1. Are you over the age of 18?

2. What is your gender?

3. Where is your current residence located?

4. In what state the residence located?

5. How many people are living or staying in your current place of residence(house, apartment, mobile home, etc.) today?

Include	Do NOT Include
Foster childeren, roomers, or housemates	College students living away from home
People staying here today who have no other permanent place to stay	People currently in correctional facility, nursing home, or mental hospital
People living here most of the time while working, even if they have another place to live	People in the Armed Forces who live somewhere else
People temporarily away on a business trip, on vacation, etc.	People who live or stay at another place most of the time

6. How many of the people living in your household are enrolled members of the Citizen Potawatomi Nation?

7. Does head of household identify themselves as an AIAN?

8. What was your household income last year, before taxes, from all sources - include all sources for all household members; sources include:

1) All wages, salary, commissions, bonuses, or tips from all jobs

2) Self-employment income from own farm or non-farm business, including proprietorships and partnerships

3) Interest, dividends, net rental income, royalty income, or income from estates and trusts

4) Social Security or railroad retirement

5) Supplemental Security Income (SSI)

6) Any public assistance or welfare payments from the state, local or tribal welfare office

7) Any other sources of income received regularly such as Veteran payment, unemployment compensation, child support or alimony

9. What is the highest level of education you or someone in your household have completed?

10. Are you Employed?