CONFIDENTIAL

The information collected in this sur-vey will be strictly confidential ac-cording to the survey ordinance andindividual level information will notbe divulged to any person or agency.

SURVEY SCHEDULE

Department of Census & StatisticsMinistry of Finance and Planning

Sri Lanka

NATIONAL HOUSEHOLD SAMPLE SURVEY PROGRAMME

DistrictSectorMonth

P.S.U.No.

S.S.U. &Household.No.

D.S.Division

(for office use only)

HOUSEHOLD INCOME AND EXPENDITURE SURVEY - 2005

IDENTIFICATION INFORMATIONS

D.S.DivisionDistrictERU

Sector

(01-12) (001 - 999) (1 - 10) (1 - 9)

Result CodeCompleted...............................................1Deferred..................................................2No competent respondant at home.........3Refused...................................................4Household is temporarily closed...... ......5Household is demolished/Vacant:.. ........6Other (Specify)....... ................................9

1. Housing units in D.S. Divisions unaffected by the Tsunami2. (i) Housing units in unaffected census blocks in affected D.S.Divisions (ii) Housing units in affected census blocks in affected D.S.Divisions (iii) Families live in transist camps and transist houses.

Month ofSurvey

P.S.U. No. HouseholdNo.

S.S.UNo.

(Select and circle the perticular number)

1

1. Address (Location) :......................................................................

.........................................................................

2. Province:........................................................................................

3. District : ........................................................................................

4. D.S.Division:.................................................................................

5. Name of MC/UC:-.........................................................................(If Urban Sector)

6. G.N.Division : No......................... Name: ....................................

7. Name of Village :...........................................................................

(If Rural Sector)

8. Name of Estate: .............................................................................

(If Estate Sector)

9. C.B. No.:-............................... S.S.U. No......................................

10. Survey Month:-..............................................................................

11. Sample Stratum:-...............................................................

Number of Households

Result

Name of the Head of the household - ..........

..................................

Interviewer's

Name

Signature:- Date

Supervising Officer's

Name

Signature:- Date

Code for Section - 1

Col 3 Relationship to head of the household

Head of the Household...............................1Wife / Husband ..........................................2Son/Daughter .............................................3Parents .......................................................4Other Relative ............................................5Domestic Servants......................................6Boarder.......................................................7Other...........................................................9

Col. 6 - Ethnicity

Sinhala . ..............................1Sri Lanka Tamil .. ...............2Indian Tamil ......... ..............3Sri Lanka Moors ......... .......4Malay ..... ...........................5Burgher.. .............................6Other ....... ...........................9

Col. 8 Level of Education

Studing Grade 1 ............................... 00Passed Grade 1 .................................01Passed Grade 2 .................................02Passed Grade 3 ..................................03Passed Grade 4...................................04Passed Grade 5 ................................. 05Passed Grade 6 ................................. 06Passed Grade 7...................................07Passed Grade 8.................................. 08Passed Grade 9................................. 09Pssed Grade 10..................................10Passed G.C.E.(O/L) or equivalent..........11Pssed Grade 12 ............................... .12Passed G.C.E. (A/L)/ or equivalent.... . 13Passed G.A.Q./ G.S.Q.......................... .14Passed Degree...................................... 15Passed Post Graduate Degree/Diploma 16No Schooling .......................................19

Col. 7 - Religion

Buddhist . ....................................1Hindu.. ........................................2Islam ......... ..................................3Roman Catholic/ Other Christian. ....................4Other ...........................................9

Col. 9 Marital Status

Never Married ................... 1Married .............................. 2Widowed ............................ 3Divorced ............................. 4Separated ............................ 5

Col. 10 - Usual Activity

Employed .......................... ......... 1Unemployed ........................... .. 2Student ....................................... 3Household Work ......................... 4Unable/ To old to work .............. 5Other ............................................ 9

2

Col. 4 Sex

Male ........................... 1 Female........................ 2

Name of all persons who usuallylive in this household

For persons 10 years and over

For Employedpersons only

Did this person engage in any of the followingactivities during last month or last cultivation

year as employer, employee orown account worker?

