/8 = .625
3/4 = .75
7/8 = .875

@ %
Mark One Only

RE21

SECOND MORTGAGE
Is the interest rate variable or fixed?
VARIABLE INTEREST RATES CAN CHANGE OVER THE TERM OF THE MORTGAGE
OR LOAN
(1)
(2)

Variable interest rate
Fixed interest rate

@

Page 12 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only

RE22

SECOND MORTGAGE
Was this mortgage obtained through an FHA or VA mortgage
program?
(1) Yes - FHA LOAN
(2) Yes - VA LOAN
(3) No
@
Enter Number

RE23

THIRD+ MORTGAGE
How much principal is currently owed on all the remaining
mortgages or loans not reported previously?
If possible, please check any records you may have from any
other lender or mortgage company to obtain the most accurate
estimate available.
$@
Enter Number

RE24

What is the current value of this property; that is, how
much do you think it would sell for on today's market if it
were for sale? Include rental properties attached to or
located on this residence.
$@
Mark One Only

RE25

MOBILE HOME
Is there a mortgage, installment loan, contract to purchase,
or other debt on this mobile home or site?
(1) Yes
(2) No
@
Mark One Only

RE26

MOBILE HOME
Is this mortgage, contract, or other debt for just the site,
or does it also apply to this mobile home?
(1) Mobile home only
(2) Site only
(3) Site and home
@

Thursday, March 05, 2009

Page 13 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

RE27

Enter Number
MOBILE HOME
How much principal is currently owed on all mortgages?
$@

RE28

Enter Number
MOBILE HOME
How much do you think this mobile home [fill TEMP1] would sell
for today if it were for sale?
$@

RE29

Enter Number
How much was this household's[if TENURE eq <2>] [fill TEMP1]
[else] [fill TEMP2] [endif]last month[fill CONDOFIL]
[fill FEEFIL]
IF RESPONDENT REPORTS "0" ENTER (N) FOR NONE
$@

RE30

Enter Number
How much did this household pay for electricity, gas, basic
telephone service, and other utilities last month?
[r]H[n]
IF RESPONDENT REPORTS "0", NOTHING,
OR INCLUDED IN RENT ENTER (N) FOR NONE
$@
Mark One Only

RE31

Did more than one of the persons living
here pay the [fill TEMP1] last month?
(1) Yes
(2) No
@
Enter Number

RE32

Which person paid?
ENTER LINE NUMBER OF PERSON WHO PAID
@

Page 14 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Multiple Entry

RE33

Which persons paid and how much did each
pay?
IF 4 OR MORE PEOPLE ARE PAYING, LIST
ONLY THE AMOUNT THE FIRST 3 RESPONDENTS PAY
ENTER LINE NUMBERS OF PERSONS WHO PAID
ENTER (N) FOR NO MORE
Person 1:
Person 2:
Person 3:

Line number
@LN1
@LN2
@LN3

Amount paid last month
$@AMT1
$@AMT2
$@AMT3

Mark One Only

RE34

Last month, did anyone here pay for the care of a child or a
disabled person so that a household member could work,
attend training, or look for a job?
(1) Yes
(2) No
@
Enter Number

RE35

What was the total cost of these care arrangements last month?
$@
Mark One Only

RE36

OTHER REAL ESTATE
[if PCNT eq <1>]
Do you own any other real estate such as a vacation home or
undeveloped lot? Exclude rental property previously reported or
rental property attached to or located on the same land as your
own residence.
[else]
Does anyone in this household own any other real estate such as a
vacation home or undeveloped lot? Exclude rental property
previously reported or rental property attached to or located on
the same land as your own residence. [endif]
(1) Yes
(2) No
@
Multiple Entry

RE37

OTHER REAL ESTATE
Which household members own this property?
ENTER LINE NUMBERS OF HOUSEHOLD MEMBERS
WHO OWN PROPERTY.
ENTER (N) FOR NONE/NO MORE.
@1

@2

Thursday, March 05, 2009

@3

Page 15 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

RE38

Enter Number
OTHER REAL ESTATE
What is the total value of the equity in this real estate?
[r]H[n]
$@
Mark One Only

RE39

Does anyone in this household own a car, van, or truck,
excluding recreational vehicles (RV's) and motorcycles?
DO NOT INCLUDE LEASED VEHICLES OR COMPANY CARS AS BEING
OWNED BY THE RESPONDENT.
(1)
(2)

Yes
No

@
Enter Number

RE40

[if PCNT eq <1>]
How many cars, trucks, or vans do you own?
[else]
How many cars, trucks, or vans do members of this household own?
[endif]
DO NOT INCLUDE LEASED VEHICLES OR COMPANY CARS AS BEING
OWNED BY THE RESPONDENT.
@ Number of motor vehicles
Multiple Entry

RE41

[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 1: NEWEST VEHICLE
Who owns [fill TEMP1]?
ENTER LINE NUMBER OF PERSON(S) WHO OWN
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1

@LN2
Enter Number

RE42

VEHICLE 1: NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@

Page 16 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only
Vehicle 1:

RE43

Newest vehicle

What is the make of this vehicle?
ALL MINIVANS ARE CLASSIFIED AS A TRUCK
(E.G.,ENTER CODE 13 DODGE TRUCK FOR DODGE CARAVAN).
ALL FOREIGN MODELS (TRUCKS AND PASSENGER CARS),
MADE IN THE U.S. OR ABROAD, APPEAR IN THE SAME CATEGORY
(E.G., TOYOTA CAMRY AND TOYOTA TACOMA APPEAR UNDER CODE 51 FOR TOYOTA).
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
Thursday, March 05, 2009

ACURA
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
JEEP TRUCK
KIA
LAND ROVER
LAMBORGHINI
LEXUS
LINCOLN
LINCOLN TRUCK
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERCURY TRUCK
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
OLDSMOBILE TRUCK
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Page 17 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(57)
(58)
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(99)

Items Booklet

PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE

@
Enter Text
Vehicle 1:

RE44

Newest vehicle

What is the make of this vehicle?
@

Page 18 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only

RE45

VEHICLE 1: NEWEST VEHICLE
What is the model of this vehicle?
[if RE43 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)

CL
INTEGRA
LEGEND
MDX
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER

[else] [if RE43 eq <02>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)

164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER

[else] [if RE43 eq <03>]
(01)
(02)
(03)
(99)

ALLIANCE
AMC
EAGLE
OTHER

[else] [if RE43 eq <04>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE43 eq <05>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

100
80 SERIES
90 SERIES
A4
A6
A8
ALL ROAD
QUATTRO
RS6
S4
S6
S8
TT
V8 SEDAN
OTHER

[else] [if RE43 eq <06>]
(01)
(02)
(03)
(99)

ARNAGE
AZURE
CONTINENTAL
OTHER

[else] [if RE43 eq <07>]
Thursday, March 05, 2009

Page 19 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(99)

Items Booklet

325
238
330
525
528
530
540
735
740
750
840
850
3-SERIES
5-SERIES
6-SERIES
7-SERIES
L6
L7
M3
M5
M6
X3-SERIES
X5
X5-SERIES
Z3
Z4-SERIES
Z8
Z8-SERIES
OTHER

[else] [if RE43 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

CENTURY
CENTURY CUSTOM-V6
CENTURY SPECIAL-V6
ESTATE WAGON
LESABRE
LESABRE CUSTOM-V6
PARK AVENUE
PARK AVENUE-V6
RAINIER
REATTA-V6
REGAL
REGAL CUSTOM-V6
REGAL LS-V6
RENDEZVOUS
RIVIERA-V6
ROADMASTER
ROADMASTER ESTATE WAGON
ROADMASTER LIMITED
SKYLARK CUSTOM-L4
SKYLARK CUSTOM-V6
SKYLARK-L4
SKYLARK-V6
OTHER

[else] [if RE43 eq <09>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
Page 20 of 120

ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
ELDORADO
FLEETWOOD
FLEETWOOD SIXTY SPECIAL
SEVILLE
SIXTY SPECIAL
XLR
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(99) OTHER

[else] [if RE43 eq <10>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE43 eq <11>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CAVALIER RS
CORSICA-L4
CORSICA-V6
CORVETTE
IMPALA-V8
LUMINA-V6
MALIBU-V6
METRO
MONTE CARLO-V6
PRIZM
OTHER

[else] [if RE43 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(99)

APV/LUMINA
ASTRO
ASTRO CARGO VAN
ASTRO PASSENGER
AVALANCHE
BLAZER
BLAZER EXTREME
BLAZER LS
BLAZER LT
BLAZER ZR2
C/K 3500
C1500 PICKUP
C3500 HD
COLORADO
EXPRESS
EXPRESS CARGO VAN
EXPRESS PASSENGER
G10 VAN
G20 VAN
G2500 VAN
G30 VAN
K1500 BLAZER
LUMINA MINIVAN
S-10
S10 BLAZER
S10 PICKUP
SILVERADO
SILVERADO 1500
SILVERADO 2500
SILVERADO 2500HD
SILVERADO 3500
SILVERADO SS
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
V1500 BLAZER
VENTURE
OTHER

[else] [if RE43 eq <13>]
Thursday, March 05, 2009

Page 21 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(99)

Items Booklet

300M
CIRRUS-V6
CONCORDE
CONCORDE-V6
IMPERIAL
LEBARON
LEBARON COUPE-4 CYLINDER
LEBARON COUPE-V6
LEBARON SEDAN-4 CYLINDER
LEBARON SEDAN-V6
LHS-V6
NEON
NEW YORKER FIFTH AVENUE-V6
NEW YORKER -V6
PACIFICA
PROWLER
PT CRUISER
SEBRING
SEBRING CONVERTIBLE
SEBRING COUPE
SEBRING SEDAN
SEBRING-4 CYLINDER
SEBRING-V6
OTHER

[else] [if RE43 eq <14>]
(01) TOWN & COUNTRY
(02) VOYAGER
(99) OTHER
[else] [if RE43 eq <15>]
(01)
(02)
(03)
(99)

LANOS-4 CYLINDER
LEGANZA-4 CYLINDER
NUBIRA-4 CYLINDER
OTHER

[else] [if RE43 eq <16>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE43 eq <17>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

AVENGER
COLT
DAYTONA-4 CYLINDER
DYNASTY-V6
INTREPID-V6
MONACO
NEON-4 CYLINDER
SHADOW-4 CYLINDER
SPIRIT-4 CYLINDER
STEALTH-V6
STRATUS-V6
VIPER
OTHER

[else] [if RE43 eq <18>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
Page 22 of 120

B150 VAN
B250 VAN
CARAVAN
CARAVAN C/V
D150 PICKUP
DAKOTA PICKUP
DURANGO
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)

GRAND CARAVAN
RAM 1500 PICKUP
RAM 2500
RAM 3500
RAM 50 PICKUP
RAM BR CHASSIS CAB 2500
RAM BR CHASSIS CAB 3500
RAM CHARGER
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
SPRINTER WAGON
OTHER

[else] [if RE43 eq <19>]
(01)
(02)
(03)
(04)
(99)

PREMIER-V6
SUMMIT-4 CYLINDER
TALON-4 CYLINDER
VISION-V6
OTHER

[else] [if RE43 eq <20>]
(01)
(02)
(03)
(04)
(99)

360
456M
575M MARANELLO
ENZO
OTHER

[else] [if RE43 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ASPIRE
CONTOUR-4 CYLINDER
CROWN VICTORIA-V8
ESCORT
FESTIVA-4 CYLINDER
FOCUS
LTD CROWN VICTORIA-V8
MUSTANG-4 CYLINDER
MUSTANG-V6
PROBE
TAURUS-V6
TEMPO GL-4 CYLINDER
THUNDERBIRD-V6
ZX2
OTHER

[else] [if RE43 eq <22>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
Thursday, March 05, 2009

AEROSTAR
BRONCO
E150 CLUB WAGON
ECONOLINE E150 VAN
ECONOLINE E150 WAGON
ECONOLINE E350
ESCAPE
EXPEDITION
EXPLORER
F150 PICKUP
F-250
F-350
F-450
F-550
F-650
F-750
FREESTAR
RANGER
WINDSTAR
Page 23 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(20) EXCURSION
(99) OTHER
[else] [if RE43 eq <23>]
(01)
(02)
(03)
(04)
(05)
(99)

METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER

[else] [if RE43 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

C1500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA 1500
NEW SIERRA 2500
S15 JIMMY
SAFARI
SAVANNA
SIERRA 1500 PICKUP
SIERRA 2500
SIERRA 3500
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER

[else] [if RE43 eq <25>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CR-V
CRX
DEL SOL
ELEMENT
INSIGHT
ODYSSEY
PASSPORT
PILOT
PRELUDE
S2000
OTHER

[else] [if RE43 eq <26>]
(01) H1
(02) H2
(99) OTHER
[else] [if RE43 eq <27>]
(01)
(02)
(03)
(04)
(05)
(06)
Page 24 of 120

ACCENT
ELANTRA
EXCEL
SANTA FE
SCOUPE
SONATA
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(07)
(08)
(09)
(99)

TIBURON
XG300
XG350
OTHER

[else] [if RE43 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
I30
I35
J30
M30
M45
Q45
QX4
OTHER

[else] [if RE43 eq <29>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)

AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUP
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER

[else] [if RE43 eq <30>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

S-TYPE
XJ SEDAN
XJ SERIES
XJ6
XJ8
XJS
XJS6
XK SERIES
XK8
X-TYPE
OTHER

[else] [if RE43 eq <31>]
(01)
(02)
(03)
(04)
(99)

CHEROKEE-6 CYLINDER
GRAND CHEROKEE-6 CYLINDER
GRAND WAGONEER-V8
LIBERTY
OTHER

[else] [if RE43 eq <32>]
(01) COMANCHE
(02) WRANGLER-4WD
(99) OTHER
[else] [if RE43 eq <33>]
(01) OPTIMA
(02) RIO
Thursday, March 05, 2009

Page 25 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(03)
(04)
(05)
(06)
(07)
(99)

Items Booklet

SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER

[else] [if RE43 eq <34>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE43 eq <35>]
(01)
(02)
(03)
(99)

DISCOVERY
FREELANDER
RANGE ROVER
OTHER

[else] [if RE43 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(99)

ES 330
ES250
ES300
GS 430
GS300
GX 470
IS300
LS400
LS430
LX450
LX470-V8
RX 330
RX300-V6
SC300
SC400
SC430
OTHER

[else] [if RE43 eq <37>]
(01)
(02)
(03)
(04)
(05)
(99)

CONTINENTAL
LS
MARK VII
MARK VIII
TOWN CAR
OTHER

[else] [if RE43 eq <38>]
(01)
(02)
(03)
(99)

