Question
Your Answer
Information about the question.
1. Counting yourself, how many people are in your home?
1 2
3 4
5 6
7 8
or more
These are all the adults and children who live at your address
and have their meals with you.
2. How many children live with you?
0 1
2 3
4 5
6 7
or more
These may be your children, grandchildren or other children in
your care. If you are pregnant, please include that unborn child.
3. How much money do you earn in a month?
Click to select
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
$250
$260
$270
$280
$290
$300
$310
$320
$330
$340
$350
$360
$370
$380
$390
$400
$410
$420
$430
$440
$450
$460
$470
$480
$490
$500
$510
$520
$530
$540
$550
$560
$570
$580
$590
$600
$610
$620
$630
$640
$650
$660
$670
$680
$690
$700
$710
$720
$730
$740
$750
$760
$770
$780
$790
$800
$810
$820
$830
$840
$850
$860
$870
$880
$890
$900
$910
$920
$930
$940
$950
$960
$970
$980
$990
$1000
$1010
$1020
$1030
$1040
$1050
$1060
$1070
$1080
$1090
$1100
$1110
$1120
$1130
$1140
$1150
$1160
$1170
$1180
$1190
$1200
$1210
$1220
$1230
$1240
$1250
$1260
$1270
$1280
$1290
$1300
$1310
$1320
$1330
$1340
$1350
$1360
$1370
$1380
$1390
$1400
$1410
$1420
$1430
$1440
$1450
$1460
$1470
$1480
$1490
$1500
$1510
$1520
$1530
$1540
$1550
$1560
$1570
$1580
$1590
$1600
$1610
$1620
$1630
$1640
$1650
$1660
$1670
$1680
$1690
$1700
$1710
$1720
$1730
$1740
$1750
$1760
$1770
$1780
$1790
$1800
$1810
$1820
$1830
$1840
$1850
$1860
$1870
$1880
$1890
$1900
$1910
$1920
$1930
$1940
$1950
$1960
$1970
$1980
$1990
$2000
$2010
$2020
$2030
$2040
$2050
$2060
$2070
$2080
$2090
$2100
$2110
$2120
$2130
$2140
$2150
$2160
$2170
$2180
$2190
$2200
$2210
$2220
$2230
$2240
$2250
$2260
$2270
$2280
$2290
$2300
$2310
$2320
$2330
$2340
$2350
$2360
$2370
$2380
$2390
$2400
$2410
$2420
$2430
$2440
$2450
$2460
$2470
$2480
$2490
$2500
$2510
$2520
$2530
$2540
$2550
$2560
$2570
$2580
$2590
$2600
$2610
$2620
$2630
$2640
$2650
$2660
$2670
$2680
$2690
$2700
$2710
$2720
$2730
$2740
$2750
$2760
$2770
$2780
$2790
$2800
$2810
$2820
$2830
$2840
$2850
$2860
$2870
$2880
$2890
$2900
$2910
$2920
$2930
$2940
$2950
$2960
$2970
$2980
$2990
$3000
$3010
$3020
$3030
$3040
$3050
$3060
$3070
$3080
$3090
$3100
$3110
$3120
$3130
$3140
$3150
$3160
$3170
$3180
$3190
$3200
$3210
$3220
$3230
$3240
$3250
$3260
$3270
$3280
$3290
$3300
$3310
$3320
$3330
$3340
$3350
$3360
$3370
$3380
$3390
$3400
$3410
$3420
$3430
$3440
$3450
$3460
$3470
$3480
$3490
$3500
$3510
$3520
$3530
$3540
$3550
$3560
$3570
$3580
$3590
$3600
$3610
$3620
$3630
$3640
$3650
$3660
$3670
$3680
$3690
$3700
$3710
$3720
$3730
$3740
$3750
$3760
$3770
$3780
$3790
$3800
$3810
$3820
$3830
$3840
$3850
$3860
$3870
$3880
$3890
$3900
$3910
$3920
$3930
$3940
$3950
$3960
$3970
$3980
$3990
$4000
over $4000
(Round down)
Use the amount you get paid before taxes are taken out.