Relationshipto head of the

household

42434445

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

1 3 9 164 6 11 12 13 14 15108

* **

SerialNo.

* *2 43

Ser

ial N

o.

Rel

atio

nshi

p to

hea

d of

the

hous

ehol

d

Sex

Age

as

at la

st b

irth

day

SECTION 01 - DEMOGRAPHIC CHARACTERISTICS

Eth

nici

ty

Lev

el o

f E

duca

tion

(5 y

ears

and

ove

r)

Rel

igio

n

Mar

ital

sta

tus

Usu

al A

ctiv

ity

Indu

stry

Pai

dE

mpl

oym

ent

Agr

icul

tura

lA

ctiv

itie

s(S

easo

nal C

rops

)

Agr

icul

tura

lac

tivi

ties

(Non

sea

sona

lcr

ops,

live

stoc

kfi

shin

g) Non

agri

cult

ural

acti

viti

es

Mai

nO

ccup

atio

n

Industry(discribe)

2

3

* Main Occupation(discribe)

Names of the persons who are members of this household & usually live elsewhere in thecountry or abroad

Usually live in1. In the country2. Abroad

CodeQty,

UnitItem

2 3 4

0102

010301040105

0106

0107

01080109

0110

01110112

0113

0114

0115

0201

0203

0204

0205

0206

0207

0208

02

01

Consumed

5

0101

1 2 3 4 5

0211

0212

02130214

0215

0219

0210

0209

3. Pulses

1. Dhal

2. Green Gram

3. Gram

4. Cowpea

5. Soya

6. Soya meat

7. Other ........

03

9. Those/Itly

10. Rice (Meat & Vegetables)

11. Rice (Fish & Vegetables)

12. Rice (Vegetable only)

13. Curry (Meat)

14. Curry (Fish)

15. Curry (Vegetables)

16. Other .........

03010302

0303

03040305

0306

0309

4. Vegetables

1. Ash plantain

2. Brinjal

3. Ladies Fingers (Bandakka)

4. Bitter gourd

5. Long beans

Snake gourd

Ridge gourd

8 Sweet pumpkin

04

2.1 Weekly consumption on Food and Drink

0402

0401

0403

0404

0405

0406

0407

0408

0119

(Rs.)

Section 2 - Expenditure

Value Item Code UnitConsumed

Qty.Value(Rs.)

grams

grams

grams

grams

gramsgramsgrams

grams

grams

grams

0202

numbernumber

number

number

numbernumber

number

number

1. Cereals

1. Rice - (Kekulu)

2. Rice - (Samba)

3. Rice - (Nadu)

4. Rice - (Basmathi)

5. Rice flour

6. Wheet flour

7. Kurakkan flour

8. Maize

9. Samaposha

10. Noodles

11. Papadam

12. Infants cereal foods (Nestum)

13. Barley

14. Sago

15. Corn flakes

16. Other .........

2. Prepared foods

1. Bread (Normal)

2. Bread (Special)

3. Rospaan

4. Buns/Spanchi

5. Hoppers

6. String Hoppers

7. Pittu

8. Rotti

4

number

number

grams

grmas

gramsgrams

grams

grams

grams

gramsgrams

grams

gramsgrams

grams

gramsgrams

grams

grams

gramsgramsgrams

grams

grams

CodeQty.

