Your Daily Expenses Your Daily Expenses

Help us learn about the buying habits of people in the United States

FORM CE-801 (7-1-2005)

When you write down how you spend your money in this diary, you will help us understand

more about the products and services that are bought by the people in the United States.

By law (title 13, U.S. Code), we must keep your information confidential; we use it for statistical purposes only.

Field representative’s name:

Acting as a collecting agent for

U.S. Department of Labor

Bureau of Labor Statistics

UREAU OF THE CENSU

OMB No. 1220-0050

I will return on: _______________________________________

Field representative supervisor’s name:

Telephone:

Telephone:

If you have any questions, please call:

Please record your expenses and purchases

for the following period

1

2

3

4

5

6

7

Day Date

USCENSUSBUREAU

Black Ink (40% and 100%)

If you have comments regarding this survey, please send them to the Division of Consumer Expenditure Surveys,

2 Massachusetts Avenue N.E., Room 3985, Washington, DC 20212.
(continued on other side)

If the items are identical, you can combine them

on the same line and enter the total cost of all

the items. See examples on pages 5 and 6.

3.

Record the expense when you pay for it, not

when you use it.

How should I record pre-payments such

as a subway fare card?

Record the individual expense on the day that

you use your credit card to pay for something,

not on the day you pay your entire credit card

bill.

4. How should I record credit card

purchases?

5.

Yes, record automatic deductions (such as

health insurance premiums taken out of your

account or paycheck) only if they are deducted

that week. Write them in the section called All

Other Products, Services, and Expenses (Part 4).

Should I record automatic deductions

taken from my paycheck or bank

account?

6. Should I record typical monthly bills?

Yes, record typical monthly bills only if you pay

them during the week that you have the diary.

Write them in the section called All Other

Products, Services, and Expenses (Part 4).

7.

Subtract the discount from the original price and

write the amount that you paid.

What should I do when I use coupons,

discount cards, or loyalty cards?

8.

No, we need you to actually write the

information in the diary. We encourage you to

save your receipts to review them with your

field representative at the end of the week. You

can use the pocket on the inside of the back

cover to store your receipts until you’re ready to

record your purchases.

Can I just give you receipts instead of

writing the information down?

9.

Write down the amount paid.

How should I record items if I don’t 

know whether it includes tax?

FORM CE-801 (7-1-2005)

CE-801, Panton Blue 313 (20% and 100%)Black Ink (40% and 100%)
(continued on other side)

What about gift certificates or gift

cards?

If you buy a gift certificate to give to someone,

write down the cost of it under the appropriate

section (e.g. a certificate to a clothing store

would go under Clothing, Shoes, Jewelry, and

Accessories (Part 3) and a certificate to a

department store would go under All Other

Products, Services, and Expenses (Part 4)). If

you buy something using a gift card, write

down the full amount for your purchase

ignoring the gift card.

If an item is bought and returned during the

diary week, it can be erased or crossed out. If it

was bought outside the week and returned

during the week, do not make an entry. If an

item is exchanged during the week, change the

entry. If the new cost is different, cross out the

old cost and write in the new cost (see

examples on page 7).

12. What do I do about returns & exchanges?

Yes, but if someone not on your list pays for or

helps pay for an expense or if you will be

reimbursed for an expense, only record any

extra amount that you or someone on your list

has to pay.

13. Should I record subsidized/reimbursed

expenses?

Record the items bought under the appropriate

section and then record the shipping and

handling cost separately under the section

called All Other Products, Services, and

Expenses (Part 4).

14. What should I do about shipping &

handling costs?

A concession stand has to stay in a permanent

location and a mobile vendor does not. Some

mobile vendors may seem permanent because

they are usually in the same location, but they

are still considered mobile vendors because

they have the option to change locations.

15. What’s the difference between a

concession stand and a mobile vendor?

FORM CE-801 (7-1-2005)

CE-801, Pantone Blue 313 (20% and 100%)

11.

Black Ink (40% and 100%)
(continued on other side)

2. Food and Drinks for Home Consumption

3. Clothing, Shoes, Jewelry, and Accessories

pp)

Employer and School Cafeterias 

Includes elementary school pre-payments

■

Grain Products (cake mixes, cereal, cornmeal, flour,

pasta, rice, spaghetti, etc.)

■

Bakery Products (cakes, cookies, frozen waffles, pies,

white bread, other bread, etc.)

■

Beef (briskets, ground beef, round & other roasts,

sirloin, etc.)