4. How much money do you get in a month other than earnings?
Click to select
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
$250
$260
$270
$280
$290
$300
$310
$320
$330
$340
$350
$360
$370
$380
$390
$400
$410
$420
$430
$440
$450
$460
$470
$480
$490
$500
$510
$520
$530
$540
$550
$560
$570
$580
$590
$600
$610
$620
$630
$640
$650
$660
$670
$680
$690
$700
$710
$720
$730
$740
$750
$760
$770
$780
$790
$800
$810
$820
$830
$840
$850
$860
$870
$880
$890
$900
$910
$920
$930
$940
$950
$960
$970
$980
$990
$1000
$1010
$1020
$1030
$1040
$1050
$1060
$1070
$1080
$1090
$1100
$1110
$1120
$1130
$1140
$1150
$1160
$1170
$1180
$1190
$1200
$1210
$1220
$1230
$1240
$1250
$1260
$1270
$1280
$1290
$1300
$1310
$1320
$1330
$1340
$1350
$1360
$1370
$1380
$1390
$1400
$1410
$1420
$1430
$1440
$1450
$1460
$1470
$1480
$1490
$1500
$1510
$1520
$1530
$1540
$1550
$1560
$1570
$1580
$1590
$1600
$1610
$1620
$1630
$1640
$1650
$1660
$1670
$1680
$1690
$1700
$1710
$1720
$1730
$1740
$1750
$1760
$1770
$1780
$1790
$1800
$1810
$1820
$1830
$1840
$1850
$1860
$1870
$1880
$1890
$1900
$1910
$1920
$1930
$1940
$1950
$1960
$1970
$1980
$1990
$2000
$2010
$2020
$2030
$2040
$2050
$2060
$2070
$2080
$2090
$2100
$2110
$2120
$2130
$2140
$2150
$2160
$2170
$2180
$2190
$2200
$2210
$2220
$2230
$2240
$2250
$2260
$2270
$2280
$2290
$2300
$2310
$2320
$2330
$2340
$2350
$2360
$2370
$2380
$2390
$2400
$2410
$2420
$2430
$2440
$2450
$2460
$2470
$2480
$2490
$2500
$2510
$2520
$2530
$2540
$2550
$2560
$2570
$2580
$2590
$2600
$2610
$2620
$2630
$2640
$2650
$2660
$2670
$2680
$2690
$2700
$2710
$2720
$2730
$2740
$2750
$2760
$2770
$2780
$2790
$2800
$2810
$2820
$2830
$2840
$2850
$2860
$2870
$2880
$2890
$2900
$2910
$2920
$2930
$2940
$2950
$2960
$2970
$2980
$2990
$3000
$3010
$3020
$3030
$3040
$3050
$3060
$3070
$3080
$3090
$3100
$3110
$3120
$3130
$3140
$3150
$3160
$3170
$3180
$3190
$3200
$3210
$3220
$3230
$3240
$3250
$3260
$3270
$3280
$3290
$3300
$3310
$3320
$3330
$3340
$3350
$3360
$3370
$3380
$3390
$3400
$3410
$3420
$3430
$3440
$3450
$3460
$3470
$3480
$3490
$3500
$3510
$3520
$3530
$3540
$3550
$3560
$3570
$3580
$3590
$3600
$3610
$3620
$3630
$3640
$3650
$3660
$3670
$3680
$3690
$3700
$3710
$3720
$3730
$3740
$3750
$3760
$3770
$3780
$3790
$3800
$3810
$3820
$3830
$3840
$3850
$3860
$3870
$3880
$3890
$3900
$3910
$3920
$3930
$3940
$3950
$3960
$3970
$3980
$3990
$4000
over $4000
(Round down)
This could be unemployment, retirement, child support, SSA/SSI,
etc.
5. How much money do you have?
Click to select
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
$250
$260
$270
$280
$290
$300
$310
$320
$330
$340
$350
$360
$370
$380
$390
$400
$410
$420
$430
$440
$450
$460
$470
$480
$490
$500
$510
$520
$530
$540
$550
$560
$570
$580
$590
$600
$610
$620
$630
$640
$650
$660
$670
$680
$690
$700
$710
$720
$730
$740
$750
$760
$770
$780
$790
$800
$810
$820
$830
$840
$850
$860
$870
$880
$890
$900
$910
$920
$930
$940
$950
$960
$970
$980
$990
$1000
$1010
$1020
$1030
$1040
$1050
$1060
$1070
$1080
$1090
$1100
$1110
$1120
$1130
$1140
$1150
$1160
$1170
$1180
$1190
$1200
$1210
$1220
$1230
$1240
$1250
$1260
$1270
$1280
$1290
$1300
$1310
$1320
$1330
$1340
$1350
$1360
$1370
$1380
$1390
$1400
$1410
$1420
$1430
$1440
$1450
$1460
$1470
$1480
$1490
$1500
$1510
$1520
$1530
$1540
$1550
$1560
$1570
$1580
$1590
$1600
$1610
$1620
$1630
$1640
$1650
$1660
$1670
$1680
$1690
$1700
$1710
$1720
$1730
$1740
$1750
$1760
$1770
$1780
$1790
$1800
$1810
$1820
$1830
$1840
$1850
$1860
$1870
$1880
$1890
$1900
$1910
$1920
$1930
$1940
$1950
$1960
$1970
$1980
$1990
$2000
$2010
$2020
$2030
$2040
$2050
$2060
$2070
$2080
$2090
$2100
$2110
$2120
$2130
$2140
$2150
$2160
$2170
$2180
$2190
$2200
$2210
$2220
$2230
$2240
$2250
$2260
$2270
$2280
$2290
$2300
$2310
$2320
$2330
$2340
$2350
$2360
$2370
$2380
$2390
$2400
$2410
$2420
$2430
$2440
$2450
$2460
$2470
$2480
$2490
$2500
$2510
$2520
$2530
$2540
$2550
$2560
$2570
$2580
$2590
$2600
$2610
$2620
$2630
$2640
$2650
$2660
$2670
$2680
$2690
$2700
$2710
$2720
$2730
$2740
$2750
$2760
$2770
$2780
$2790
$2800
$2810
$2820
$2830
$2840
$2850
$2860
$2870
$2880
$2890
$2900
$2910
$2920
$2930
$2940
$2950
$2960
$2970
$2980
$2990
$3000
$3010
$3020
$3030
$3040
$3050
$3060
$3070
$3080
$3090
$3100
$3110
$3120
$3130
$3140
$3150
$3160
$3170
$3180
$3190
$3200
$3210
$3220
$3230
$3240
$3250
$3260
$3270
$3280
$3290
$3300
$3310
$3320
$3330
$3340
$3350
$3360
$3370
$3380
$3390
$3400
$3410
$3420
$3430
$3440
$3450
$3460
$3470
$3480
$3490
$3500
$3510
$3520
$3530
$3540
$3550
$3560
$3570
$3580
$3590
$3600
$3610
$3620
$3630
$3640
$3650
$3660
$3670
$3680
$3690
$3700
$3710
$3720
$3730
$3740
$3750
$3760
$3770
$3780
$3790
$3800
$3810
$3820
$3830
$3840
$3850
$3860
$3870
$3880
$3890
$3900
$3910
$3920
$3930
$3940
$3950
$3960
$3970
$3980
$3990
$4000
over $4000
(Round down)
Include cash and bank accounts for everyone in the household.