UnitItemConsumed

Value

9. Beans

10. Carrot

11. Beet root

12. Cabbage

13. Tomatoes

14. Leeks

15. Knol khol

16. Capsicum

17. Dambala

18. Raddish

19. Drumstick

20. Cucumber

21. Kekiri

22. Ash pumpkin

23. Elabatu (Thalana batu)

24. Kohila yams

25. Lotus stemo

26. Plantain flower

27. Ambarella

28. Cadjunuts (raw)

29. Mashrooms

30. Jack immatured (Polos)

31. Other .........

4. Katurumurunga

0414

0415

0416

0417

0418

0419

0420

0421

0422

0423

0424

0425

0426

0427

0428

0429

04300439

0409 grams

0410

0411

04120413

0445

0446

0447

0448

0449

0450

0459

0441

0442

04430444

0601

0602

0604

0501

0502

0503

0504

0505

0506

0507

0509

05

06 6. Meat

1. Chicken

2. Beef

3. Mutton

4. Pork

5. Sausages / Meetballs

6. Other ........

0603

0609

0605

(Rs.)

1. Mukunuwenna

2. Gotukola

3. Kankun

Leafy Vegetables

grams

grams

grams

grams

grams

gramsgrams

grams

grams

grams

gramsgramsgrams

grams

grams

grams

grams

Item Code UnitConsumed

Qty. Value(Rs.)

grams

grams

grams

grams

grams

grams

5. Nivithi

6. Thampala

7. Sarana

8. Kohila leaves

9. Onion leaves

10. Cabbage leaves

11. Other.......

number

gramsgrams

grams

grams

grams

grams

5. Yams and other

1. Jak/jak seeds

2. Bread fruit

3. Potatoes

4. Sweet potatoes

5. Mannioc

6. Kiriala

7. Innala

8. Other yams.........gramsgrams

grams

5

bundles

bundlesbundles

bundles

bundlesbundles

bundles

bundles

bundlesbundles

7. Fish

1. Balaya

2. Seer

3. Mora

4. Paraw

5. Thalapath

6. Kelawalla

7. Other large fish

8. Sprats

9. Hurulla

0701

0702

0703

0704

0705

0706

07070708

0709

07

9. Balaya

10. Mora/Keelan

11. Paraw

12. Anguluwa

13. Prawns

14. Cuttle fish

15. Fresh water fish - dried

16. Jadi

17. Other......

0711

07120713

0714

0715

0716

071707180719

0801

0802

0803

08040805

0806

0807

0808

0710

0809

0810

0811

0812

0813

0814

0815

1101

1102

0901 number

0909

1001 number

1002

11031104

1105

1106

number

1107

09

10

11

10. Karalla/Katuwalla

11. Kumbalawa/Angila

12. Salaya/Sudaya

13. Other small fish

14. Lula

15. Teppili/Telapiya/Korali

16. Other fresh water fish

17. Prawns

18. Crabs

19. Cuttle fish

20. Canned fish (Salmon) 0720

088. Dried Fish

1. Sprats

2. Keeramin

3. Salaya

4. Hurulla

5. Seer

6. Katta

8. Anjila7. Koduwa

0816

0819

Code Qty.UnitItem

Consumed

Code Qty.UnitItem

Consumed

gramsgrams

grams

grams

grams

grams

gramsgrams

grams

grams

grams

gramsgramsgrams

grams

grams

grams

grams

gramsgrams

grams

grams

grams

grams

gramsgrams

grams

grams

grams

gramsgrams

grams

grams

grams

grams

grams

grams

grams

gramsgrams

grams

grams

grams

grams

grams

6

Value(Rs.)

Value(Rs.)

