Form Vs243 – Fill Out and Use This PDF

1.

HUSBAND/SPOUSE NAME (First, Middle, Last)

2.

HUSBAND/SPOUSE LAST NAME PRIOR TO FIRST MARRIAGE

3. DATE OF BIRTH (Month, Day, Year)

4 RESIDENCE-STATE

5

COUNTY

6.

WIFE/SPOUSE NAME (First, Middle, Last)

7.

WIFE/SPOUSE LAST NAME PRIOR TO FIRST MARRIAGE

8.

DATE OF BIRTH (Month, Day, Year)

9. RESIDENCE-STATE

10. COUNTY

11. PLACE OF THIS MARRIAGE - STATE OR

12. COUNTY

13. DATE OF THIS MARRIAGE

14. NUMBER OF CHILDREN UNDER 18 IN THIS

FOREIGN COUNTRY

(Month, Day, Year)

HOUSEHOLD AS OF DATE IN ITEM 18

22. HUSBAND/SPOUSE SOCIAL SECURITY NUMBER & GENDER

23. WIFE/SPOUSE SOCIAL SECURITY NUMBER & GENDER

_____/_____/______

 Male

 Female

_____/_____/______

 Male

 Female

24. NUMBER OF THIS MARRIAGE First, Second, etc.

25. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED

(Specify below)

By Death, Divorce, or Annulment (Specify below)

Date (Month, Day, Year)

24a. HUSBAND/SPOUSE

25a. HUSBAND/SPOUSE

25b HUSBAND/SPOUSE

24b. WIFE/SPOUSE

25c. WIFE/SPOUSE

25d. WIFE/SPOUSE

26. HISPANIC ORIGIN (Check the box or boxes that best describes

27. RACE (Check one or more boxes to indicate what race(s) you consider yourself to be.)

whether you are Spanish, Hispanic, or Latino. Check the “no” box if

you are not Spanish, Hispanic, or Latino.)

27a. HUSBAND/SPOUSE

27b. WIFE/SPOUSE

26a. HUSBAND/SPOUSE

26b. WIFE/SPOUSE

 White

 Korean

 White

 Korean

 No, not Spanish/

 No, not Spanish/

 Black or

 Vietnamese

 Black or

 Vietnamese

Hispanic/Latino

Hispanic/Latina

African American

African American

 Yes, Mexican/Mexican

 Yes, Mexican/Mexican

 American Indian or

 Other Asian (Specify)

 American Indian or

 Other Asian (Specify)

American/Chicano

American/Chicana

Alaska Native

Alaska Native

 Yes, Puerto Rican

 Yes, Puerto Rican

(Name of the enrolled

(Name of the enrolled

or principal tribes)

or principal tribes)

 Yes, Cuban

 Yes, Cuban

 Yes, Central American

 Yes, Central American

 Native Hawaiian

 Native Hawaiian

 Yes, South American

 Yes, South American

 Asian Indian

 Guamanian or

 Asian Indian

 Guamanian or

 Yes, other Spanish/

 Yes, other Spanish/

Chamorro

Chamorro

Hispanic/Latino (Specify)

Hispanic/Latina (Specify)

 Chinese

 Samoan

 Chinese

 Samoan

 Filipino

 Other Pacific Islander

 Filipino

 Other Pacific Islander

 Unknown

 Unknown

 Japanese

(Specify)

 Japanese

(Specify)

 Other (Specify)

 Other (Specify)

 Unknown

 Unknown

28. EDUCATION (Check the box that best describes the highest degree or level of school completed.)

28a. HUSBAND/SPOUSE EDUCATION 8th grade or less

 9th - 12th grade; no diploma

 High school graduate or GED

 Some College credit, but no degree

 Associate degree (e.g., AA,AS)

 Bachelor’s degree (e.g., BA, AB, BS)

 Unknown

 Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

 Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

28b. WIFE/SPOUSE EDUCATION  8th grade or less

 9th - 12th grade; no diploma

 High school graduate or GED

 Some College credit, but no degree

 Associate degree (e.g., AA,AS)

 Bachelor’s degree (e.g., BA, AB, BS)

 Unknown

 Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

 Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)