■

■ Pork (bacon, ham, pork chops, sausage, etc.)

■ Poultry (chicken parts, duck, whole turkey, etc.)

Other meats (bologna, frankfurters, lamb, liverwurst,

organ meats, salami, etc.)

■

■ Fish & Seafood (fish, shellfish, etc.)

Oils, Fats & Dressings (salad dressing, shortening,

vinegar, etc.)

■

Eggs & Dairy Products (butter, cream, cheese, ice

cream, skim milk, powdered milk, etc.)

■

Fruits & Fruit Juices (apples, bananas, cranberry

juice, oranges, orange juice, etc.)

■

Sugar, Sugar Substitutes & Sweets (artificial

sweeteners, candy, gum, jams, jellies, etc.)

■

Vegetables & Vegetable juices (beans, corn, lettuce,

potatoes, tomatoes, tomato juice, etc.)

■

Other Food Items (baby food, pet food, frozen foods,

gourmet/specialty items, sauces, seasonings, soups,

etc.)

■

Non-Alcoholic Beverages (carbonated &

non-carbonated waters, cola & other carbonated

beverages, fruit-flavored beverages, instant & ground

coffee, tea, etc.)

■

Alcoholic Beverages (beer, champagne, liqueurs,

whiskey, wine, etc.)

■

Food & Beverages Purchases as Gifts for someone 

not on your list (candy, cheese, fruit baskets, wine, etc.)

■

Casual, Sportswear, Formal (dress, pants, shirt, shorts, 

suit, sweater, etc.)

■

Undergarments & Sleep Clothes (hosiery, lingerie,

pajamas, socks, etc.)

■

Outdoor, Work, School, Costumes (coat, jacket, 

thermals, uniform, windbreaker, etc.)

■

■ Shoes (boots, dress, sandals, slippers, sneakers, etc.)

Sports-team Clothes & Sports Shoes (cleats, golf 

shoes, ski boots, team uniform, etc.)

■

Jewelry, Accessories, & Sewing Items (belt, buttons,

hairpiece, hat, ring, thread, umbrella, etc.)

■

FORM CE-801 (7-1-2005)

CE-801, Pantone Blue 313 (20% and 100%)Black Ink (40% and 100%)
(continued on other side)

FORM CE-801 (7-1-2005)

etc.)

Tobacco & Smoking Supplies (cigarettes, cigars, pipes,

smoking accessories, tobacco, etc.)

■

Gasoline, Oil, & Additives (brake fluid, coolants,

gasoline, motor oil, etc.)

■

■ Personal Care Products & Services (cosmetics, dental

products, deodorants, hair care products, hand soap,

men’s & women’s haircuts, perfume, shaving products,

skin care products, etc.)

Housekeeping Supplies & Services (bathroom tissue,

brooms, laundry & cleaning detergents, light bulbs,

maid service, mops, paper towels, sponges, etc.)

■

Housewares & Small Household Appliances

(blenders, coffee makers, cooking utensils,

dinnerware, glassware, irons, utensils, pots & pans,

telephones, & toasters, etc.)

■

Home Furnishings, Decorative Items, Linens, & Major

Appliances (art work, clocks, curtains, lamps, picture

frames, pillows, plants, refrigerators, rugs, sheets,

sofas, stoves, table cloths, tables, towels, vases, etc.)

■

Home Maintenance, Hardware, Lawn Supplies &

Services (hand tools, improvement & repair 

equipment, lawn/garden equipment, nails, power 

tools, screws, supplies, services, etc.)

■

Housing Expenses (cable service, electricity, garbage

removal, heating/cooling, insurance, maintenance

fees, mortgage payments, property taxes, rent,

telephone, etc.)

■

Entertainment/Amusements & Sports/Recreation

(admissions to movies, clubs, sporting & cultural

events, camping, CDs, concert tickets, hunting, sports

& exercise equipment, tapes, toys, TVs, video/stereo

equipment, video purchase/rental, etc.)

■

Transportation Expenses (airline fares, buses, car

rental, commuter fares, new & used cars,

maintenance and repair, parking fees, taxis, tolls, train

fares, etc.)

■

School Expenses (daycare, high school & college

tuition, room & board, school supplies, textbooks, etc.)

■

All Other Expenses (alteration & repair of household

furnishings, ATM service fees, babysitting, books,

club dues, diaper services, donations, legal &

accounting fees, magazines, newspapers, pet supplies

& veterinary services, photographic supplies, postage,

sewing goods, shipping & handling, stationery, etc.)