9. Eggs1. Hen

2. Other...

10. Coconuts

1. Nuts

2. Cocnut milk powder

11. Condiments

1. Dried chillies

2. Chilly powder

3. Red onions

4. Bombey onions

5. Garlic

6. Maldive fish

7. Pepper

Code UnitItemConsumed

1108

1109

11101111

1112

11131114

1115

1116

1117

1118

111911201121112211231129

12. Other foods

1 Sauce

2 Marmite / Vegemite

3 Soup cubes

4 Lime pickle

5 Chutney

6 Canned fruits

7 Other....

1201

120212031204

1205

1206

1209

1302

1303

1304

13051306

1307

13081309

13101319

1301

1 Coconut oil

2 Vegetable oil

3 Gingerley oil

4 Ghee

5 Other....

1401

140214031404

1409

14. Fats & Oils14

1501

150215031504

1509

13. Milk & Milk Foods13

7

8 Turmeric / Turmeric powder

9 Curry powder (sarakku)

10 Green chillies

11 Limes

12 Cumin seeds

13 Fennel seeds

14 Coriander

15 Mathe seeds

16 Mustard

17 Goraka

18 Tamarind19 Cinnamon

20 Salt

21 Karapincha/ Rampe

22 Ginger

23 Vinegar

24 Other....

number

gramsgrams

grams

12

Code Unit Value(Rs.)

Qty.

Consumed

ml1 Cow milk

2 Goat milk

3 Curd

4 Yoghurt / Moru

5 Condensed milk

6 Milk powder

7 Infant milk powder

8 Butter

9 Margarine

10 Cheese

11 Other...

grams

gramsgrams

gramsgramsgrams

ml

ml

ml

mlml

ml

ml

15. Sugar / Juggery / Treacle

1 Sugar

2 Juggery

15

3 Treacle

4 Honey

5 Other....

grams

grams

ItemQty. Value

(Rs.)

Code UnitItemConsumed

1601

1602

1603

1604

1605

16061607

1608

1609

1610

1619

16. Fruits

1 Banana

2 Pineapple

3 Papaw

4 Mangoes

5 Apple

6 Avacado

7 Wood apple

8 Oranges

9 King coconuts / Kurumba

10 Grapes

11 Other....

1651

1652

1653

16541659

grams

gramsgrams

gramsgrams

17. Confectionery & Short eats

1 Jam

2 Ice cream

3 Chocolates

4 Toffees

5 Biscuits

6 Jelly packets

17

grams

Item Code UnitQty.

1707

1708

1709

1710

1711

1712

1719

1701

17021703

17041705

1706

grams

grams

Consumed

Value(Rs.)

7 Snacks

8 Cake

9 Kewum/ Kokis etc.

10 Musket/ Kaludodol etc.

11 Thalabola/ Rulan etc.

12 Cutlets/ Patis / Wade /Pestry etc.

13 Other.....

1801

1802

1803

1804

18051806

180718081809

18101811

18121819

number

16

Dried fruits

1 Dates

2 Cajunuts

3 Ground nuts

4 Plums

5 Other....

number

numbernumbernumber

number

number

number

grams

number

18

gramsgrams

grams

grams

grams

number

numbernumber

number

number

8

number

number

number

numbernumber

Qty. Value(Rs.)

18.Beverages (Non Alcoholic)

1 Tea Dust/ Leaves

2 Coffee powder/ Seeds

3 Soft drink

4 Fruit drink/ Cordial

5 Saruwath

6 Milk tea

7 Plain tea

8 Milk coffee

9 Coffee

10 Ice packets

11 Gruel

13 Bottled water

12 Other.....

1905

1906

1907

1908

19091910

1911

1912

1919

1920

1921

1922

1923

1924

19044. Beer/Stout

5. Whiskey/Brandy

6. Gin

7. Wine

8. Other liquor

9. Drugs (Ganja,Haroin etc.)

10. Cigarettes

11. Cigars

12. Beedi

13. Other pipe tobacco

14. Betel leaves

15. Arecanuts

16. Tobacco chewing

17. Chunam

18. Bulathwita/Saravita

1. Toddy

2. Arrack

3. Kassippu

1901

1902

1903

19

19. Liquor, Drugs andTobacco

Code Qty.Unit

Consumed

(Rs.)

Item

numbernumber

number

number

9

number

number

Value

2101

2103

2104

2105

2106

2107

number

number

number

22052204

2203

∗

2102 ml.

2208

2209

2219

2403

Main household - include all members of the household exclude servants and boarders.

2001

2002

2003

kg.

kg.

2201

2301Fees to private medical practitioners

(including cost of medicine)

Fees to Ayurvedic medical practitioners

Consultation fees to specialists

Payments to medical laboratories for

test analysis etc.

