1.

Age:
a) 31-40
b) 41-50
c) 51-60
2. Gender:
Male Female
3. City of Residence (in capital letters): ______________
4. Are you financially independent?
Yes, I am financially independent. In this case:
i. Are you supporting anyone beside yourself?
Yes, please indicate how many people________ (including you)
No, just myself
ii. What is your personal monthly income?
a) ≤ Rs. 10,000 d) Rs. 30,001- Rs. 50,000
b) Rs. 10,001- Rs. 20,000 e) Rs. 50,001- Rs. 1,00,000
c) Rs. 20,001- Rs. 30,000 f) > Rs. 1,00,000
No, I depend on someone. In this case:
i. How many dependents are in your family________ (including your parents)?
ii. What is your family monthly income?
a) ≤ Rs. 25,000 d) Rs. 1,00,001- Rs. 2,00,000
b) Rs. 25,001- Rs. 50,000 e) Rs. 2,00,001- Rs. 5,00,000
c) Rs. 50,001- Rs. 1,00,000 f) > Rs. 5,00,000

5. Occupation:
a) Employed d) Business
b) Professional e) Student
c) Micro entrepreneur
6. Educational Qualification:
a) Below high school d) High school
b) Graduation e) Diploma