■

Black Ink (40% and 100%) CE-801, Pantone Blue 313 (20% and 100%)
FORM CE-801 (7-1-2005)

Notes Notes

Black Ink (40% and 100%)
Questions?

Here are some of the uses of the Consumer Price Index:

Americans. Among the most important, it is used to help calculate the

Consumer Price Index, or CPI, which is a basic measure of the rate of

inflation.

♦ Provide cost-of-living wage adjustments for millions of American workers

♦ Adjust Social Security payments

♦ Determine the cost of school lunches

♦ Adjust Federal income-tax brackets

Some Frequently Asked Questions are answered on the flap attached to the back cover.

If you still have questions after reviewing these, please call your field representative.

FORM CE-801 (7-1-2005)

Questions?

Office Use: Place the barcode label here

1

For more information about the survey, visit: http://www.bls.gov/cex and http://www.census.gov

§)""¤

080101

Black Ink (40% and 100%)
Refer to the flap

attached to the

front cover for

Examples of Expenses.

Do NOT record:

Refer to the flap

attached to the

back cover for answers to

Frequently Asked Questions.

♦ Expenses of people on your list while they were away from home overnight.

■ We recommend that you record your expenses each day.

Think about where you went and what you’ve done.

■ Talk to the people on your list every day to find out how they spent their money.

■ Include payments by:

Cash

Check

Food Stamps

Credit/Debit Card

Money Order

WIC Voucher

Automatic Withdrawal/Payroll Deduction

Store Charge Card

Grocery Certificate

■ Keep receipts and other records so that you will remember to record what you

bought or paid for. Use the pocket at the back of the diary to store them.

Receipts

Utility Bills

Pay Stubs

Some record types include:

Include items that you bought for people who are not on your list, such as gifts.

♦ Business or farm operating expenses

♦ Sales tax for:

Part 2. Food and Drinks for Home Consumption

Part 3. Clothing, Shoes, Jewelry, and Accessories

Part 4. All Other Products, Services, and Expenses

Bank Statements

Telephone Bills

Catalog/Internet Order Invoices

Credit Card Statements

2

FORM CE-801 (1-1-2005)

CE-801, Page 2, Pantone Blue 313 (20%, 40%, and 100%)

1 §)"#¤

080102

Black Ink

FORM CE-801 (7-1-2005)
Look on the next 4 pages for examples and tips

on how to record your purchases.

1. Food and Drinks Away from Home

■

■

■ Enter the total cost with tax and tip.

If alcohol was part of the purchase, check whether it was wine, beer, and/or other 

alcohol and enter the total cost of the alcohol.

■

Mark one of the four choices that best describes where you made the purchase.

2. Food and Drinks for Home Consumption

■

■ Mark whether the item was fresh, frozen, bottled/canned, or other.

■ Enter the cost without tax and deduct any discounts or coupons.

Describe the item.

■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

3. Clothing, Shoes, Jewelry, and Accessories

■

■ Mark the appropriate sex and age range of the person for whom the item was bought.

Describe the item and enter the cost without tax.

■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

4. All Other Products, Services, and Expenses

■

■ Mark the last column if the item was purchased for someone not on your list (e.g. gifts).

Describe the item and enter the total cost without tax.

There is an "Additional Pages" section on pages 36–44 in case you

run out of lines on any particular day.

*Please Note: If you are unsure about whether to include an item or

where to record an item, write it down wherever it seems best or 

make a note and ask your field representative.

Mark one of the four choices that best describes the type of meal and describe briefly.

FORM CE-801 (7-1-2005) 3

CE-801, Page 3, Pantone Blue 313 (20%, 40%, and 100%)

3

§)"$¤

080103

Black Ink
3

1 23

X X

Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

FR USE: None TR VC FORM CE-801 (7-1-2005)

§)"%¤

080104

wine

beer

other

4

Description

CE-801, Page 4, Pantone Blue 313 (20%, 40%, & 100%)

bagel, juice

Xpizza

coffee

sandwich, soda

chips

elem.school lunch - month

soda

buffet

drinks from cash bar

X

X

X

X

X

X

X

X

X

X

X

X

X

79

X X

X

45

62

15

57

35

15

70

00

65

23

00

2

5

1

5

12 00

15 00

☛ Level of detail needed: 

briefly describe the meal.

Include tax & tip

for part 1 only.