Payments to private hospitals and

nursing homes.

Purchase of medical and pharmaceutical

products.

2302

2303

2304

2305

2306

2309

23

Taxi/three wheelers (other than schooling)

2401

2402

2.2 Household expenditure on Housing, Fuel and Light, Non-durable goods, Services and Consumer durables for main Household

2109

2108 number

2207

Toilet soap

Tooth paste

Tooth brushes

Powder(Cosmetic powder)

Perfumes

Face cream / Lotions

Hair oils , cream & Hair dye

22

3. Personal care expenses(Last month)

2202

2206

2210

CodeQty.

Unit

Main household

Item

∗Code

Qty.Unit

Main householdItem

4. Health expenses(Last month)

∗

10

Electricity (Monthly average)

Kerosene oil (Monthly average)

Fire wood (Monthly average)

Gas (Monthly average)

Bulbes (Last month)

Match box (Last month)

Candles (Last month)

Battery (Last month)

Other ...... (Last month)

5. Transport (Last month)Transport fees

Train/bus (other than schooling)

Van (other than schooling)

Value(Rs.)

Value(Rs.)

1. Housing (Average per month)

Rent (Estimated rent of owner occupiedhouse should be included in Col.5)

Taxes

Water bills

212. Fuel & Light (Average Per Month)

Lipstick / Cutex

Shaving equipment

Hair cut/ Hair dressing & shaving charges

Other......

Main householdItem Code Unit

Qty.

2404

Main householdItem Code Unit

Qty.

∗ ∗

2606

∗

2405

2409

2411

2412

2413

2414

2415

2501

2502

2601

2602

2603

2607

2604

2605

2608

2619

2609

2701

2702

2703

2704

2705

2706

2707

2708

2709

2710

2719

2419

Repair charges of spare partsaccessaries

2509

Value(Rs.)

Value(Rs.)

Cinamas / Drama / Video films

Books/ News papers / Magazines

Diploma etc.)

Lotteries/ Bettings

Arts/ Music/ Dancing

Pets/ Aquarium

Sports

Beauty care/ Cookery/ Dress making

Toys

Maintanence of radio receivers,television & Video decks

Main household - include all members of the household exclude servants & boarders.

25

267. Education ( Last month)

27

Other.....

Transport charges for schooling

Ships & air lines

Other....

Maintance of Private Vehicals Petrol & other fuel

Oil Tyre, tube & spare parts

Licence & insurance

Other.....

6. Communication ( Last month)

Excursions/ Piligrimages

Postal & Tlegraph Charges

2503

2504

Telephone charges (Taken from outside)

Other.....

School text books

School facility fees (Government)

School fees (Private)

Tution fees

Boarding fees

Fees for higher education

(External Degree / Post graduate Degree

Fees for professional & Technical education

Other.....

8. Recreation, entertainment & Cultural activities (Last month)

Telephone charges (Domestic/ Mobile) (Avrege permonth)

Exercise book/ Stationeries

News papers/ Magazines (Related to education)

Telephone charges ( E-mail, internet)

∗

3002

3003

3004

3005

3042

3043

3049

3016

3029

c. m.

c.m.

c.m.

c.m.

9. Non-durable household goods (Last month)

Washing soapWashing powderMosquito coilsDetergentsInsecticides (for home use)PoslishesPaintsOther....

28

280128022803

2804280528062807

2809

2901

2902

3001

2903

2909

3006

Housecoats/Komonas/Night dresses

Brassieres

Socks/Stockings

Ties

Handkerchiefs

Children's dresses

School uniforms

Towels

Bed sheets

Pillow cases

Mosquito nets

Other.....

Materials purchase in meters

For clothing

For school uniforms

For curtains/Furnishing materials

Other.....

Tailoring charges

For clothing

For schooling uniforms

Skirts/Blouses

Banians

Men's under wears

Women's under wears

3011

3017

3015

3014

3013

3012

3018

3019

3020

3021

3041

3010

3009

3008

30613062

10. Household services

(Last month)

Laundry charges

Grinding charges

Wages to servants and chauffers

Payments for other household services

11. Clothing and Textiles

(Last six months)

TrousersShirts

Sarees

T-shirts

Sarongs/VettiesFrock

29

∗Code

Main household

ItemCode UnitItem

Main household - include all members of the household exclude servants and boarders. ∗

number

number

number

number

numbernumber

number

number

number

number

number

number

number

number

number

number

number

number

number

number

number

Unit

number3007

12

Qty. Qty. Value

(Rs.)Value(Rs.)

Main household

Main household

Value(Rs.)

Item Code UnitQty.

Main household

Value(Rs.)

Item Code UnitQty.

∗ ∗

3101

3102

3103

3105

3210

3211

3212

32133214

3219

3302

3303

3301

3305

3106

3304

3306

3307

3308

3309

3310

3311

3313

3107

3104

3109

3202

3201

3204

3203

3205

3206

3207

3209

∗

3312

320831

32

number

number

number

number

number

number

number

number

numbernumber

number

numbernumber

number

number

number

number

numbernumber

number

numbernumber

number

Main household - include all members of the household exclude servants & boarders

number

number

number

number

number

number

number

33

13

Brooms/ Brushes/ Ekels

Mats/ Pillows

Rugs/ Carpets

Mettress

Torches

Thermos flasks

Twines/ Ropes

Other......

14. Durable household goods (Last 12 months)

Chairs (Plastic / Wood)

Tables

Settees

Almyrahs

Beds

Other furniture

Clocks/ Wrist watches

Cookers (Kerosene/ gas/ Eletric)

Mixing machines, Grinders, Beaters

Irons

Refrigerators

Fans

Sewing machines

number

number

number

number

number

12. Footwear & other personal effects

(Last 6 months)

Shoes

Sandals / Slippers

Umbrellas

Hand bags/ Travelling bags

Hats/ Helmets

Rain coats

Repair charges for shoes, bags, umbrellas

etc.

Other....

13. Durable household goods

(Last 6 months)

Glass ware

Plastic ware

Aluminium ware

Clary ware/ Pots

Cane ware

Cutlery

Lamp/ Lamp shades

3321

3320

3315

3316

3319

33223323

3324

3325

3314

3317

3318

3326

3329

3327

3339

Contribution to trade unions,

Thrift societies etc.

Insurance / Agrahara

Other savings (including seettu)

Payments of debits

Income tax

Other...

34

Main household∗

Qty.Code UnitItem

Value(Rs.)

Main household - include all members of the household exclude servants and boarders.∗

number

number

number

number

number

number

number

number

number

number

number

numbernumber

number

number

Item

14

15. Other expenses

(Last month)

Provident funds, W.& O.P.fund

Radio, Record players and Tape recorders

Television and Vedio decks

Washing machines

Musical instruments

Bicycles

Motor cycles/Scooters

Motor cars/Vans

Prams/Gocarts/Tricycles

Garderning tools and equipments

Cameras and Projectors

Computers

Jewelleries

Telephones / Cellular phones

Other kitchen appliances

(Heaters, Rice cookers etc.)

Other...

Durable goods purchased in instalments .

16. Other adhoe (rarely) expenses(Last 12 months)

3501

3502

3503

3504

3505

3506

3507

3509

Qty.

∗

UnitCode

3401

3402

3403

3404

3405

3406

3409

Expenditure on weddings/ Funerals for family

members

Social activities/ Ceremonies

Litigation

Gift, Donation, Similar tranfers

Maintance/ Repairing

Purchased properties, houses

Loans givien

Other...

Main household

Value(Rs).

15141312111098765432

1

If any boarder or domestic servant given in column 1 of section 1, not spent any of the above. Please note down here.

If any of the items in column 3-15, have been received free of charge, their estimated value should also be included as an expenditure.

1

1.

2.

3.

4.

5

6

7

2.3 Expenditure on Housing, Fuel and Light, Non durable goods, Services and Consumer durables for Boarders and Domestic Servants.

Name of boarders and DomesticServants who has spent moneyon any of the following column 3-15

2 Go to section 3

Ser

ial n

umbe

r as

giv

en in

col

umn

1 of

sec

tion

1

Foo

d pu

rcha

sed

outs

ide t

heho

useh

old

(Las

t wee

k)

Fue

l and

ligh

t(L

ast m

onth

)

Clo

thin

g an

d te

xtil

es(L

ast s

ix m

onth

s)

Non

dur

able

hou

seho

ldgo

ods

(Las

t mon

th)

Hou

seho

ld s

ervi

ces

(Las

t mon

th)

Per

sona

l car

e an

d H

ealt

hex

pens

es(L

ast m

onth

)

Tra

nspo

rt a

ndC

omm

unic

atio

ns(L

ast m

onth

)

Rec

reat

ion,

Ent

erta

inm

ents

Edu

cati

on, C

ultu

ral a

ctiv

i-ti

es e

tc. (

Las

t mon

th)

Mis

cell

aneo

us(L

ast m

onth

)

Boa

rdin

g, f

ee p

aid

(Las

t mon

th)

Am

ount

sen

t to

fam

ily/

pare

nts

(Las

t mon

th)

Am

ount

tra

nsfe

red

as s

avin

gs,

prov

iden

t fu

nds,

W

&O

P t

axes

,do

nati

ons

etc.

(L

ast m

onth

)

(Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.)

Are there Boarders and/or Domestic Servants in this household Yes No

15

Dur

able

hou

seho

ld g

oods

(Las

t 12

mon

ths)

Section 3 - Income

2

2

2

1

2

1

2

1

2

1

1

2

1

1

2

1

List all the household members (usually live inthis household) including boarders and domes-tic servants who were paid employees duringlast four weeks/ Last calendar month.

3.1 Income from paid employment/s during last four weeks/last calendar month

(Rs.)

During last calendar month

If any of the household members (usually live ) engage as an employee during last 4 weeks / Last calender month. Fill in the relevant columns.

Main - 1

Secondary - 2

(discribe the occupation)

Principal/Secondaryoccupation

Ser

ial n

umbe

r as

giv

en in

colu

mn

1 of

sec

tion

1

Tip

s, C

omm

issi

ons,

All

owan

ces,

Ove

r-ti

me

pay

etc.

Sal

arie

s/ W

ages

Bon

us, A

rrea

rspa

ymen

t

(Rs.) (Rs.)

16

Last 12 months

Serialnumberas given

incolumn

1 ofsection 1

Value of amountconsumed by this

householdValue ofout put

Codes for column 3

Paddy................................... 1Chillies................................ 2Onions................................. 3Vegetables ..........................4Cereal items........................ 5Yams...................................6Tobacco...............................7Other................................... 9

Last cultivation year

Last two cultivation season

(Yala/Maha or Maha/Yala)

**

Total

3.2 Income from Agricultural activities - Paddy, Other seasonal crops and Tobacco

** Last cultivation year

List all the household members (usually live)including boarders and domestic servants who haveany cultivated paddy and/ or other seasonal crops asemployers or own accounts workers.

*

**

Paddy Other seasonalcrops and Tobacco

R P

(Rs.) (Rs.) (Rs.)

Cultivatedland area

* CostCod

e(f

or o

ffic

e us

e on

ly

A

Hired Labour

Seeds

Fertilizer

Chemicals

Transpor charges

Other...

17

(If any of the household members cultivate paddy, other seasonal crops and tobacco as an employer or own account worker for sale and/or household consumptionduring last cultivation year. Fill in the relevant columns)

3.3 Income from other agricultural activities

Value of out put

(Rs.)

*Value of amountconsumed by this

household(Rs.)

Agricultural product(Describe)

*

List all household members (usually live)including boarders & domestic servants who haveengaged any other agricultural activities/Livestock as employers or own accountsworkers.

Last month / Average per month

+

Serialnumberas given

incolumn 1

ofsection 1 +

Cultivated areaCost(Rs.)

PRA

Fish ........................................06Eggs. ......................................07Milk........................................08Other food items.. ..................09Fire wood ...............................10Other.......................................19

Not necessary for cultivated area under the codes from 05-10 in column 4

18

Tea, Rubber..... .......................01Coconuts ................................02Coffe, Pepper, Betel etc..........03Banana/ Fruits.........................04Meat........................................05

Codes for column 3........ Hired Labour

Seeds

Fertilizer

Chemicals

Transports/ Tractor charges

Other

Total

If any of the household members engage in any other agricultural activities / Livestock as an employer or own account workers for sale during last 12 months. Fill in the relevent columns.

Cod

e

3.4 Income from Non-agricultural activities during last calendar month

1.

2.

3.

4

5

6

7

8

9

10

1 2 43 5 6

*

(If any of the household members engage in any non - agricultural activities as an employer or own account worker for sale during last cultivation year. Fill in therelevant columns)

List all the household members(usually live)including boarders domestic servants whohave engaged Non- agricultural activities asemployers or own account workers.

Serialnumberas given

in column1 of

section 1

Economic activity

Cod

e(f

or o

ffic

e us

e on

ly Last calendar month

Mining and Quarrying................................1Manufacturing............................................2Construction...............................................3Trade..........................................................4Transport....................................................5Guest house, restaurants, bars, hotels etc..6Other services............................................7

Code for column 3

(Rs.)(Rs.)

19

* CostValue ofout put

Hired Labour

Inputs

Transport

Other...

Total

(Describe)

3.5.1 Income from Other cash receipt during last calendar month/ Last 12 months

Income in last month

Pensionpayment

Current remittance andtransfers

During last 12 months

Sales of assests(Land , house,

jewellery)

3.5.2 Income by chance or adhoc gains during last 12 months

List all the household members (usually live) in-cluding boarders and servants who have receivedany other cash receipt.

Ser

ial n

umbe

r as

give

n co

lum

n 1

ofse

ctio

n 1

(Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.)

(Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.)

20

Samurdhi/Food

stamps

Rents fromproperties/

Boarding feesetc.

OtherIncome

Dividendsinterests etc.

Income fromabroad

Loans takenfrom banks/

Money lendersetc.

Withdrawal fromsavings & bank

deposits.

Lottery/ Anyadhoc gains

Seettu/Repayments

of loansgivien

List all the household members (usually live) ex-cluding boarders and servants who have receivedany income by chance or rarely.

Ser

ial n

umbe

r as

give

n co

lum

n 1

ofse

ctio

n 1

Compansation Other(Specify)

(Rs.)

Within thecountry

Disability andrelief payments

List all the household members in-cluding boarders domestic servants whohave received income in kind.

Other 2

Employer 1

Employer 1

3.7 Monthly rental value of owner occupied house

Q. Did the household occupy its own house last calendar month.

1Yes

2

→

Please Note:- If items like cloths, warrants etc. have been received relief payments, their estimated value should be filled under the head of the household.

(Last week) (Last month) (Last 6 months) (Last month)(Last month)

From employers/Others.

3.6 Income in kind during last calendar month(If any of the household members receive any of the following items as a payment or fringe benefit/donation/gift from the employer or other during relevant

period. Fill in the relevant columns)

Serialnumberas given

incolumn

1 ofsection 1

(Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.)

Other 2

Employer 1

Employer 1

Other 2

Employer 1

Employer 1

Other 2

Other 2

Other 2

Employer 1

Other 2

No

What is the estimated gross rental value per month Rs.

21

Meals, Fooditems etc.

Housing Clothing OtherMedicalfacilities

Warrants/Passes etc.

(last month)(Including free

transport)