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Demographics Survey

Dear Sir / Madam,

If you would take the time to fill out this short demographic survey, we hope to use the data collected to better understand and therefore serve you as a citizen better in future.

1 Are you male or female?
Required answer

2 Which category best represents your age?
Required answer

3 What is your marital status?
Required answer

4 In what state or territory do you live?
Required answer

250 characters remaining

5 In what ZIP code is your home located?
Required answer

Enter 5-digit ZIP code; for example, 00544 or 94305

20 characters remaining

6 What is the highest level of school you have completed or the highest degree you have received?
Required answer

7 Does anyone in your household own a small business or farm?
Required answer

8 Which of the following categories best describes your employment status?
Required answer

9 What was your Net income in the last year?
Required answer

This includes working income; income from business, rental income; pensions; dividends; interest; social security income; Please report the total amount of money you earned - do not subtract the amoun

10 What was your Net Household income in the last year?
Required answer

This includes working income; Business income, Rental income; pensions; dividends; interest; social security income; and all other monetary income received by taxpaying adult members of your household

11 Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, Hispanic, Latino or other Spanish denomination?
Required answer

12 Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian / Pacific islander or other?
Required answer

13 What are your current living conditions?
Required answer

14 How many children age 17 below live in your household?
Required answer

20 characters remaining