AVIATOR
BLACKWOOD
NAVIGATOR
OTHER

[else] [if RE43 eq <39>]
(01) ESPRIT
(99) OTHER
[else] [if RE43 eq <40>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE43 eq <41>]
(01) 57
(02) 62
Page 26 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(99) OTHER

[else] [if RE43 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)

323
626
929
B SERIES PICKUP
MAZDA6
MILLENIA
MPV
MX 6
MX-3
MX-5 MIATA
NAVAJO
PROTÉGÉ
PROTÉGÉ5
RX7
RX-8
OTHER

[else] [if RE43 eq <43>]
(01)
(02)
(03)
(04)
(05)
(99)

2WD TRUCK
4WE TRUCK
B-SERIES 2WD TRUCK
B-SERIES 4WD TRUCK
TRIBUTE SUV
OTHER

[else] [if RE43 eq <44>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(99)

190
300
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
F CLASS
M CLASS
ML320
S CLASS
SL CLASS
SLK CLASS
350
260E
G CLASS
OTHER

[else] [if RE43 eq <45>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

CAPRI-4 CYLINDER
COUGAR XR-7
COUGAR-V4
COUGAR-V6
GRAND MARQUIS-V8
MARAUDER
MYSTIQUE-4 CYLINDER
SABLE-V6
TOPAZ GS-4 CYLINDER
TRACER-4 CYLINDER
OTHER

[else] [if RE43 eq <46>]
(01) MOUNTAINEER
Thursday, March 05, 2009

Page 27 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(02) VILLAGER
(99) OTHER
[else] [if RE43 eq <47>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE43 eq <48>]
(01) COOPER
(99) OTHER
[else] [if RE43 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PRECIS
SIGMA
STARGION
TREDIA
OTHER

[else] [if RE43 eq <50>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER

[else] [if RE43 eq <51>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

FRONTIER 2WD
FRONTIER 4WD
MURANO
PATHFINDER
PATHFINDER ARMADA
QUEST
TITAN
XTERRA
OTHER

[else] [if RE43 eq <52>]
(01) 98 REGENCY ELITE-V6
(02) 98 REGENCY-V6
(03) ACHIEVA SL-4 CYLINDER
Page 28 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(99)

ACHIEVA S-QUAD 4
ALERO-V4
ALERO-V6
AURORA-V6
AURORA-V8
CIERA SL-V6
CUSTOM CRUISER-V8
CUTLASS CALAIS S-L4
CUTLASS CALAIS-L4
CUTLASS CIERA SL-V6
CUTLASS CIERA S-V6
CUTLASS CIERA-V6
CUTLASS SUPREME SL-V6
CUTLASS SUPREME S-V6
CUTLASS SUPREME-V6
CUTLASS-V6
EIGHTY-EIGHT ROYALE-V6
EIGHTY-EIGHT-V6
INTRIGUE-V6
LSS-V6
REGENCY
TORNADO-V6
OTHER

[else] [if RE43 eq <53>]
(01) SILHOUETTE
(02) BRAVADA
(99) OTHER
[else] [if RE43 eq <54>]
(01) 405
(02) 505
(99) 0THER
[else] [if RE43 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

ACCLAIM-4 CYLINDER
BREEZE-4 CYLINER
COLT-4 CYLINDER
LASER-4 CYLINDER
NEON-4 CYLINDER
PROWLER
SUNDANCE-4 CYLINDER
OTHER

[else] [if RE43 eq <56>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE43 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)
Thursday, March 05, 2009

6000
6000 LE-V6
BONNEVILLE-V6
FIREBIRD-V6
FIREBIRD-V8
GRAND AM
GRAND AM LE-4 CYLINDER
GRAND AM SE-V6
GRAND PRIX-V6
LEMANS
SUNBIRD
SUNBIRD LE
SUNFIRE SE
VIBE
OTHER
Page 29 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

[else] [if RE43 eq <58>]
(01)
(02)
(03)
(04)
(99)

AZTEK
AZTEK GT
MONTANA-V6
TRANS SPORT
OTHER

[else] [if RE43 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

911
968
928GTS
928S4
944S2
BOXSTER
CAYENNE
OTHER

[else] [if RE43 eq <60>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE43 eq <61>]
(01) PHANTOM
(99) OTHER
[else] [if RE43 eq <62>]
(01)
(02)
(03)
(04)
(99)

900
9000
9-3
9-5
OTHER

[else] [if RE43 eq <63>]
(01)
(02)
(03)
(04)
(05)
(99)

ION
L-SERIES
SATURN
S-SERIES
VUE
OTHER

[else] [if RE43 eq <64>]
(01) XA
(02) XB
(99) OTHER
[else] [if RE43 eq <65>]
(01) 827
(99) OTHER
[else] [if RE43 eq <66>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
Page 30 of 120

BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
SVX
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(11) XT
(99) OTHER

[else] [if RE43 eq <67>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)

AERIO
ESTEEM
GRAND VITARA
SAMURAI
SIDEKICK
SWIFT
VITARA
X-90
XL-7
OTHER

[else] [if RE43 eq <68>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
LANDCRUISER
MATRIX
MR2
PASEO
PICKUP
PREVIA
PRIUS
SUPRA
T100 PICKUP
TERCEL
OTHER

[else] [if RE43 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

4RUNNER
HIGHLANDER
LAND CRUISER
RAV4
SEQUOIA
SIENNA
TACOMA
TUNDRA
OTHER

[else] [if RE43 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
Thursday, March 05, 2009

BEETLE
CABRIO
CABRIOLET
CORRADO
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW GOLF
NEW JETTA
PASSAT
PHAETON
QUANTUM
SCIRROCCO
VANAGON
Page 31 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(99) OTHER
[else] [if RE43 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
[endif all]
@

240
740
850
940
960
C70
S40
S60
S70
S80
S90
V40
V70
V90
XC90
OTHER

Mark One Only

RE47

VEHICLE 1: NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number

RE48

VEHICLE 1: NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only

RE49

VEHICLE 1: NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@

Page 32 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Multiple Entry

RE50

[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 2: SECOND NEWEST VEHICLE
Who owns [fill TEMP1]?
ENTER LINE NUMBER OF PERSON(S) WHO OWN
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1

@LN2
Enter Number

RE51

VEHICLE 2: SECOND NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@

Thursday, March 05, 2009

Page 33 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

Mark One Only

RE52

VEHICLE 2: SECOND NEWEST VEHICLE
What is the make of this vehicle?
ALL MINIVANS ARE CLASSIFIED AS A TRUCK (E.G., ENTER CODE 13
DODGE TRUCK FOR DODGE CARAVAN.)
ALL FOREIGN MODELS (TRUCKS AND PASSENGER CARS), MADE IN THE U.S. OR
ABROAD, APPEAR IN THE SAME CATEGORY (E.G., TOYOTA CAMRY AND TOYOTA
TACOMA APPEAR UNDER CODE 51 FOR TOYOTA).
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
Page 34 of 120

ACURA
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
JEEP TRUCK
KIA
LAND ROVER
LAMBORGHINI
LEXUS
LINCOLN
LINCOLN TRUCK
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERCURY TRUCK
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
OLDSMOBILE TRUCK
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(57)
(58)
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(99)

PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE

@

Thursday, March 05, 2009

Page 35 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

Mark One Only

RE54

VEHICLE 2: SECOND NEWEST VEHICLE
What is the model of this vehicle?
[if RE52 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)

CL
INTEGRA
LEGEND
MDX
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER

[else] [if RE52 eq <02>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)

164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER

[else] [if RE52 eq <03>]
(01)
(02)
(03)
(99)

ALLIANCE
AMC
EAGLE
OTHER

[else] [if RE52 eq <04>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE52 eq <05>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

100
80 SERIES
90 SERIES
A4
A6
A8
ALL ROAD
QUATTRO
RS6
S4
S6
S8
TT
V8 SEDAN
OTHER

[else] [if RE52 eq <06>]
(01)
(02)
(03)
(99)

Page 36 of 120

ARNAGE
AZURE
CONTINENTAL
OTHER

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles

[else] [if RE52 eq <07>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(99)

325
238
330
525
528
530
540
735
740
750
840
850
3-SERIES
5-SERIES
6-SERIES
7-SERIES
L6
L7
M3
M5
M6
X3-SERIES
X5
X5-SERIES
Z3
Z4-SERIES
Z8
Z8-SERIES
OTHER

[else] [if RE52 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

CENTURY
CENTURY CUSTOM-V6
CENTURY SPECIAL-V6
ESTATE WAGON
LESABRE
LESABRE CUSTOM-V6
PARK AVENUE
PARK AVENUE-V6
RAINIER
REATTA-V6
REGAL
REGAL CUSTOM-V6
REGAL LS-V6
RENDEZVOUS
RIVIERA-V6
ROADMASTER
ROADMASTER ESTATE WAGON
ROADMASTER LIMITED
SKYLARK CUSTOM-L4
SKYLARK CUSTOM-V6
SKYLARK-L4
SKYLARK-V6
OTHER

[else] [if RE52 eq <09>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
Thursday, March 05, 2009

ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
ELDORADO
FLEETWOOD
FLEETWOOD SIXTY SPECIAL
SEVILLE
SIXTY SPECIAL
Page 37 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(11) XLR
(99) OTHER
[else] [if RE52 eq <10>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE52 eq <11>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CAVALIER RS
CORSICA-L4
CORSICA-V6
CORVETTE
IMPALA-V8
LUMINA-V6
MALIBU-V6
METRO
MONTE CARLO-V6
PRIZM
OTHER

[else] [if RE52 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(99)

Page 38 of 120

APV/LUMINA
ASTRO
ASTRO CARGO VAN
ASTRO PASSENGER
AVALANCHE
BLAZER
BLAZER EXTREME
BLAZER LS
BLAZER LT
BLAZER ZR2
C/K 3500
C1500 PICKUP
C3500 HD
COLORADO
EXPRESS
EXPRESS CARGO VAN
EXPRESS PASSENGER
G10 VAN
G20 VAN
G2500 VAN
G30 VAN
K1500 BLAZER
LUMINA MINIVAN
S-10
S10 BLAZER
S10 PICKUP
SILVERADO
SILVERADO 1500
SILVERADO 2500
SILVERADO 2500HD
SILVERADO 3500
SILVERADO SS
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
V1500 BLAZER
VENTURE
OTHER

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles

[else] [if RE52 eq <13>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(99)

300M
CIRRUS-V6
CONCORDE
CONCORDE-V6
IMPERIAL
LEBARON
LEBARON COUPE-4 CYLINDER
LEBARON COUPE-V6
LEBARON SEDAN-4 CYLINDER
LEBARON SEDAN-V6
LHS-V6
NEON
NEW YORKER FIFTH AVENUE-V6
NEW YORKER -V6
PACIFICA
PROWLER
PT CRUISER
SEBRING
SEBRING CONVERTIBLE
SEBRING COUPE
SEBRING SEDAN
SEBRING-4 CYLINDER
SEBRING-V6
OTHER

[else] [if RE52 eq <14>]
(01) TOWN & COUNTRY
(02) VOYAGER
(99) OTHER
[else] [if RE52 eq <15>]
(01)
(02)
(03)
(99)

LANOS-4 CYLINDER
LEGANZA-4 CYLINDER
NUBIRA-4 CYLINDER
OTHER

[else] [if RE52 eq <16>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE52 eq <17>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

AVENGER
COLT
DAYTONA-4 CYLINDER
DYNASTY-V6
INTREPID-V6
MONACO
NEON-4 CYLINDER
SHADOW-4 CYLINDER
SPIRIT-4 CYLINDER
STEALTH-V6
STRATUS-V6
VIPER
OTHER

[else] [if RE52 eq <18>]
(01)
(02)
(03)
(04)
(05)
(06)
Thursday, March 05, 2009

B150 VAN
B250 VAN
CARAVAN
CARAVAN C/V
D150 PICKUP
DAKOTA PICKUP
Page 39 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)

Items Booklet

DURANGO
GRAND CARAVAN
RAM 1500 PICKUP
RAM 2500
RAM 3500
RAM 50 PICKUP
RAM BR CHASSIS CAB 2500
RAM BR CHASSIS CAB 3500
RAM CHARGER
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
SPRINTER WAGON
OTHER

[else] [if RE52 eq <19>]
(01)
(02)
(03)
(04)
(99)

PREMIER-V6
SUMMIT-4 CYLINDER
TALON-4 CYLINDER
VISION-V6
OTHER

[else] [if RE52 eq <20>]
(01)
(02)
(03)
(04)
(99)

360
456M
575M MARANELLO
ENZO
OTHER

[else] [if RE52 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ASPIRE
CONTOUR-4 CYLINDER
CROWN VICTORIA-V8
ESCORT
FESTIVA-4 CYLINDER
FOCUS
LTD CROWN VICTORIA-V8
MUSTANG-4 CYLINDER
MUSTANG-V6
PROBE
TAURUS-V6
TEMPO GL-4 CYLINDER
THUNDERBIRD-V6
ZX2
OTHER

[else] [if RE52 eq <22>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 40 of 120

AEROSTAR
BRONCO
E150 CLUB WAGON
ECONOLINE E150 VAN
ECONOLINE E150 WAGON
ECONOLINE E350
ESCAPE
EXPEDITION
EXPLORER
F150 PICKUP
F-250
F-350
F-450
F-550
F-650
F-750
FREESTAR
RANGER
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(19) WINDSTAR
(20) EXCURSION
(99) OTHER

[else] [if RE52 eq <23>]
(01)
(02)
(03)
(04)
(05)
(99)

METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER

[else] [if RE52 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

C1500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA 1500
NEW SIERRA 2500
S15 JIMMY
SAFARI
SAVANNA
SIERRA 1500 PICKUP
SIERRA 2500
SIERRA 3500
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER

[else] [if RE52 eq <25>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CR-V
CRX
DEL SOL
ELEMENT
INSIGHT
ODYSSEY
PASSPORT
PILOT
PRELUDE
S2000
OTHER

[else] [if RE52 eq <26>]
(01) H1
(02) H2
(99) OTHER
[else] [if RE52 eq <27>]
(01)
(02)
(03)
(04)
(05)
Thursday, March 05, 2009

ACCENT
ELANTRA
EXCEL
SANTA FE
SCOUPE
Page 41 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(06)
(07)
(08)
(09)
(99)

Items Booklet

SONATA
TIBURON
XG300
XG350
OTHER

[else] [if RE52 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
I30
I35
J30
M30
M45
Q45
QX4
OTHER

[else] [if RE52 eq <29>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)

AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUP
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER

[else] [if RE52 eq <30>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

S-TYPE
XJ SEDAN
XJ SERIES
XJ6
XJ8
XJS
XJS6
XK SERIES
XK8
X-TYPE
OTHER

[else] [if RE52 eq <31>]
(01)
(02)
(03)
(04)
(99)

CHEROKEE-6 CYLINDER
GRAND CHEROKEE-6 CYLINDER
GRAND WAGONEER-V8
LIBERTY
OTHER

[else] [if RE52 eq <32>]
(01) COMANCHE
(02) WRANGLER-4WD
(99) OTHER
[else] [if RE52 eq <33>]
(01) OPTIMA
Page 42 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(02)
(03)
(04)
(05)
(06)
(07)
(99)

RIO
SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER

[else] [if RE52 eq <34>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE52 eq <35>]
(01)
(02)
(03)
(99)

DISCOVERY
FREELANDER
RANGE ROVER
OTHER

[else] [if RE52 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(99)

ES 330
ES250
ES300
GS 430
GS300
GX 470
IS300
LS400
LS430
LX450
LX470-V8
RX 330
RX300-V6
SC300
SC400
SC430
OTHER

[else] [if RE52 eq <37>]
(01)
(02)
(03)
(04)
(05)
(99)

CONTINENTAL
LS
MARK VII
MARK VIII
TOWN CAR
OTHER

[else] [if RE52 eq <38>]
(01)
(02)
(03)
(99)

AVIATOR
BLACKWOOD
NAVIGATOR
OTHER

[else] [if RE52 eq <39>]
(01) ESPRIT
(99) OTHER
[else] [if RE52 eq <40>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE52 eq <41>]
(01) 57
Thursday, March 05, 2009

Page 43 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(02) 62
(99) OTHER
[else] [if RE52 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)

323
626
929
B SERIES PICKUP
MAZDA6
MILLENIA
MPV
MX 6
MX-3
MX-5 MIATA
NAVAJO
PROTÉGÉ
PROTÉGÉ5
RX7
RX-8
OTHER

[else] [if RE52 eq <43>]
(01)
(02)
(03)
(04)
(05)
(99)

2WD TRUCK
4WE TRUCK
B-SERIES 2WD TRUCK
B-SERIES 4WD TRUCK
TRIBUTE SUV
OTHER

[else] [if RE52 eq <44>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(99)

190
300
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
F CLASS
M CLASS
ML320
S CLASS
SL CLASS
SLK CLASS
350
260E
G CLASS
OTHER

[else] [if RE52 eq <45>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

CAPRI-4 CYLINDER
COUGAR XR-7
COUGAR-V4
COUGAR-V6
GRAND MARQUIS-V8
MARAUDER
MYSTIQUE-4 CYLINDER
SABLE-V6
TOPAZ GS-4 CYLINDER
TRACER-4 CYLINDER
OTHER

[else] [if RE52 eq <46>]

Page 44 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(01) MOUNTAINEER
(02) VILLAGER
(99) OTHER

[else] [if RE52 eq <47>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE52 eq <48>]
(01) COOPER
(99) OTHER
[else] [if RE52 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PRECIS
SIGMA
STARGION
TREDIA
OTHER

[else] [if RE52 eq <50>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER

[else] [if RE52 eq <51>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

FRONTIER 2WD
FRONTIER 4WD
MURANO
PATHFINDER
PATHFINDER ARMADA
QUEST
TITAN
XTERRA
OTHER

[else] [if RE52 eq <52>]
(01) 98 REGENCY ELITE-V6
(02) 98 REGENCY-V6
Thursday, March 05, 2009

Page 45 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(99)

Items Booklet

ACHIEVA SL-4 CYLINDER
ACHIEVA S-QUAD 4
ALERO-V4
ALERO-V6
AURORA-V6
AURORA-V8
CIERA SL-V6
CUSTOM CRUISER-V8
CUTLASS CALAIS S-L4
CUTLASS CALAIS-L4
CUTLASS CIERA SL-V6
CUTLASS CIERA S-V6
CUTLASS CIERA-V6
CUTLASS SUPREME SL-V6
CUTLASS SUPREME S-V6
CUTLASS SUPREME-V6
CUTLASS-V6
EIGHTY-EIGHT ROYALE-V6
EIGHTY-EIGHT-V6
INTRIGUE-V6
LSS-V6
REGENCY
TORNADO-V6
OTHER

[else] [if RE52 eq <53>]
(01) SILHOUETTE
(02) BRAVADA
(99) OTHER
[else] [if RE52 eq <54>]
(01) 405
(02) 505
(99) 0THER
[else] [if RE52 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

ACCLAIM-4 CYLINDER
BREEZE-4 CYLINER
COLT-4 CYLINDER
LASER-4 CYLINDER
NEON-4 CYLINDER
PROWLER
SUNDANCE-4 CYLINDER
OTHER

[else] [if RE52 eq <56>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE52 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
Page 46 of 120

6000
6000 LE-V6
BONNEVILLE-V6
FIREBIRD-V6
FIREBIRD-V8
GRAND AM
GRAND AM LE-4 CYLINDER
GRAND AM SE-V6
GRAND PRIX-V6
LEMANS
SUNBIRD
SUNBIRD LE
SUNFIRE SE
VIBE
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(99) OTHER

[else] [if RE52 eq <58>]
(01)
(02)
(03)
(04)
(99)

AZTEK
AZTEK GT
MONTANA-V6
TRANS SPORT
OTHER

[else] [if RE52 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

911
968
928GTS
928S4
944S2
BOXSTER
CAYENNE
OTHER

[else] [if RE52 eq <60>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE52 eq <61>]
(01) PHANTOM
(99) OTHER
[else] [if RE52 eq <62>]
(01)
(02)
(03)
(04)
(99)

900
9000
9-3
9-5
OTHER

[else] [if RE52 eq <63>]
(01)
(02)
(03)
(04)
(05)
(99)

ION
L-SERIES
SATURN
S-SERIES
VUE
OTHER

[else] [if RE52 eq <64>]
(01) XA
(02) XB
(99) OTHER
[else] [if RE52 eq <65>]
(01) 827
(99) OTHER
[else] [if RE52 eq <66>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
Thursday, March 05, 2009

BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
Page 47 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(10) SVX
(11) XT
(99) OTHER
[else] [if RE52 eq <67>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)

AERIO
ESTEEM
GRAND VITARA
SAMURAI
SIDEKICK
SWIFT
VITARA
X-90
XL-7
OTHER

[else] [if RE52 eq <68>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
LANDCRUISER
MATRIX
MR2
PASEO
PICKUP
PREVIA
PRIUS
SUPRA
T100 PICKUP
TERCEL
OTHER

[else] [if RE52 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

4RUNNER
HIGHLANDER
LAND CRUISER
RAV4
SEQUOIA
SIENNA
TACOMA
TUNDRA
OTHER

[else] [if RE52 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 48 of 120

BEETLE
CABRIO
CABRIOLET
CORRADO
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW GOLF
NEW JETTA
PASSAT
PHAETON
QUANTUM
SCIRROCCO
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(19) VANAGON
(99) OTHER

[else] [if RE52 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
[endif all]

240
740
850
940
960
C70
S40
S60
S70
S80
S90
V40
V70
V90
XC90
OTHER

@
Mark One Only

RE56

VEHICLE 2: SECOND NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number

RE57

VEHICLE 2: SECOND NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only

RE58

VEHICLE 2: SECOND NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@

Thursday, March 05, 2009

Page 49 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
Multiple Entry

Items Booklet

RE59

[if PCNT eq <1>]ASK IF NECESSARY
[endif]VEHICLE 3: THIRD NEWEST VEHICLE
Who owns the third newest motor vehicle?
ENTER LINE NUMBER OF PERSON(S) WHO OWNS
MOTOR VEHICLE.
ENTER (N) FOR NO MORE.
@LN1

@LN2
Enter Number

RE60

VEHICLE 3: THIRD NEWEST VEHICLE
What is the model year of this vehicle?
(ENTER 4 DIGIT YEAR)
@

Page 50 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only

RE61

VEHICLE 3: THIRD NEWEST VEHICLE
What is the make of this vehicle?
ALL MINIVANS ARE CLASSIFIED AS A TRUCK (E.G., ENTER CODE 13
DODGE TRUCK FOR DODGE CARAVAN).
ALL FOREIGN MODELS (TRUCKS AND PASSENGER CARS), MADE IN THE
U.S. OR ABROAD, APPEAR IN THE SAME CATEGORY (E.G., TOYOTA
CAMRY AND TOYOTA TACOMA APPEAR UNDER CODE 51 FOR TOYOTA).
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
(56)
Thursday, March 05, 2009

ACURA
ALFA ROMEO
AMERICAN MOTORS
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CADILLAC TRUCK
CHEVROLET
CHEVROLET TRUCK
CHRYSLER
CHRYSLER TRUCK
DAEWOO
DAIHATSU
DODGE
DODGE TRUCK
EAGLE
FERRARI
FORD
FORD TRUCK
GEO
GMC TRUCK
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
JEEP TRUCK
KIA
LAND ROVER
LAMBORGHINI
LEXUS
LINCOLN
LINCOLN TRUCK
LOTUS
MASERATI
MAYBACH
MAZDA
MAZDA TRUCK
MERCEDES-BENZ
MERCURY
MERCURY TRUCK
MERKUR
MINI
MITSUBISHI
NISSAN
NISSAN TRUCK
OLDSMOBILE
OLDSMOBILE TRUCK
PEUGEOT
PLYMOUTH
PLYMOUTH TRUCK
Page 51 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(57)
(58)
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
(70)
(71)
(99)

Items Booklet

PONTIAC
PONTIAC TRUCK
PORSCHE
RENAULT
ROLLS ROYCE
SAAB
SATURN
SCION
STERLING
SUBARU
SUZUKI
TOYOTA
TOYOTA TRUCK
VOLKSWAGON
VOLVO
OTHER MAKE

@

Page 52 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
Mark One Only

RE63

VEHICLE 3: THIRD NEWEST VEHICLE
What is the model of this vehicle?
[if RE61 eq <01>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(99)

CL
INTEGRA
LEGEND
MDX
NSX
RL
RSX
SLX
TL
TSX
VIGOR
OTHER

[else] [if RE61 eq <02>]
(01)
(02)
(03)
(04)
(05)
(06)
(99)

164
GRADUATE
GTV6
MILANO
QUADRIFOGLIO
SPIDER
OTHER

[else] [if RE61 eq <03>]
(01)
(02)
(03)
(99)

ALLIANCE
AMC
EAGLE
OTHER

[else] [if RE61 eq <04>]
(01) DB7
(02) VANQUISH
(99) OTHER
[else] [if RE61 eq <05>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

100
80 SERIES
90 SERIES
A4
A6
A8
ALL ROAD
QUATTRO
RS6
S4
S6
S8
TT
V8 SEDAN
OTHER

[else] [if RE61 eq <06>]
(01)
(02)
(03)
(99)

Thursday, March 05, 2009

ARNAGE
AZURE
CONTINENTAL
OTHER

Page 53 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

[else] [if RE61 eq <07>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(99)

325
238
330
525
528
530
540
735
740
750
840
850
3-SERIES
5-SERIES
6-SERIES
7-SERIES
L6
L7
M3
M5
M6
X3-SERIES
X5
X5-SERIES
Z3
Z4-SERIES
Z8
Z8-SERIES
OTHER

[else] [if RE61 eq <08>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

CENTURY
CENTURY CUSTOM-V6
CENTURY SPECIAL-V6
ESTATE WAGON
LESABRE
LESABRE CUSTOM-V6
PARK AVENUE
PARK AVENUE-V6
RAINIER
REATTA-V6
REGAL
REGAL CUSTOM-V6
REGAL LS-V6
RENDEZVOUS
RIVIERA-V6
ROADMASTER
ROADMASTER ESTATE WAGON
ROADMASTER LIMITED
SKYLARK CUSTOM-L4
SKYLARK CUSTOM-V6
SKYLARK-L4
SKYLARK-V6
OTHER

[else] [if RE61 eq <09>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
Page 54 of 120

ALLANTE
BROUGHAM
CATERA
CTS
DEVILLE
ELDORADO
FLEETWOOD
FLEETWOOD SIXTY SPECIAL
SEVILLE
SIXTY SPECIAL
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(11) XLR
(99) OTHER

[else] [if RE61 eq <10>]
(01) ESCALADE
(02) SRX
(99) OTHER
[else] [if RE61 eq <11>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

CAMARO-V6
CAMARO-V8
CAPRICE CLASSIC-V8
CAVALIER
CAVALIER RS
CORSICA-L4
CORSICA-V6
CORVETTE
IMPALA-V8
LUMINA-V6
MALIBU-V6
METRO
MONTE CARLO-V6
PRIZM
OTHER

[else] [if RE61 eq <12>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(99)

Thursday, March 05, 2009

APV/LUMINA
ASTRO
ASTRO CARGO VAN
ASTRO PASSENGER
AVALANCHE
BLAZER
BLAZER EXTREME
BLAZER LS
BLAZER LT
BLAZER ZR2
C/K 3500
C1500 PICKUP
C3500 HD
COLORADO
EXPRESS
EXPRESS CARGO VAN
EXPRESS PASSENGER
G10 VAN
G20 VAN
G2500 VAN
G30 VAN
K1500 BLAZER
LUMINA MINIVAN
S-10
S10 BLAZER
S10 PICKUP
SILVERADO
SILVERADO 1500
SILVERADO 2500
SILVERADO 2500HD
SILVERADO 3500
SILVERADO SS
SSR
SUBURBAN
TAHOE
TRACKER
TRAILBLAZER
V1500 BLAZER
VENTURE
OTHER

Page 55 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

[else] [if RE61 eq <13>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(99)

300M
CIRRUS-V6
CONCORDE
CONCORDE-V6
IMPERIAL
LEBARON
LEBARON COUPE-4 CYLINDER
LEBARON COUPE-V6
LEBARON SEDAN-4 CYLINDER
LEBARON SEDAN-V6
LHS-V6
NEON
NEW YORKER FIFTH AVENUE-V6
NEW YORKER -V6
PACIFICA
PROWLER
PT CRUISER
SEBRING
SEBRING CONVERTIBLE
SEBRING COUPE
SEBRING SEDAN
SEBRING-4 CYLINDER
SEBRING-V6
OTHER

[else] [if RE61 eq <14>]
(01) TOWN & COUNTRY
(02) VOYAGER
(99) OTHER
[else] [if RE61 eq <15>]
(01)
(02)
(03)
(99)

LANOS-4 CYLINDER
LEGANZA-4 CYLINDER
NUBIRA-4 CYLINDER
OTHER

[else] [if RE61 eq <16>]
(01) CHARADE
(02) ROCKY
(99) OTHER
[else] [if RE61 eq <17>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

AVENGER
COLT
DAYTONA-4 CYLINDER
DYNASTY-V6
INTREPID-V6
MONACO
NEON-4 CYLINDER
SHADOW-4 CYLINDER
SPIRIT-4 CYLINDER
STEALTH-V6
STRATUS-V6
VIPER
OTHER

[else] [if RE61 eq <18>]
(01)
(02)
(03)
(04)
(05)
(06)
Page 56 of 120

B150 VAN
B250 VAN
CARAVAN
CARAVAN C/V
D150 PICKUP
DAKOTA PICKUP
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(99)

DURANGO
GRAND CARAVAN
RAM 1500 PICKUP
RAM 2500
RAM 3500
RAM 50 PICKUP
RAM BR CHASSIS CAB 2500
RAM BR CHASSIS CAB 3500
RAM CHARGER
RAM SRT-10
RAM VAN
RAM WAGON
SPRINTER
SPRINTER WAGON
OTHER

[else] [if RE61 eq <19>]
(01)
(02)
(03)
(04)
(99)

PREMIER-V6
SUMMIT-4 CYLINDER
TALON-4 CYLINDER
VISION-V6
OTHER

[else] [if RE61 eq <20>]
(01)
(02)
(03)
(04)
(99)

360
456M
575M MARANELLO
ENZO
OTHER

[else] [if RE61 eq <21>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ASPIRE
CONTOUR-4 CYLINDER
CROWN VICTORIA-V8
ESCORT
FESTIVA-4 CYLINDER
FOCUS
LTD CROWN VICTORIA-V8
MUSTANG-4 CYLINDER
MUSTANG-V6
PROBE
TAURUS-V6
TEMPO GL-4 CYLINDER
THUNDERBIRD-V6
ZX2
OTHER

[else] [if RE61 eq <22>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Thursday, March 05, 2009

AEROSTAR
BRONCO
E150 CLUB WAGON
ECONOLINE E150 VAN
ECONOLINE E150 WAGON
ECONOLINE E350
ESCAPE
EXPEDITION
EXPLORER
F150 PICKUP
F-250
F-350
F-450
F-550
F-650
F-750
FREESTAR
RANGER
Page 57 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(19) WINDSTAR
(20) EXCURSION
(99) OTHER
[else] [if RE61 eq <23>]
(01)
(02)
(03)
(04)
(05)
(99)

METRO
PRIZM
SPECTRUM
STORM
TRACKER
OTHER

[else] [if RE61 eq <24>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(99)

C1500 PICKUP
CANYON
CLASSIC SIERRA 2500
CLASSIC SIERRA 3500
DENALI
ENVOY
G1500 VAN
G2500 VAN
G3500 VAN
JIMMY
NEW SIERRA 1500
NEW SIERRA 2500
S15 JIMMY
SAFARI
SAVANNA
SIERRA 1500 PICKUP
SIERRA 2500
SIERRA 3500
SONOMA
SUBURBAN
V1500 JIMMY
YUKON
OTHER

[else] [if RE61 eq <25>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

ACCORD
CIVIC
CIVIC CRX
CIVIC DEL SOL
CR-V
CRX
DEL SOL
ELEMENT
INSIGHT
ODYSSEY
PASSPORT
PILOT
PRELUDE
S2000
OTHER

[else] [if RE61 eq <26>]
(01) H1
(02) H2
(99) OTHER
[else] [if RE61 eq <27>]
(01)
(02)
(03)
(04)
(05)
Page 58 of 120

ACCENT
ELANTRA
EXCEL
SANTA FE
SCOUPE
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(06)
(07)
(08)
(09)
(99)

SONATA
TIBURON
XG300
XG350
OTHER

[else] [if RE61 eq <28>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(99)

FX35
FX45
G20
G35 SEDAN
G35 SPORT COUPE
I30
I35
J30
M30
M45
Q45
QX4
OTHER

[else] [if RE61 eq <29>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(99)

AMIGO
ASCENDER
AXIOM
HOMBRE
I-MARK
IMPULSE
OASIS
PICKUP
RODEO
RODEO SPORT
STYLUS
TROOPER
VEHICROSS
OTHER

[else] [if RE61 eq <30>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

S-TYPE
XJ SEDAN
XJ SERIES
XJ6
XJ8
XJS
XJS6
XK SERIES
XK8
X-TYPE
OTHER

[else] [if RE61 eq <31>]
(01)
(02)
(03)
(04)
(99)

CHEROKEE-6 CYLINDER
GRAND CHEROKEE-6 CYLINDER
GRAND WAGONEER-V8
LIBERTY
OTHER

[else] [if RE61 eq <32>]
(01) COMANCHE
(02) WRANGLER-4WD
(99) OTHER
[else] [if RE61 eq <33>]
(01) OPTIMA
Thursday, March 05, 2009

Page 59 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
(02)
(03)
(04)
(05)
(06)
(07)
(99)

Items Booklet

RIO
SEDONA
SEPHIA
SORENTO
SPECTRA
SPORTAGE
OTHER

[else] [if RE61 eq <34>]
(01) MURCIELAGO
(99) OTHER
[else] [if RE61 eq <35>]
(01)
(02)
(03)
(99)

DISCOVERY
FREELANDER
RANGE ROVER
OTHER

[else] [if RE61 eq <36>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(99)

ES 330
ES250
ES300
GS 430
GS300
GX 470
IS300
LS400
LS430
LX450
LX470-V8
RX 330
RX300-V6
SC300
SC400
SC430
OTHER

[else] [if RE61 eq <37>]
(01)
(02)
(03)
(04)
(05)
(99)

CONTINENTAL
LS
MARK VII
MARK VIII
TOWN CAR
OTHER

[else] [if RE61 eq <38>]
(01)
(02)
(03)
(99)

AVIATOR
BLACKWOOD
NAVIGATOR
OTHER

[else] [if RE61 eq <39>]
(01) ESPRIT
(99) OTHER
[else] [if RE61 eq <40>]
(01) COUPE
(02) SPYDER
(99) OTHER
[else] [if RE61 eq <41>]
(01) 57
Page 60 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(02) 62
(99) OTHER

[else] [if RE61 eq <42>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)

323
626
929
B SERIES PICKUP
MAZDA6
MILLENIA
MPV
MX 6
MX-3
MX-5 MIATA
NAVAJO
PROTÉGÉ
PROTÉGÉ5
RX7
RX-8
OTHER

[else] [if RE61 eq <43>]
(01)
(02)
(03)
(04)
(05)
(99)

2WD TRUCK
4WE TRUCK
B-SERIES 2WD TRUCK
B-SERIES 4WD TRUCK
TRIBUTE SUV
OTHER

[else] [if RE61 eq <44>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(99)

190
300
400
420
500
560
600
C CLASS
CL CLASS
CLK CLASS
F CLASS
M CLASS
ML320
S CLASS
SL CLASS
SLK CLASS
350
260E
G CLASS
OTHER

[else] [if RE61 eq <45>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(99)

CAPRI-4 CYLINDER
COUGAR XR-7
COUGAR-V4
COUGAR-V6
GRAND MARQUIS-V8
MARAUDER
MYSTIQUE-4 CYLINDER
SABLE-V6
TOPAZ GS-4 CYLINDER
TRACER-4 CYLINDER
OTHER

[else] [if RE61 eq <46>]

Thursday, March 05, 2009

Page 61 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(01) MOUNTAINEER
(02) VILLAGER
(99) OTHER
[else] [if RE61 eq <47>]
(01) SCORPIO
(02) XR4TI
(99) OTHER
[else] [if RE61 eq <48>]
(01) COOPER
(99) OTHER
[else] [if RE61 eq <49>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

3000GT
CORDIA
DIAMANTE
ECLIPSE
ENDEAVOR
EXPO
GALANT
LANCER
MIRAGE
MONTERO
MONTERO SPORT
OUTLANDER
PICKUP
PRECIS
SIGMA
STARGION
TREDIA
OTHER

[else] [if RE61 eq <50>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(99)

200SX
240SX
300ZX
350Z
ALTIMA
AXXESS
FRONTIER
MAXIMA
NX
PICKUP
PULSAR
SENTRA
STANZA
STANZA ALTIMA
OTHER

[else] [if RE61 eq <51>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

FRONTIER 2WD
FRONTIER 4WD
MURANO
PATHFINDER
PATHFINDER ARMADA
QUEST
TITAN
XTERRA
OTHER

[else] [if RE61 eq <52>]
(01) 98 REGENCY ELITE-V6
(02) 98 REGENCY-V6
Page 62 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(99)

ACHIEVA SL-4 CYLINDER
ACHIEVA S-QUAD 4
ALERO-V4
ALERO-V6
AURORA-V6
AURORA-V8
CIERA SL-V6
CUSTOM CRUISER-V8
CUTLASS CALAIS S-L4
CUTLASS CALAIS-L4
CUTLASS CIERA SL-V6
CUTLASS CIERA S-V6
CUTLASS CIERA-V6
CUTLASS SUPREME SL-V6
CUTLASS SUPREME S-V6
CUTLASS SUPREME-V6
CUTLASS-V6
EIGHTY-EIGHT ROYALE-V6
EIGHTY-EIGHT-V6
INTRIGUE-V6
LSS-V6
REGENCY
TORNADO-V6
OTHER

[else] [if RE61 eq <53>]
(01) SILHOUETTE
(02) BRAVADA
(99) OTHER
[else] [if RE61 eq <54>]
(01) 405
(02) 505
(99) 0THER
[else] [if RE61 eq <55>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

ACCLAIM-4 CYLINDER
BREEZE-4 CYLINER
COLT-4 CYLINDER
LASER-4 CYLINDER
NEON-4 CYLINDER
PROWLER
SUNDANCE-4 CYLINDER
OTHER

[else] [if RE61 eq <56>]
(01) GRAND VOYAGER
(02) VOYAGER
(99) OTHER
[else] [if RE61 eq <57>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
Thursday, March 05, 2009

6000
6000 LE-V6
BONNEVILLE-V6
FIREBIRD-V6
FIREBIRD-V8
GRAND AM
GRAND AM LE-4 CYLINDER
GRAND AM SE-V6
GRAND PRIX-V6
LEMANS
SUNBIRD
SUNBIRD LE
SUNFIRE SE
VIBE
Page 63 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(99) OTHER
[else] [if RE61 eq <58>]
(01)
(02)
(03)
(04)
(99)

AZTEK
AZTEK GT
MONTANA-V6
TRANS SPORT
OTHER

[else] [if RE61 eq <59>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(99)

911
968
928GTS
928S4
944S2
BOXSTER
CAYENNE
OTHER

[else] [if RE61 eq <60>]
(01) SPORTWAGON
(99) OTHER
[else] [if RE61 eq <61>]
(01) PHANTOM
(99) OTHER
[else] [if RE61 eq <62>]
(01)
(02)
(03)
(04)
(99)

900
9000
9-3
9-5
OTHER

[else] [if RE61 eq <63>]
(01)
(02)
(03)
(04)
(05)
(99)

ION
L-SERIES
SATURN
S-SERIES
VUE
OTHER

[else] [if RE61 eq <64>]
(01) XA
(02) XB
(99) OTHER
[else] [if RE61 eq <65>]
(01) 827
(99) OTHER
[else] [if RE61 eq <66>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
Page 64 of 120

BAJA
BRATT
DL
FORESTER
GL
IMPREZA
JUSTY
LEGACY
LOYALE
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles
(10) SVX
(11) XT
(99) OTHER

[else] [if RE61 eq <67>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(99)

AERIO
ESTEEM
GRAND VITARA
SAMURAI
SIDEKICK
SWIFT
VITARA
X-90
XL-7
OTHER

[else] [if RE61 eq <68>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(99)

AVALON
CAMRY
CAMRY SOLARA
CELICA
COROLLA
CRESSIDA
ECHO
LANDCRUISER
MATRIX
MR2
PASEO
PICKUP
PREVIA
PRIUS
SUPRA
T100 PICKUP
TERCEL
OTHER

[else] [if RE61 eq <69>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(99)

4RUNNER
HIGHLANDER
LAND CRUISER
RAV4
SEQUOIA
SIENNA
TACOMA
TUNDRA
OTHER

[else] [if RE61 eq <70>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Thursday, March 05, 2009

BEETLE
CABRIO
CABRIOLET
CORRADO
EUROVAN
FOX
FOX WOLFSBURG
GOLF
GTI
JETTA
JETTA III
NEW BEETLE
NEW GOLF
NEW JETTA
PASSAT
PHAETON
QUANTUM
SCIRROCCO
Page 65 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles

Items Booklet

(19) VANAGON
(99) OTHER
[else] [if RE61 eq <71>]
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(99)
[endif all]

240
740
850
940
960
C70
S40
S60
S70
S80
S90
V40
V70
V90
XC90
OTHER

@
Mark One Only

RE65

VEHICLE 3: THIRD NEWEST VEHICLE
Is this vehicle owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number

RE66

VEHICLE 3: THIRD NEWEST VEHICLE
How much is currently owed for this vehicle?
$@
Mark One Only

RE67

VEHICLE 3: THIRD NEWEST VEHICLE
Is this vehicle used primarily either for business purposes
or for the transportation of a disabled person?
(1) Yes
(2) No
@
Mark One Only

RE68

Does anyone in this household own any other type of vehicle,
not used for business, such as a motorcycle, boat, or
recreational vehicle (RV)?
(1) Yes
(2) No
@
Page 66 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Real, Shelter, Dependent, Vechicles

RE69

Multiple Entry
Does anyone own:
(1)
(1)
(2)
(3)
(4)

Yes

(2)

No

A motorcycle:
A boat:
A recreational vehicle (RV):
Another type of vehicle:

@MTRCYCL
@BOAT
@RV
@OTHERV

IF RESPONDENT OWNS MORE THAN ONE MOTORCYCLE, BOAT, OR RV, REPORT
THE 2ND MOTORCYCLE, BOAT, OR RV UNDER (4) ANOTHER TYPE OF VEHICLE.
(INCLUDE THE VALUE/AMOUNT OWED IN THE "OTHER VEHICLE 2" SCREENS.)
Multiple Entry

RE70

OTHER VEHICLE 1
Which household members own [fill TEMP1]?
ENTER LINE NUMBER FOR HOUSEHOLD MEMBER(S).
ENTER (N) FOR NO MORE.
@1
@2
Enter Number

RE71

OTHER VEHICLE 1
If this [fill TEMP1] were sold, what would it sell for in its
present condition?
$@
Mark One Only

RE72

OTHER VEHICLE 1
Is this [fill TEMP1] owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number

RE73

OTHER VEHICLE 1
How much is currently owed for this [fill TEMP1]?
$@
Multiple Entry

RE74

OTHER VEHICLE 2
Which household members own [fill TEMP1]?
ENTER LINE NUMBER FOR HOUSEHOLD MEMBER(S).
ENTER (N) FOR NO MORE.
@1
@2

Thursday, March 05, 2009

Page 67 of 120

Survey:
Section: Real, Shelter, Dependent, Vechicles
Enter Number

Items Booklet

RE75

OTHER VEHICLE 2
If this [fill TEMP1] were sold, what would it sell for in its
present condition?
$@
Mark One Only

RE76

OTHER VEHICLE 2
Is this [fill TEMP1] owned free and clear, or is there still
money owed on it?
(1) Money owed
(2) Free and clear
@
Enter Number

RE77

OTHER VEHICLE 2
How much is currently owed for this [fill TEMP1]?
$@

Page 68 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Value of Business

VB03

Enter Number
As of [fill LDORP], what percent of
[fill ALLBUS] did [fill TEMPNAME] own?
(Value Between 1% and 100%)
@

VB04

Mark One Only
DO NOT READ TO RESPONDENT
Has information below about the total value and total debt
for [fill ALLBUS] already been obtained from another
household member?
(1) Yes
(2) No
@

VB05

Enter Number
As of [fill LDORP], what was the
total value of [fill ALLBUS] before figuring in any
debts that might be owed against it?
[r]H[n]
ENTER (N) FOR NONE
$@

VB07

Mark One Only
Was the value:
(1)
(2)
(3)
(4)
(5)

Less than $1
Between $1 and $1,000
Between $1,001 to $10,000
Between $10,001 to $100,000
More than $100,000?

@

VB08

Enter Number
As of [fill LDORP], what was the
total debt owed against [fill ALLBUS]?
[r]H[n]
ENTER (N) FOR NONE
$@
Mark One Only

VB10

Was the debt:
(1)
(2)
(3)
(4)
(5)

Less than $1
Between $1 to $1,000
Between $1,001 to $10,000
Between $ 10,001 to $100,000
More than $100,000?

@

Thursday, March 05, 2009

Page 69 of 120

Survey:
Section: Intrest Earning Account

Page 70 of 120

Items Booklet

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Intrest Earning Account
Enter Number

IAJ07

Earlier I recorded that [fill TEMPNAME]
owned the following assets jointly with
[fill HISHER] spouse [fill OTHERSFIL]:
[if FLAGCK(<1>) eq <1>]
an interest earning checking account
[endif]
[if FLAGCK(<2>) eq <1>]
a savings account
[endif]
[if FLAGCK(<3>) eq <1>]
a money market deposit account
[endif]
[if FLAGCK(<4>) eq <1>]
a certificate of deposit (CD)
[endif]
As of [fill LDORP], what
[fill SHAREOFFIL] the total amount of
money held in these joint
account(s) [fill BELONGFIL]?
ENTER (N) FOR NONE
$@
Mark One Only

IAJ08

Was it (1)
(2)
(3)
(4)

Less than $500
$500 to $1,000
$1,001 to $5,000
More than $5,000

@
Enter Number

IAI03

[fill OTHFIL]
Earlier I recorded that [fill TEMPNAME]
owned the following asset(s):
[if FLAGCK2(<1>) eq <1>]
an interest earning checking account
[endif]
[if FLAGCK2(<2>) eq <1>]
a savings account
[endif]
[if FLAGCK2(<3>) eq <1>]
a money market deposit acount
[endif]
[if FLAGCK2(<4>) eq <1>]
a certificate of deposit (CD)
[endif]
As of [fill LDORP], what was
[fill SHAREOFFIL] the total amount of
money held in these account(s)?
ENTER (N) FOR NONE
$@

Thursday, March 05, 2009

Page 71 of 120

Survey:
Section: Intrest Earning Account

Items Booklet

Mark One Only

IAI04

Was it (1)
(2)
(3)
(4)

Less than $500
$500 to $1,000
$1,001 to $5,000
More than $5,000?

@
Enter Number

IMJ05

Earlier I recorded that [fill TEMPNAME]
owned the following assets jointly with
[fill HISHER] spouse [fill OTHERSFIL]:
[if FLAGCK(<5>) eq <1>]
Municipal or Corporate Bonds
[endif]
[if FLAGCK(<6>) eq <1>]
U.S. Government Securities
[endif]
As of
[fill
money
[fill

[fill LDORP], what
SHAREOFFIL] the total amount of
held in these joint account(s)
BELONGFIL]?

ENTER (N) FOR NONE
$@
Mark One Only

IMJ06

Was it (1)
(2)
(3)
(4)

Less than
$1,000 to
$5,001 to
More than

$1,000
$5,000
$10,000
$10,000?

@
Enter Number

IMI03

[fill OTHFIL]
Earlier I recorded that [fill TEMPNAME]
owned the following asset(s):
[if FLAGCK2(<5>) eq <1>]
Municipal or Corporate Bonds
[endif]
[if FLAGCK2(<6>) eq <1>]
U.S. Government Securities
[endif]
As of [fill LDORP], what was
[fill SHAREOFFIL] the total amount of
money held in these account(s)?
ENTER (N) FOR NONE
$@

Page 72 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Intrest Earning Account
Mark One Only

IMI04

Was it (1)
(2)
(3)
(4)

Less than
$1,000 to
$5,001 TO
More than

$1,000
$5,000
$10,000
$10,000?

@

Thursday, March 05, 2009

Page 73 of 120

Survey:
Section: Rental Property

Items Booklet

RJ01

Mark One Only
[if JTCI9_ARR(<1>) eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with [fill HISHER] [fill SPOUSE],
Did [fill HESHE] and
property as of [fill
[else]
Did [fill HESHE] and
property as of [fill
[endif]
(1)
(2)

[fill HISHER] [fill SPOUSE] own rental
LDORP]?
[fill HISHER] [fill SPOUSE] own rental
LDORP]?

Yes
No

@

RJ02

Enter Number
Earlier I recorded that [fill TEMPNAME] owned rental property
joint with [fill HISHER] [fill SPOUSE].
How many properties did [fill TEMPNAME] own jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(01 to 99)
@

RJ03

Multiple Entry
What type of [if RJ02 eq <1>][fill TEMP1][else][fill TEMP2][endif]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1

Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2

@3

@4

@5

@6

Enter Text

RJ04

Please specify the type of property.
@
Mark One Only

RJ05

[if RJ02 eq <1>][fill TEMP1] [else][fill TEMP2] [endif]
attached to or located on the same land as [fill HISHER]
own residence?
(1)
(2)

Yes
No

@

Page 74 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Rental Property
Mark One Only

RJ06

ASK OR VERIFY:
Were all of these properties attached to or located
on the same land as [fill HISHER] own residence?
(1)
(2)

Yes
No

@
Enter Number

RJ07

[if RJ06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[else]
[if RJ05 eq <2>]
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[endif] [endif]
$@
Mark One Only
Was it

RJ08

-

(1)
(2)
(3)
(4)

Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000

@
Mark One Only

RJ09

[if RJ06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP1] as of [fill LDORP]?
[else]
[if RJ05 eq <2>]
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP1] as of [fill LDORP]?
[endif] [endif]
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 75 of 120

Survey:
Section: Rental Property

Items Booklet

Enter Number

RJ10

[if RJ02 eq <1>]
As of [fill LDORP], how much principal was owed on the
property?
[else]
As of [fill LDORP], how much principal was owed on the
properties?
[endif]
(N) None
$@
Mark One Only
Was it

RJ11

-

(1)
(2)
(3)
(4)

Less than $25,000
$25,000 to $50,000
$50,001 to $100,000
More than $100,000

@
Mark One Only

RI01

[if OWNRNT eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
in [fill HISHER] own name.
Did [fill HESHE] own
own name as of [fill
[else]
Did [fill HESHE] own
own name as of [fill
[endif]
(1)
(2)

any rental property in [fill HISHER]
LDORP]?
any rental property in [fill HISHER]
LDORP]?

Yes
No

@
Enter Number

RI02

Earlier I recorded that [fill TEMPNAME] owned rental property in
[fill HISHER] own name.
How many properties did [fill TEMPNAME] own in
[fill HISHER] OWN name as of [fill LDORP]?
@

Page 76 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Rental Property

RI03

Multiple Entry
What type of [if RI02 eq <1>][fill TEMP1][else][fill TEMP2][endif]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1

Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2

@3

@4

@5

@6

Enter Text

RI04

Please specify the type of property.
@
Mark One Only

RI05

[if RI02 eq <1>][fill TEMP1] [else][fill TEMP2] [endif]
attached to or located on the same
land as [fill HISHER] own residence?
(1)
(2)

Yes
No

@
Mark One Only

RI06

ASK OR VERIFY:
Were all of these properties attached to or located on
the same land as [fill HISHER] own residence?
(1)
(2)

Yes
No

@
Enter Number

RI07

[if RI06 eq <2>]
Excluding properties attached to or located on [fill HISHER]
own residence,
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[else]
[if RI05 eq <2>]
What was the total market value of the rental [fill TEMP1]
as of [fill LDORP]?
[endif] [endif]
$@

Thursday, March 05, 2009

Page 77 of 120

Survey:
Section: Rental Property

Items Booklet

Mark One Only
Was it

RI08

-

(1)
(2)
(3)
(4)

Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000

@
Mark One Only

RI09

[if RI06 eq <2>]
Excluding properties attached to or located on
[fill PTEMPNAME] own residence,
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP2] as of [fill LDORP]?
[else]
[if RI05 eq <2>]
Was there a mortgage, deed of trust, or other debt on the
[fill TEMP2] as of [fill LDORP]?
[endif] [endif]
(1)
(2)

Yes
No

@
Enter Number

RI10

As of [fill LDORP], how much principal was owed on the
[if RI02 eq <1>][fill TEMP4] [else][fill TEMP5] [endif]?
ENTER (N) FOR NONE
$@
Mark One Only
Was it

RI11

-

(1)
(2)
(3)
(4)

Less than $25,000
$25,000 to $50,000
$50,001 to $100,000
More than $100,000

@

Page 78 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Rental Property

RNT01

Mark One Only
[if JTCI9_ARR(<2>) eq <1> and RJ01 eq <1>]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with other people besides [fill HISHER] [fill SPOUSE].
Did [fill HESHE] jointly own any rental property jointly with
other people besides [fill HISHER] [fill SPOUSE] as of
[fill LDORP]?
[else]
[if JTCI9_ARR(<2>) eq <1> and (RJ01 eq <2> or MS gt <1>)]
I recorded earlier that [fill TEMPNAME] owned rental property
jointly with other people.
Did [fill HESHE] jointly
other people as of [fill
[else]
Did [fill HESHE] jointly
other people as of [fill
[endif] [endif]
(1)
(2)

own any rental property jointly with
LDORP]?
own any rental property jointly with
LDORP]?

Yes
No

@

RNT02

Enter Number
Earlier I recorded that [fill TEMPNAME] owned rental property
jointly with other people [fill BESIDESPOUFIL].
How many properties did [fill TEMPNAME] own jointly with other
people as of [fill LDORP]?
@

RNT03

Multiple Entry
What type of [fill TEMP1]?
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1

Vacation home
Other residential property
Farm property
Commercial property
Equipment
Other
@2

@3

@4

@5

@6

Enter Text

RNT04

Please specify the type of property.
@
Enter Number

RNT07

What was the total market value of the rental
[fill TEMP5] as of [fill LDORP]?
$@

Thursday, March 05, 2009

Page 79 of 120

Survey:
Section: Rental Property

Items Booklet

Mark One Only

RNT08

Was there a mortgage, deed of trust, or other debt
on the [fill TEMP5] as of [fill LDORP]?
(1)
(2)

Yes
No

@
Enter Number

RNT09

As of [fill LDORP], how much principal was owed on the
[fill TEMP5]?
ENTER (N) FOR NONE
$@
Enter Number

RNT10

What was the total value of [fill HISHER] share of equity,
(or loss) in the rental [fill TEMP5] owned jointly with
others as of [fill LDORP]?
"EQUITY" IS THE TOTAL MARKET VALUE OF THE PROPERTY, LESS
ANY DEBTS HELD AGAINST IT.
ENTER (N) FOR NONE
$@
Mark One Only
Was it

RNT11

-

(1)
(2)
(3)
(4)

Less than $25,000
$25,000 to $75,000
$75,001 to $100,000
More than $100,000

@

Page 80 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Stocks and Mutual Funds
Mark One Only

SMJ02

I recorded earlier that [fill TEMPNAME] owned mutual
funds.
Did [fill TEMPNAME] own any of these funds jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(1)
(2)

Yes
No

@
Mark One Only

SMJ03

I recorded earlier that [fill TEMPNAME] owned stocks.
Did [fill TEMPNAME] own any of these stocks jointly with
[fill HISHER] [fill SPOUSE] as of [fill LDORP]?
(1)
(2)

Yes
No

@
Enter Number

SMJ04

Earlier I recorded that [fill TEMPNAME]
held [fill STOCMUTFIL] jointly with
[fill HISHER] spouse [fill OTHERSFIL].
As of [fill LDORP], what was
[fill SHAREFIL] market value of the
[fill STOCMUTFIL] held [fill SPOUSEFIL]?
EXCLUDE STOCK IN OWN CORPORATION IF THE
VALUE OF THAT CORPORATION WAS ALREADY
OBTAINED
ENTER (N) FOR NONE
$@
Mark One Only

SMJ05

Was it (1)
(2)
(3)
(4)

Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More then $25,000?

@
Mark One Only

SMJ06

Was any debt or margin account held against
these jointly held [if SMJ02 eq <1>][fill TEMP1] [endif]
[if SMJ02 eq <1> and SMJ03 eq <1>][fill TEMP2] [endif]
[if SMJ03 eq <1>][fill TEMP3] [endif]
as of [fill LDORP]?
(1)
(2)

Yes
No

@
Thursday, March 05, 2009

Page 81 of 120

Survey:
Section: Stocks and Mutual Funds
Enter Number

Items Booklet

SMJ07

As of [fill LDORP], what was the
amount of the debt or margin account?
ENTER (N) FOR NONE
$@
Mark One Only

SMI02

[if SMJ02 eq <1> or SMJ03 eq <1>]
Besides the stocks or mutual fund shares held jointly with
[fill PTEMPNAME] [fill SPOUSE], did [fill TEMPNAME] hold
any other stocks or mutual fund shares in [fill HISHER]
own name as of [fill LDORP]?
[else]
[if MS eq <1> and SMJ02 ne <1> and SMJ03 ne <1>]
Did [fill TEMPNAME] hold any stocks or mutual fund shares in
[fill HISHER] own name as of [fill LDORP]?
[else]
[if MS gt <1> and (AST3A eq <1> or AST3B eq <1>)]
I recorded earlier that [fill TEMPNAME] owned
[fill TEMP1]. Did [fill TEMPNAME] hold any stocks or mutual fund
shares in [fill HISHER] own name as of [fill LDORP]?
[endif] [endif] [endif]
(1)
(2)

Yes
No

@
Enter Number

SMI03

Earlier I recorded that [fill TEMPNAME]
held [fill STOCMUTFIL].
As of [fill LDORP], what was
[fill SHAREFIL] the market value of the
[fill STOCMUTFIL]?
EXCLUDE STOCK IN OWN CORPORATION IF
VALUE OF THAT CORPORATION WAS ALREADY
OBTAINED
ENTER (N) FOR NONE
$@
Mark One Only

SMI04

Was it (1)
(2)
(3)
(4)

Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More than $25,000

@

Page 82 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Stocks and Mutual Funds
Mark One Only

SMI05

Did [fill TEMPNAME] have a debt or margin account held
against these stocks or mutual funds as of [fill LDORP]?
(1)
(2)

Yes
No

@
Enter Number

SMI06

As of [fill LDORP], what was the amount of the debt or margin account?
ENTER (N) FOR NONE
$@

Thursday, March 05, 2009

Page 83 of 120

Survey:
Section: Mortgages

Items Booklet

Enter Number

MO2A

Earlier I recorded that [fill TEMPNAME]
held mortgages jointly with [fill HISHER]
spouse [fill OTHERSFIL].
As of [fill LDORP], what was
[fill SHAREFIL] of the principal owed on
this mortgage or these mortgages?
INCLUDE PRINCIPAL FOR ALL MORTGAGES
JOINTLY HELD
ENTER (N) FOR NONE
$@
Mark One Only

MO2B

Was it (1)
(2)
(3)
(4)

Less than $10,000
$10,000 to $25,000
$25,001 to $50,000
Over $50,000

@
Enter Number

M04

Earlier I recorded that [fill TEMPNAME]
held a mortgage from which [fill HESHE]
received payments.
As of [fill LDORP], what was
[fill SHAREFIL] the principal owed on
this mortgage or these mortgages?
ENTER (N) FOR NONE
$@
Mark One Only

MO5

Was it (1)
(2)
(3)
(4)

Less than $10,000
$10,000 to $25,000
$25,001 to $50,000
Over $50,000

@

Page 84 of 120

Thursday, March 05, 2009

Items Booklet

Thursday, March 05, 2009

Survey:
Section: Other Assets

Page 85 of 120

Survey:
Section: Other Assets

Items Booklet

Enter Number

OA02

Earlier [fill TEMPNAME] reported owning other financial
investments:
[fill OTHFIN]
As of [fill LDORP], what was
[fill HISHER] equity in these investments?
(Equity is the total market value of the property, less any debts
held against it. If the investment is jointly owned, count
only [fill HISHER] share of equity.)
ENTER (N) FOR NONE
$@
Mark One Only

OA03

Was it (1)
(2)
(3)
(4)

Less than $1,000
$1,000 to $10,000
$10,001 to $25,000
More than $25,000?

@

Page 86 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being
Enter Number

STATUS

[fill C_AREIS] [fill TEMPNAME] available to answer some
questions about the children in the household?
May I speak to [fill TEMPNAME]?
(1)

Yes

No, F1 TO BACK UP.

THEN F9 TO SKIP PERSON OR F10 TO EXIT CASE.

@
Mark One Only

CW3a

AN "IMMEDIATE FAMILY MEMBER" CAN BE ANY RELATIVE THE
RESPONDENT CONSIDERS TO BE PART OF THEIR IMMEDIATE FAMILY.
Other than members of [fill CDNAME]'s immediate family,
has [fill CDNAME] EVER been cared for regularly
in any Head Start, day care, or pre-school programs or by
any day care providers or babysitters?
(1)
(2)

Yes
No

@
Multiple Entry

CW3b

How old was [fill CDNAME] when [fill HESHEG] was
FIRST cared for by someone other than
[fill TEMPNAME] or an immediate family member
on a regular basis?
@1
@2

Years (Range 0-17)
Months (Range 0-11)
Enter Number

CW3c

Thinking back to that time, for how many hours each
WEEK was [fill CDNAME] usually cared for
by someone else?
Number of hours: @
Mark One Only

CW4a

Has [fill CDNAME] ever lived apart from [fill TEMPNAME],
for any reason, for a MONTH OR MORE?
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 87 of 120

Survey:
Section: Child Well Being

Items Booklet

Mark One Only

CW4b

CATEGORY (3) TO BE USED ONLY IF CHILD LIVED APART FROM
RESPONDENT MORE THAN ONE TIME.
Thinking about these instances, did [fill TEMPNAME]
send this child to live with someone else because
[fill HESHE] [fill WASWERE] not able to keep [fill CDNAME]
with [fill TEMPNAME]?
(1)
(2)

Yes
No

(3)

Sometimes yes, sometimes no

@
Mark One Only

CW4c

Did this happen at any time during the
PAST 12 MONTHS?
(1)
(2)

Yes
No

@
Enter Number

CW5

About how many times in the PAST MONTH did
[fill TEMPNAME] or any family member take [fill CDNAME]
on any kind of outing - out to the park, to church, to a
playground, to visit with friends or relatives, etc.?
@ Number of times
(N) None
Enter Number

CW6a

THE TOTAL SHOULD INCLUDE THE COMBINED NUMBER OF TIMES
THAT THE MOTHER, FATHER, AND ALL OTHER FAMILY MEMBERS READ
TO THE CHILD. IF TWO OR MORE PEOPLE READ TO THE CHILD
TOGETHER, COUNT IT ONLY ONCE.
About how many times in the PAST WEEK, in total,
did any family member read stories to [fill CDNAME]?
Number of times: @
(N) None
Enter Number

CW6b

INCLUDE ALL THE TIMES THE DESIGNATED PARENT READ TO
THE CHILD AND THE TIMES THE DESIGNATED PARENT WAS PRESENT
WHEN SOMEONE ELSE READ TO THE CHILD.
About how many times in the PAST WEEK did
[fill TEMPNAME] read to [fill CDNAME]?
Number of times: @
(N) None

Page 88 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being
Enter Number

CW6c

INCLUDE ALL THE TIMES THE FATHER READ TO THE CHILD
AND THE TIMES HE WAS PRESENT WHEN SOMEONE ELSE READ TO THE
CHILD.
And, about how many times in the PAST WEEK did
[fill DADNAME] read to [fill CDNAME]?
Number of times: @
(N) None
Mark One Only

CW7a

Are there family rules for [fill CDNAME] about
what television programs [fill HESHEG] can watch?
(1)
(2)

Yes
No

@
Mark One Only

CW7b

Are there family rules about how early or late
[fill CDNAME] may watch television?
(1)
(2)

Yes
No

@
Mark One Only

CW7c

Are there family rules about how many hours
[fill CDNAME] may watch television?
(1)
(2)

Yes
No

@
Enter Number

CW8a

In a TYPICAL WEEK LAST MONTH, how many
DAYS did [fill TEMPNAME] eat BREAKFAST
with [fill CDNAME]?
DAYS: @
(N) None
Enter Number

CW8b

In a TYPICAL WEEK LAST MONTH, how many
DAYS did [fill TEMPNAME] eat DINNER
with [fill CDNAME]?
DAYS:

@

(N) None

Thursday, March 05, 2009

Page 89 of 120

Survey:
Section: Child Well Being

Items Booklet

Enter Number

CW8c

In a TYPICAL WEEK LAST MONTH, how many
DAYS did [fill DADNAME] eat
BREAKFAST with [fill CDNAME]?
DAYS:@
(N) None
Enter Number

CW8d

In a TYPICAL WEEK LAST MONTH, how many
DAYS did [fill DADNAME] eat
DINNER with [fill CDNAME]?
DAYS:

@

(N) None
Mark One Only

CW9a

How often [fill DODOES] [fill TEMPNAME] and [fill CDNAME]
talk or play with each other for 5 minutes or more, just
for fun?
READ CATEGORIES
(1)
(2)
(3)
(4)
(5)

Never
About once a week (or less)
A few times a week
One or two times a day
Many times each day

@
Mark One Only

CW9b

How often do [fill DADNAME] and
[fill CDNAME] talk or play with each other for 5 minutes
or more, just for fun?
READ CATEGORIES
(1)
(2)
(3)
(4)
(5)

Never
About once a week (or less)
A few times a week
One or two times a day
Many times each day

@

Page 90 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being
Mark One Only

CW10a

How often [fill DODOES] [fill TEMPNAME]
praise or compliment [fill CDNAME] by saying
something like, "Good for you!" or
"What a nice thing you did!" or "Way to go!"?
READ CATEGORIES
(1)
(2)
(3)
(4)
(5)

Never
About once a week (or less)
A few times a week
One or two times a day
Many times each day

@
Mark One Only
How often
praise or
something
you did!"

CW10b

[fill DDOES] [fill DADNAME]
compliment [fill CDNAME] by saying
like, "Good for you!" or "What a nice thing
or "Way to go!"?

READ CATEGORIES
(1)
(2)
(3)
(4)
(5)

Never
About once a week (or less)
A few times a week
One or two times a day
Many times each day

@
Mark One Only

CW11a

How far would [fill TEMPNAME] LIKE
[fill CDNAME] to go in school?
(1)
(2)
(3)
(4)
(5)

Leave school before graduation
Graduate from high school
Get some college or other training
Graduate from college
Take further education or training after college

@
Mark One Only

CW11b

How far would [fill DADNAME] LIKE
[fill CDNAME] to go in school?
(1)
(2)
(3)
(4)
(5)

Leave school before graduation
Graduate from high school
Get some college or other training
Graduate from college
Take further education or training after college

@

Thursday, March 05, 2009

Page 91 of 120

Survey:
Section: Child Well Being

Items Booklet

Mark One Only

CW12

How far do you THINK [fill CDNAME]
will go in school?
(1)
(2)
(3)
(4)
(5)

Leave school before graduation
Graduate from high school
Get some college or other training
Graduate from college
Take further education or training after college

@
Mark One Only

CW13a

Has [fill CDNAME] EVER attended or been
enrolled in kindergarten?
(1)
(2)

Yes
No

@
Multiple Entry

CW13b

How old was [fill CDNAME] in years and months when
[fill HESHEG] first started kindergarten?
@1

Years

@2

Months
Mark One Only

CW13c

Has [fill CDNAME] EVER attended or been enrolled
in first grade?
(1)
(2)

Yes
No

@
Multiple Entry

CW13d

How old was [fill CDNAME] in years and months when
[fill HESHEG] first started first grade?
@1

Years
OR

@2

Months
Mark One Only

CW13e

Has [fill CDNAME] EVER attended or been
enrolled in kindergarten or elementary school
IN ANY GRADE?
(1)
(2)

Yes
No

@

Page 92 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being
Mark One Only

CW14

What is the highest grade or year [fill CDNAME] has completed?
(K)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(C)
(N)

Kindergarten
First grade
Second grade
Third grade
Fourth grade
Fifth grade
Sixth grade
Seventh grade
Eighth grade
Ninth grade
Tenth grade
Eleventh grade
Twelfth grade
College, one year or more
No grade completed

@
Mark One Only

CW15a

Was [fill CDNAME] attending or enrolled in school during the
past school year?
(1)
(2)

Yes
No

@
Mark One Only

CW15b

What grade or year in school was [fill CDNAME] attending?
(K)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(C)

Kindergarten
First grade
Second grade
Third grade
Fourth grade
Fifth grade
Sixth grade
Seventh grade
Eighth grade
Ninth grade
Tenth grade
Eleventh grade
Twelfth grade
College, one year or more

@
Mark One Only

CW15c

Was [fill CDNAME] enrolled in public school
OR private school?
(1)
(2)

Public
Private

@

Thursday, March 05, 2009

Page 93 of 120

Survey:
Section: Child Well Being

Items Booklet

Mark One Only

CW15d

Was [fill CDNAME]'s school the regularly assigned
neighborhood/community school, or a school you chose?
(1)
(2)

Assigned
Chosen

(3)

Both -- assigned school is school of choice

@
Mark One Only

CW15e

Was [fill CDNAME]'s school affiliated with a religion?
(1)
(2)

Yes
No

@
Mark One Only

CW15f

Did [fill CDNAME] go to a special class for gifted
students, or do advanced work in any subjects?
(1)
(2)

Yes
No

@
Mark One Only

CW16

Was [fill CDNAME] on a sports team either in or
out of school?
(1)
(2)

Yes
No

@
Mark One Only

CW17

Did [fill CDNAME] take lessons after school or
on weekends in subjects like music, dance, language,
computers, or religion?
(1)
(2)

Yes
No

@
Mark One Only

CW18

Did [fill CDNAME] participate in any clubs or
organizations after school or on weekends, such as
Scouts, a religious group, or a Girls or Boys club?
(1)
(2)

Yes
No

@

Page 94 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being

CW18a

Mark One Only
How often does [fill CDNAME] go to a religious service,
a religious social event, or to religious education such
as Sunday School?
[r]H[n]
(1)
(2)
(3)
(4)
(5)

Never
Several times a year
About once a month
About once a week
Everyday or almost everyday

@
Mark One Only

CW19a

QUESTION CW19 ASKS THE RESPONDENT TO REPORT HER/HIS OWN PERSPECTIVE.
THESE QUESTIONS ARE ASKED OF THE DESIGNATED PARENT/GUARDIAN,
OR THE SPOUSE.
Now I'm going to read you some statements. Please tell me
if you think each statement is not true, sometimes true or
often true.
In general, [fill CDNAME] likes to go to school.
Would you say this statement is not true, sometimes true,
or often true?
(1)
(2)
(3)

Not true
Sometimes true
Often true

@
Mark One Only

CW19b

[fill CDNAME] is interested in school work.
Would you say this statement is not true, sometimes true,
or often true?
(1)
(2)
(3)

Not true
Sometimes true
Often true

@
Mark One Only

CW19c

[fill CDNAME] works hard at school.
Would you say this statement is not true, sometimes true,
or often true?
(1)
(2)
(3)

Not true
Sometimes true
Often true

@

Thursday, March 05, 2009

Page 95 of 120

Survey:
Section: Child Well Being

Items Booklet

Mark One Only

CW20a

Other than graduating from one school to another,
has [fill CDNAME] EVER changed schools since
entering the first grade?
(1)
(2)