6. How much money do you pay each month in child support?
Click to select
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
$250
$260
$270
$280
$290
$300
$310
$320
$330
$340
$350
$360
$370
$380
$390
$400
$410
$420
$430
$440
$450
$460
$470
$480
$490
$500
$510
$520
$530
$540
$550
$560
$570
$580
$590
$600
$610
$620
$630
$640
$650
$660
$670
$680
$690
$700
$710
$720
$730
$740
$750
$760
$770
$780
$790
$800
$810
$820
$830
$840
$850
$860
$870
$880
$890
$900
$910
$920
$930
$940
$950
$960
$970
$980
$990
$1000
$1010
$1020
$1030
$1040
$1050
$1060
$1070
$1080
$1090
$1100
$1110
$1120
$1130
$1140
$1150
$1160
$1170
$1180
$1190
$1200
$1210
$1220
$1230
$1240
$1250
$1260
$1270
$1280
$1290
$1300
$1310
$1320
$1330
$1340
$1350
$1360
$1370
$1380
$1390
$1400
$1410
$1420
$1430
$1440
$1450
$1460
$1470
$1480
$1490
$1500
$1510
$1520
$1530
$1540
$1550
$1560
$1570
$1580
$1590
$1600
$1610
$1620
$1630
$1640
$1650
$1660
$1670
$1680
$1690
$1700
$1710
$1720
$1730
$1740
$1750
$1760
$1770
$1780
$1790
$1800
$1810
$1820
$1830
$1840
$1850
$1860
$1870
$1880
$1890
$1900
$1910
$1920
$1930
$1940
$1950
$1960
$1970
$1980
$1990
$2000
$2010
$2020
$2030
$2040
$2050
$2060
$2070
$2080
$2090
$2100
$2110
$2120
$2130
$2140
$2150
$2160
$2170
$2180
$2190
$2200
$2210
$2220
$2230
$2240
$2250
$2260
$2270
$2280
$2290
$2300
$2310
$2320
$2330
$2340
$2350
$2360
$2370
$2380
$2390
$2400
$2410
$2420
$2430
$2440
$2450
$2460
$2470
$2480
$2490
$2500
$2510
$2520
$2530
$2540
$2550
$2560
$2570
$2580
$2590
$2600
$2610
$2620
$2630
$2640
$2650
$2660
$2670
$2680
$2690
$2700
$2710
$2720
$2730
$2740
$2750
$2760
$2770
$2780
$2790
$2800
$2810
$2820
$2830
$2840
$2850
$2860
$2870
$2880
$2890
$2900
$2910
$2920
$2930
$2940
$2950
$2960
$2970
$2980
$2990
$3000
$3010
$3020
$3030
$3040
$3050
$3060
$3070
$3080
$3090
$3100
$3110
$3120
$3130
$3140
$3150
$3160
$3170
$3180
$3190
$3200
$3210
$3220
$3230
$3240
$3250
$3260
$3270
$3280
$3290
$3300
$3310
$3320
$3330
$3340
$3350
$3360
$3370
$3380
$3390
$3400
$3410
$3420
$3430
$3440
$3450
$3460
$3470
$3480
$3490
$3500
$3510
$3520
$3530
$3540
$3550
$3560
$3570
$3580
$3590
$3600
$3610
$3620
$3630
$3640
$3650
$3660
$3670
$3680
$3690
$3700
$3710
$3720
$3730
$3740
$3750
$3760
$3770
$3780
$3790
$3800
$3810
$3820
$3830
$3840
$3850
$3860
$3870
$3880
$3890
$3900
$3910
$3920
$3930
$3940
$3950
$3960
$3970
$3980
$3990
$4000
over $4000
(Round down)
Put 0 if you pay no child support.