☛

X

X

X

X

CE-801, Page 4, Pantone Yellow 101 (70%)

117

118

119

120

121

122

X caterer - Family Reunion 350 00 X X 95 00

1234

1234

1 234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

1 23

☛ If alcohol was included

in the purchase, mark

whether it was wine, beer,

and/or other and enter the

total cost of the alcohol.

☛ Use the pocket on the inside of the back

cover to store your receipts until you’re ready 

to record your purchases.

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

2

1 234

4

4

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

1 234

(See examples above

and on the flap)

EXAMPLE

1 2

1234

Black Ink (10%, 50%, & 100%)
bottled/

canned

Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)"&¤

080105

5

What did you buy or pay for?

Is this item:

fresh frozen other

221

222

223

224

225

wheat bread

eggs 1 50

chicken wings

apples

beer

skim milk

orange juice

candy

vegetable oil

baby food (5 jars)

potato chips

1 49

6 78

2 80

4 29

2 99

3 99

2 50

2 99

4 95

2 79

X

X

X

X

X

X

X

X

X

X

frozen meals (3 boxes) 8 97 X

ketchup

soup (4 cans)

soda (2 bottles)

pork chops

shrimp

cookies

apple pie

carbonated water

ground beef

ground coffee

bagels

wine

dog food

X 1 59

X 42 00

X 5 85

X 1 98

X 4 96

X 89

X 6 36

X 11 20

X 3 50

X 4 99

5 25

2 79

5 87

X

X

X

X

X

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

1 2 3 4

1 2 3 2

1 2 3 4

1 2 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

EXAMPLE

☛ Level of detail needed:

BREAD – Specify if white, wheat, rye, etc.

BEEF – Specify the cut and describe, such as

round roast, ground beef, etc.

PORK – Specify the cut and describe, such as

whole ham, bacon, spareribs, etc.

CHICKEN – Specify if whole or parts, such as

chicken legs, chicken wings, etc.

SOFT DRINKS – Specify if soda or other

type: if not cola, specify if carbonated or non.

COFFEE – Specify if ground or instant.

OTHER FOOD – Give a complete description,

such as scalloped potatoes.

☛List food & drinks from 

specialty food stores in this part

(i.e. bakery, liquor store, farmers’

market, convenience store, etc.)

(see examples above and on the flap)

Mark (X) one

X

Black Ink (10%, 50%, & 100%) CE-801, Page 5, Pantone Blue 313 (20%, 40%, & 100%) CE-801, Page 5, Pantone Yellow 101 (70%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"’¤

080106

6

What did you buy or pay for? Age

Under

2 2–15 16 &

Over

321

322

323

324

325

Was the 

item for:

male female

3 dress-shirts ($25 each) X

1 dress-shirt

running shoes

non-prescription sunglasses

baseball cap

bib

child’s costume (returned for refund)

wallet

necklace

scarf

trouser socks

☛ Level of detail needed: 

CLOTHING – Specify type of clothing

and give a description of the item.

SHOES – If sports shoes, specify 

sport, such as football cleats, etc.

JEWELRY – Specify type of jewelry,

such as watches, etc.

ACCESSORIES – If eyewear, specify

prescription or non-prescription.

X

X X

X X

X X

X

X

X

X

X XX

X

X X

X X

X X

X

75 00

30 00

69 00

59 00

14 99

3 50

15 00

4 99

29 00

250 00

3 99 EXAMPLE

☛ If you run out of space in any

section, continue listing the items

under that section on the Additional

Pages in the back (p. 36–44)

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

X

Black Ink (10%, 50%, & 100%) CE-801, Page 6, Pantone Blue 313 (20%, 40%, & 100%) CE-801, Page 6, Pantone Yellow 101 (70%)
00

00

00

00

Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"(¤

080107

7

What did you buy or pay for?

421

422

423

424

425

cold medicine (non-prescription) X 6 95

EXAMPLE

gasoline

highway tolls

music CD

cigarettes

dry cleaning (clothing)

lottery tickets

bus fare

piano lessons

electric drill

postage stamps

video rental

car speakers

car oil change

board game

area rug (exchanged for a different area rug)

concert tickets

dog leash dog toy (exchange)

ATM service fee

Health insurance

Mortgage payment

Telephone bill

veterinarian fees

Shipping and Handling for internet purchase

Donation

X

X

X

6 99

39 99

2

250

875

120

☛ Level of detail needed:

DOCTOR BILLS – Specify type of doctor visited, such

as an internist, orthodontist, etc.

MEDICINE – Specify if prescription or non-prescription.

TOOLS – