Surname : _____________________________________ Sex : Male Female
Age : 20 to 25 26 to 30 31 to 40 41 to 50 50 and up Type of Household: Single Family Extended Family Two or More Non-related Families/Persons No. of family members in the household: 1 to 5 6 to 10 11 to 15 16 to 20 more than 20 No. of employed family members: 1 to 2 3 to 4 5 to 6 7 to 8 more than 8
During the past month, how much did the household consume on: *estimate only
Food Items and Beverages
0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Fuel, Light, Water, and Household Operation 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Transportation and Communication 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Personal Care, Clothing, Footwear and Other Wear 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Education, Recreation and Medical Care 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Taxes 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Housing (Rent) 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Miscellaneous Expenditures 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000
How much is the total monthly income of the household based on: *estimate only
Salaries and Wages from Regular Employment
0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Cash Receipts, Support, Assistance and Relief 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000 Entrepreneurial Activities 0 - 7,500 7,501 - 15,000 15,001 - 22,500 22,501 - 30,000 more than 30,000