Yes
No

@
Enter Number

CW20b

How many times did [fill CDNAME] change schools
for reasons other than graduation?
Number of times:

@

Mark One Only

CW21a

Has [fill CDNAME] repeated any grades,
or been held back for any reason?
(1)
(2)

Yes
No

@
Multiple Entry

CW21b

Which grade or grades did [fill CDNAME] repeat?
MARK ALL THAT APPLY
(K) Kindergarten
(1) First grade
(2) Second grade
(3) Third grade
(4) Fourth grade
(5) Fifth grade
(6) Sixth grade
(7) Seventh grade
(8) Eighth grade
(9) Ninth grade
(10) Tenth grade
(11) Eleventh grade
(12) Twelfth grade
(N) No more
@1

@2

@3

@4

@5

Mark One Only

CW22a

Has [fill CDNAME] ever been suspended, excluded,
or expelled from school?
(1)
(2)

Yes
No

@
Enter Number

CW22b

How many times has this happened?
Number of times:
Page 96 of 120

@
Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being

CW22c

Mark One Only
What grade was [fill CDNAME] in when this
happened [fill TEMP1]
(K)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)

Kindergarten
First grade
Second grade
Third grade
Fourth grade
Fifth grade
Sixth grade
Seventh grade
Eighth grade
Ninth grade
Tenth grade
Eleventh grade
Twelfth grade

@

CW23a

Mark One Only
Now I'm going to read you a few statements about
feelings parents may have regarding their children.
Please tell me how often you feel this way.
My [fill TEMP] [fill TEMP3] much harder to care for than
most children. How often do you feel this way?
READ CATEGORIES
[r]H[n]
(1)
(2)
(3)
(4)

Never
Sometimes
Often
Very often

@
Mark One Only

CW23b

My [fill TEMP] [fill TEMP4] things that really bother me a
lot. How often do you feel this way?
READ CATEGORIES
(1)
(2)
(3)
(4)

Never
Sometimes
Often
Very often

@
Mark One Only

CW23c

I find myself giving up more of my life to meet my
[fill TEMP]'s needs than I ever expected.
How often do you feel this way?
READ CATEGORIES
(1)
(2)
(3)
(4)

Never
Sometimes
Often
Very often

@

Thursday, March 05, 2009

Page 97 of 120

Survey:
Section: Child Well Being

Items Booklet

CW23d

Mark One Only
I feel angry with my [fill TEMP].
this way?
(1)
(2)
(3)
(4)

How often do you feel

Never
Sometimes
Often
Very often

@

CW24a

Mark One Only
"People in this (neighborhood/community) help each
other out".
Do you strongly agree, agree, disagree, or strongly
disagree with this statement?
[r]H[n]
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@
Mark One Only

CW24b

"We watch out for each other's children in this
(neighborhood/community)". Do you strongly agree,
agree, disagree, or strongly disagree with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@
Mark One Only

CW24c

"There are people I can count on in this
(neighborhood/community)".
Do you strongly agree, agree, disagree, or strongly
disagree with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@

Page 98 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Child Well Being
Mark One Only

CW24d

"There are people in this (neighborhood/community)
who might be a bad influence on my [fill TEMP]".
Do you strongly agree, agree, disagree, or strongly
disagree with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@
Mark One Only

CW24e

"If my [fill TEMP] were outside playing and
got hurt or scared, there are adults nearby who
I trust to help [fill TEMP2]". Do you
strongly agree, agree, disagree, or strongly
disagree with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@
Mark One Only

CW24f

"I keep my [fill TEMP] inside as much as possible
because of the dangers in the (neighborhood/community)".
Do you strongly agree, agree, disagree, or strongly disagree
with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@
Mark One Only

CW24g

"There are safe places in this (neighborhood/community)
for children to play outside." Do you strongly agree, agree,
disagree, or strongly disagree with this statement?
(1)
(2)
(3)
(4)
(5)

Strongly agree
Agree
Disagree
Strongly disagree
Have no opinion

@

Thursday, March 05, 2009

Page 99 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Page 100 of 120

Items Booklet

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

FIN1

Mark One Only
Now I am going to ask questions about the sharing of major
expenses with the household.
[fill C_DODOES] [fill TEMPNAME] pay for all [fill HISHER]
housing expenses with [fill HISHER] own money?
(1)
(2)

Yes
No

@

FIN2

Mark One Only
[fill C_DODOES] [fill HESHE] pay for all [fill HISHER]
food expenses with [fill HISHER] own money?
(1)
(2)

Yes
No

@

FIN3

Mark One Only
[fill C_DODOES] [fill HESHE] pay for all [fill HISHER]
other living expenses such as clothing, transportation,
etc., with [fill HISHER] own money?
(1)
(2)

Yes
No

@

FIN4

Mark One Only
Does all or part of the money to pay for these
expenses come from someone in this household?
(1)
(2)

Yes
No

@

FIN5

Multiple Entry
Who are these persons?
ENTER (A) FOR ALL
ENTER LINE NUMBER OF EACH PERSON
ENTER (N) FOR NO MORE
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

Thursday, March 05, 2009

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Page 101 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME01

Mark One Only
These next few questions are about [fill PTEMPNAME]
health. Would you say [fill HISHER] health in
general is excellent, very good, good, fair, or poor?
(1)
(2)
(3)
(4)
(5)

Excellent
Very good
Good
Fair
Poor

@

ME02

Mark One Only
During the past 12 months- that is, since [fill MONTH5] 1st
of last year- [fill WASWERE] [fill HESHE] a patient in a
hospital overnight or longer?
(1)
(2)

Yes
No

@

ME03

Enter Number
How many nights in all did [fill HESHE] spend in a
hospital of any type during the past 12 months?
ENTER (N) FOR NONE OR NO TIMES
@

nights

ME04

Multiple Entry
Which of the following best describes why
[fill HESHE] entered the hospital most recently...
READ ALL ANSWER CATEGORIES
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
RE-ENTER PRECODE TO DELETE
[if
[if
[if
[if

@1
@2
@3
@4

eq
eq
eq
eq

<1>]X
<2>]X
<3>]X
<4>]X

[else]
[else]
[else]
[else]

[endif](1) ...for diagnostic tests to determine what was wrong?
[endif][fill TEMP]
[endif](3) ...to have an operation or surgery?
[endif](4) ...for some other treatment or therapy not including

surgery
[if @5 eq <5>]X [else]

[endif](5)

...or for any other reason

@KEY
Mark One Only

ME05

During the past 12 months (that is, since [fill MONTH5] 1st
of last year), did [fill HESHE] take any prescription
medications?
(1)
(2)

Yes
No

@

Page 102 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

ME06

Mark One Only
[fill C_DODOES] [fill HESHE] take prescription medicines on
a daily basis?
(1)
(2)

Yes
No

@

ME08

Enter Number
SHOW FLASHCARD W
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), how many visits did [fill HESHE] make to
a dentist or other dental professional?
[r]H[n]
ENTER (N) FOR NONE OR NO TIMES
@

times

ME09

Mark One Only
[fill C_HAVHAS] [fill HESHE] lost any of [FILL HISHER]
permanent adult teeth?
(1)
(2)

Yes
No

@

ME10

Mark One Only
[fill C_HAVHAS] [fill HESHE] lost ALL of [fill HISHER]
permanent adult teeth?
(1)
(2)

Yes
No

@

ME11

Enter Number
SHOW FLASHCARD X
[fill TEMP2]
past 12 months (that is, since [fill MONTH5] 1st of last year)
how many times did [fill HESHE] see or talk to a doctor, or
nurse, or any other type of medical provider about
[fill HISHER] health?
ENTER (N) FOR NONE OR NO TIMES
[r]H[n]
@ times
Mark One Only

ME12

Did that visit or call include contact with a physician?
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 103 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME13

Enter Number
About how many of those [fill ME11] visits or
calls included contact with a physician?
ENTER (A) FOR ALL TIMES
ENTER (N) FOR NONE OR NO TIMES
@

times

ME14

Mark One Only
SHOW FLASHCARD Y
In the last 12 months (that is, since [fill MONTH5] 1st
of last year), did [fill HESHE] purchase any
other medical supplies or services?
[r]H[n]
(1)
(2)

Yes
No

@
Enter Number

ME15

[fill TEMP2] past 12 months,
about how many days did illness or injury keep
[fill HIMHER] in bed more than half of the day?
ENTER (N) FOR NONE OR NO TIMES
@

days
Enter Number

ME16

[if PCNT le <1>]
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much did [fill TEMPNAME] pay
for health insurance premiums?
[else]
During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much did [fill TEMPNAME] pay
for health insurance premiums for [fill SELF] or others
in the household?
[endif]
MARK N (NONE) IF THIS PERSON PAID NO COSTS FOR ANYONE'S
HEALTH INSURANCE.
IF SOMEONE ELSE PAYS FOR THIS PERSON'S INSURANCE, DO *NOT*
REPORT THOSE COSTS HERE -- REPORT THOSE COSTS IN THE
INTERVIEW FOR THE PERSON WHO PAYS THEM.
ENTER (N) FOR NO PAYMENTS
@

Page 104 of 120

dollars

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care
Mark One Only

ME17

HEALTH INSURANCE PREMIUM COSTS LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

None
$1 to $10
$11 to $50
$51 to $100
$101 to $200
$201 to $300
$301 to $500
$501 to $1000
$1001 to $5000
$5001 or more

@
Enter Number

ME18

During the past 12 months (that is, since [fill MONTH5] 1st of
last year), about how much was paid for [fill PTEMPNAME]
own medical care, including payments for hospital visits,
medical providers, dentists, medicine, or medical supplies?
[if MECNT gt <1>]
Include any amount paid on [fill PTEMPNAME] behalf by
you or anyone else in this household.
[endif]
EXCLUDE ANY COSTS FOR HEALTH INSURANCE PREMIUMS.
ENTER (N) FOR NO PAYMENTS
@

dollars
Mark One Only

ME19

MEDICAL CARE COSTS - LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

None
$1 to $10
$11 to $50
$51 to $100
$101 to $200
$201 to $300
$301 to $500
$501 to $1000
$1001 to $5000
$5001 or more

@

Thursday, March 05, 2009

Page 105 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME20

Mark One Only
Just to be sure- were these amounts for medical care
and health insurance the total cost to [fill TEMP] or
did [fill HESHE] get reimbursed by some other outside
source?
(1)
(2)
(3)

Total Cost
Got Reimbursed
Expects to get reimbursed but has not yet

@

ME21

Multiple Entry
How much of these expenses were reimbursed?
ENTER (N) FOR NONE
ENTER (A) FOR ALL EXPENSES REIMBURSED
@1

dollars
OR

@2

% ( percent reimbursed if
answer given as a percentage )

MEWR01

Mark One Only
Earlier I recorded that [fill TEMPNAME] [fill WASWERE] not covered by
any health insurance in [fill TEMP1].
During [fill TEMP2] did [fill HESHE] go to a dentist or other dental
professional?
(1)
(2)

Yes
No

@

MEWR02

Mark One Only
[if MEWR01 ne <>]
During [fill TEMP2]
when [fill HESHE] [fill WASWERE] not insured,
go to a doctor, nurse, or another health care
[else]
Earlier I recorded that [fill TEMPNAME] [fill
by any health insurance in [fill TEMP1].
During [fill TEMP2], did [fill HESHE] go to a
another health care provider? [endif]
(1)
(2)

did [fill HESHE]
provider?
WASWERE] not covered
doctor, nurse, or

Yes
No

@
Mark One Only

MEWR03

Which of the following kinds of care did [FILL HESHE] receive?...
...treatment for an illness or injury?
(1)
(2)

Yes
No

@
Page 106 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

MEWR04

Mark One Only
...any routine or preventive care, such as a checkup, [fill TEMP1] or
family planning?
(Did [fill TEMPNAME] receive any of that kind of care while not
insured?)
(1)
(2)

Yes
No

@

MEWR05

Mark One Only
How about ...treatment for a drug or alcohol problem?
(Did [fill TEMPNAME] receive any of that kind of care while not
insured?)
(1)
(2)

Yes
No

@

MEWR06

Enter Text
What kind of treatment did [fill HESHE] receive?
@

MEWR07

Multiple Entry
[if INDEX gt <1>]
Where did [fill HESHE] go to get those health care services?
[else]
Where did [fill HESHE] go to get that health care service?
[endif]
MARK ALL THAT APPLY / ENTER (N) AFTER LAST ENTRY
[fill
[fill
[fill
[fill
[fill
[fill
[fill

MEWR07_1:b]
MEWR07_2:b]
MEWR07_3:b]
MEWR07_4:b]
MEWR07_5:b]
MEWR07_6:b]
MEWR07_7:b]

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Clinic or Public Health Department
Emergency room
Hospital, excluding emergency room
VA hospital
Doctor's office
Dentist's office
Someplace else

@1
[if MEWR07@1 eq <7> and MEWR07@14 eq <>]
Where was that?
@14
[endif]
Enter Text

MEWR07_ERR

"Don't Know and/or Refused" response not permitted with other answers
Enter (B) to backup
@

Thursday, March 05, 2009

Page 107 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care
Mark One Only

Items Booklet

MEWR08

[if INDEX gt <1>]
Were these services free, or did [fill HESHE] have to pay
something for them?
[else]
Was this service free, or did [fill HESHE] have to pay
something for them?
[endif]
"PAY SOMETHING" MEANS MORE THAN JUST BEING BILLED - IT MEANS THAT THE
PERSON ACTUALLY PAID SOME MONEY FOR THE SERVICES
(1)
(2)
(3)

Free
Paid something
Both (some were free,some costs $)

@
Mark One Only

MEWR09

[fill TEMP]
you think [FILL HESHE] paid the full price
[if TEMP2 ne <>][fill TEMP2] [endif]or do you think [FILL HESHE] paid
a reduced price?
(1)
(2)
(3)

Full price
Reduced price
Don't know

@
Mark One Only

MEWR10

Did anyone ask what [fill PTEMPNAME] income was before they set
a price for the services?
(1)
(2)

Yes
No

@

Page 108 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

ME22

Mark One Only
[if GRDINC eq <1>][if GRDFLAG eq <1>]
The next few questions are about
[fill CHILDNAME]'s health.
[else]
The next few questions are about the
health of [fill PTEMPNAME]
[fill CHILDN].
[endif]
Let's start with [fill CHILDNAME]. Would
you say [fill HISHERG] health in general is
excellent, very good, good, fair, or poor?
[else]
How about [fill CHILDNAME]...?
(Would you say [fill HISHERG] health in
general is excellent, very good, good,
fair, or poor?)[endif]
(1)
(2)
(3)
(4)
(5)

Excellent
Very good
Good
Fair
Poor

@

ME23

Mark One Only
During the past 12 months, (that is
since [fill MONTH5] 1st of last year)
[fill TEMP1] **READ NAME(S)** a patient
in a hospital overnight or longer?
(1)
(2)

Yes
No

@

ME24

Multiple Entry
ASK OR VERIFY:
Which children?
(Which children were in a hospital for
outpatient surgery, or overnight or
longer for any reason during the past 12
months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

Thursday, March 05, 2009

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Page 109 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME25

Enter Number
[if FIRST_TIME eq <0>]How many nights in all did [fill CHILDNAME] spend in a hospital
of any type during the past 12 months?
[else]How about [fill CHILDNAME]...?
(How many nights in all did [fill HESHEGR] spend in a hospital
of any type during the past 12 months?)[endif]
ENTER (N) FOR NONE OR NO TIMES
@

Nights

ME26

Multiple Entry
Which of the following best describes why [fill CHILDNAME]
entered the hospital most recently...
READ ALL ANSWER CATEGORIES
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
RE-ENTER PRECODE TO DELETE
[if
[if
[if
[if
[if

@1
@2
@3
@4
@5

eq
eq
eq
eq
eq

<1>]X [else]
<2>]X [else]
<3>]X [else]
<4>]X [else]
<5>]X [else]
surgery?
[if @6 eq <6>]X [else]

[endif](1) ...for diagnostic tests to determine what was wrong?
[endif][FILL TEMP]
[endif][FILL TEMP2]
[endif](4) ...to have an operation or surgery?
[endif](5) ...for some other treatment or therapy, not including
[endif](6)

...or for any other reason?

@KEY

ME27

Mark One Only
During the past 12 months (that is,
since [fill MONTH5] 1st of last year)
did, **READ NAME(S)** take any
prescription medications?
(1)
(2)

Yes
No

@

ME28

Multiple Entry
ASK OR VERIFY:
Which children?
(Which children took prescription
medications during the past 12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

Page 110 of 120

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

ME29

Mark One Only

[if FIRST_TIME eq <0>]Does [fill CHILDNAME] take prescription medicines on a daily basis?
[else]How about [fill CHILDNAME]...?
(Does [fill HESHEGR] take prescription medicines on a daily basis?)[endif]
(1)
(2)

Yes
No

@

ME30

Mark One Only
SHOW FLASHCARD W
During the past 12 months, (that is,
since [fill MONTH5] 1st of last year),
did **READ NAME(S)** visit a dentist, or
other dental professional?
[r]H[n]
(1)
(2)

Yes
No

@

ME31

Multiple Entry
ASK OR VERIFY:
Which children?
(Which children visited a dentist or
other dental professional during the past
12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Enter Number

ME32

SHOW FLASHCARD W
[if FIRST_TIME eq <0>]During the past 12 months, how many visits did [fill CHILDNAME] make
to a dentist or other dental professional?
[else]How about [fill CHILDNAME]...?
(During the past 12 months, how many visits did [fill HESHEGR] make to
a dentist or other dental professional?)[endif]
[r]H[n]
ENTER (N) FOR NONE OR NO TIMES
@

times

Thursday, March 05, 2009

Page 111 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME33

Mark One Only
[if MDC1 lt <1>]
Dental sealants are special plastic coatings that are painted on
the tops of the back teeth to prevent tooth decay. They are
different from fillings, caps, crowns, and fluoride treatments.
[endif]
Has [fill CHILDNAME] ever had dental sealants painted on
[fill HISHERG] teeth?
(1)
(2)

Yes
No

@

ME34

Mark One Only
SHOW FLASHCARD X
During the past 12 months (that is,
since [fill MONTH5] 1st of last year)
did [fill TEMPNAME] or anyone else see or
talk to a medical doctor or other medical
provider about **READ NAME(S)** health?
(1)
(2)

Yes
No

@

ME35

Multiple Entry
ASK OR VERIFY:
Which children?
(About which children's health did
[fill TEMPNAME] or anyone else see or
talk to a medical provider during the
past 12 months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Enter Number

ME36

SHOW FLASHCARD X
[fill TEMP2] past 12 months,(that is; since [fill MONTH5] 1st of last
year) about how many times did [fill HESHE] or anyone else see
or talk to a medical doctor or other medical provider about
[fill CHILDNAME]'s health?
ENTER (N) FOR NONE OR NO TIMES
@

Page 112 of 120

times

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care

ME37

Mark One Only
Did that visit or call include contact with a physician?
(1)
(2)

Yes
No

@

ME38

Enter Number
About how many of those [fill ME36] visits or
calls included contact with a physician?
ENTER (A) FOR ALL VISITS
ENTER (N) FOR NONE
@

times

ME39

Mark One Only
SHOW FLASHCARD Y
In the last 12 months (that is, since
[fill MONTH5] 1st of last year), did
[fill TEMPNAME] [fill ELSEFIL] buy for
**READ NAME(S)** any other medical
supplies or services?
[r]H[n]
(1)
(2)

Yes
No

@

ME40

Multiple Entry
ASK OR VERIFY:
Which children?
(For which children were medical supplies
or services purchased during the past 12
months?)
ENTER (A) FOR ALL
ENTER (N) FOR NO MORE
ENTER LINE NUMBER OF EACH CHILD
@1 @2 @3 @4 @5
@11 @12 @13 @14
@21 @22 @23 @24

Thursday, March 05, 2009

@6 @7 @8 @9 @10
@15 @16 @17 @18 @19
@25 @26 @27 @28 @29

@20
@30

Page 113 of 120

Survey:
Section: Medical Expenses and Utilization and Health Care

Items Booklet

ME40a

Enter Number
[if FIRST_TIME eq <0>]During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much was paid by anyone in this household
for [fill CHILDNAME]'s medical care, including payments for hospital
visits, medical providers, dentists, medicine, or medical supplies?
[else]How about [fill CHILDNAME]...?
(During the past 12 months (that is, since [fill MONTH5] 1st
of last year), about how much was paid by anyone in this household
for [fill CHILDNAME]'s medical care, including payments for hospital
visits, medical providers, dentists, medicine, or medical supplies?) [endif]
EXCLUDE ANY COSTS FOR HEALTH INSURANCE PREMIUMS
ENTER (N) FOR NO PAYMENTS
@

dollars
Mark One Only

ME40b

MEDICAL CARE COSTS - LAST 12 MONTHS
Was it...
(N)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

None
$1 to $10
$11 to $50
$51 to $100
$101 to $200
$201 to $300
$301 to $500
$501 to $1000
$1001 to $5000
$5001 or more

@
Mark One Only

ME40c

Just to be sure-was this the total actual cost to [fill TEMP]
for [fill CHILDNAME]'s medical care or did some of those costs
get reimbursed by an insurance company, someone outside this
household, or any other outside source?
(1)
(2)
(3)

Total actual Cost
Got Reimbursed
Expects to get reimbursed but has not yet

@
Multiple Entry

ME40d

How much of these expenses for
[fill CHILDNAME] were reimbursed?
ENTER (N) FOR NONE
ENTER (A) FOR ALL EXPENSES REIMBURSED
@1

dollars
OR

@2

Page 114 of 120

% ( percent reimbursed if
answer given as a percentage )

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Medical Expenses and Utilization and Health Care
Mark One Only

ME41

Earlier I recorded that [fill PTEMPNAME] health or condition
prevents [fill HIMHER] from working.
For how long [fill HAVHAS] [fill HESHE] been prevented
from working? Has it been a year or longer, or has it
been less than a year?
(1)
(2)

A year or longer
Less than a year

@
Mark One Only

ME42

Is it likely that [fill HESHE] will be able to work at
some time in the next 12 months?
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 115 of 120

Survey:
Section: Work-Related Expenses and Child Support Paid
Multiple Entry

Items Booklet

PV01

During the typical week since [fill MONTH1] 1st how did
[fill TEMPNAME] get to work?
Did [fill HESHE] drive [fill HISHER] own vehicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1

Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2

@3

@4

@5

Multiple Entry

PV02

During the typical week, since [fill MONTH1] 1st how did
[fill TEMPNAME] get to work?
Did [fill HESHE] drive [fill HISHER] own vechicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1

Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2

@3

@4

@5

Multiple Entry

PV03

Now I have a few questions about [fill PTEMPNAME]
work related expenses, including transportation to work.
During the typical week, since [fill MONTH1] 1st how did
[fill TEMPNAME] get to [fill HISHER] work?
Did [fill HESHE] drive [fill HISHER] own vehicle, ride in someone
else's vehicle, take public transportation, use some combination,
or some other way?
INCLUDE ALL WORK-RELATED TRAVEL *EXCEPT* TRAVEL
FOR WHICH THE COSTS TO THE PERSON ARE REIMBURSED
MARK ALL THAT APPLY / ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1

Page 116 of 120

Drove own vehicle
Rider in someone else's vehicle/van pool
Public transportation (bus, train, subway, etc.)
Walked or bicycled
Other
@2

@3

@4

@5

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Work-Related Expenses and Child Support Paid
Enter Number

PV04

During that same typical week, about how many miles,
in total, did [fill TEMPNAME] drive [fill TEMP1] to get to
and from work?
@

Miles per week
Mark One Only

PV05

(During a typical week,) [fill TEMP] [fill PTEMPNAME]
work-commuting expenses include having to pay for
any parking or tolls?
ENTER (1) FOR "YES" IF ANY PARKING COSTS OR TOLLS ARE OUT-OF-POCKET;
ENTER (2) FOR "NO" IF ALL SUCH COSTS ARE REIMBURSED
(1)
(2)

Yes
No

@
Enter Number

PV06

Typically, how much [fill TEMP] [fill TEMPNAME] spend PER WEEK
for parking or tolls?
INCLUDE ONLY COSTS THAT WERE *NOT* REIMBURSED
@ Costs per week
Enter Number

PV07

[fill TEMP1] a typical week, about how much [fill TEMP3]
[fill HISHER] [fill TEMP2] work commuting expenses?
INCLUDE ONLY [fill OTHERFIL] WORK-COMMUTING COSTS THAT WERE *NOT*
REIMBURSED
@ [fill OTHERFIL2] work-commuting costs per week
Mark One Only

PV08

Not counting expenses [fill HISHER] employer paid,
did [fill HESHE] have any work-related expenses such as
licenses, permits, union dues, special
tools, or uniforms for [fill HISHER] work?
[fill BUSFIL]
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 117 of 120

Survey:
Section: Work-Related Expenses and Child Support Paid
Enter Number

Items Booklet

PV09

Altogether, what [fill TEMP] [fill HISHER] annual expenses
for such items?
(e.g., licenses,permits,union dues, special tools, uniforms)
[fill BUSFIL]
INCLUDE ONLY WORK-RELATED EXPENSES THAT WERE *REQUIRED* FOR EMPLOYMENT
AND THAT WERE *NOT* REIMBURSED
@ Annual expenses
Mark One Only

PVCCARR

I'd like you to think about all of the child care arrangements
used for [fill HISHER] child(ren) during [fill HISHER] work hours
in the last four months. Did [fill TEMPNAME] [fill TEMP] usually
pay for any of these arrangements? [fill TEMP2]
ONLY COUNT CHILD CARE THAT HAPPENED WHILE THE PERSON WORKED OR
COMMUTED TO/FROM WORK.
DO *NOT* INCLUDE ANY TUITION COSTS FOR KINDERGARTEN OR BEYOND
(1)
(2)

Yes
No

@
Multiple Entry

PVCCFP

How much did [fill TEMPNAME] or [fill HISHER] family pay for
child care while [fill HESHE] worked:
ENTER (N) FOR NONE/NO MORE
ENTER (S) FOR SAME AS PREVIOUS AMOUNT
in a typical week in [fill MONTH4]?
@4
in a typical week in [fill MONTH3]?
@3
in a typical week in [fill MONTH2]?
@2
in a typical week in [fill MONTH1]?
@1
Mark One Only

PVCCOTH

Did anyone else pay for all or part of the cost of
[fill HISHER] child care while [fill HESHE] worked?
By this I mean a government agency, an employer, a
relative, or a friend.
(1)
(2)

Yes
No

@

Page 118 of 120

Thursday, March 05, 2009

Items Booklet

Survey:
Section: Work-Related Expenses and Child Support Paid
Multiple Entry

PVCCWHO

Who was that?
(Who or what agency helped pay for [fill HISHER] childcare?)
MARK ALL THAT APPLY
ENTER (N) FOR NONE/NO MORE
(1)
(2)
(3)
(4)
(5)
@1

Government (Federal, state, or local government
agency, or welfare office)
Child's other parent
Employer
Relative or friend
Other
@2

@3

@4

@5

Mark One Only

PV10

[fill C_DODOES] [fill HESHE] have any children
[if TEMP1 ne <>][fill TEMP1] [endif]who lived elsewhere with their other
parent or guardian at anytime during the past 4 months?
(1)
(2)

Yes
No

@
Enter Number

PV11

How many children?
@
Mark One Only

PV12

In the past 4 months- that is, since [fill MONTH1] 1st [fill WASWERE] [fill HESHE] required to pay child support [fill TEMP1]?
INCLUDE ANY PAYMENTS...
...MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
...MADE THROUGH A COURT OR AGENCY; OR
...WITHHELD FROM THIS PERSON'S PAYCHECK
(1)
(2)

Yes
No

@

Thursday, March 05, 2009

Page 119 of 120

Survey:
Section: Work-Related Expenses and Child Support Paid

Items Booklet

PV13

Multiple Entry
How much did you pay in child support in:
COUNT ALL FORMS OF CHILD SUPPORT PAYMENTS INCLUDING...
...PAYMENTS MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
...PAYMENTS MADE THROUGH A COURT OR AGENCY; AND
...PAYMENTS WITHHELD FROM THIS PERSON'S PAYCHECK
ENTER (N) FOR NONE/NO MORE. ENTER (S) FOR SAME AS PREVIOUS AMOUNT.
[fill MONTH4]
@41
@42
@43
@44
@45
[fill MONTH3]
@31
@32
@33

@34

@35

[fill MONTH2]
@21
@22
@23

@24

@25

[fill MONTH1]
@11
@12
@13

@14

@15

PV14

Multiple Entry
What is the total amount of time [fill TEMPNAME] spent with
[fill CHILDFIL] during the past 4 months?
ENTER A RESPONSE IN ONE CATEGORY ONLY
ENTER (N) FOR NONE
Days:@DAYS

Page 120 of 120

Weeks:@WEEKS

Months:@MONTHS

Thursday, March 05, 2009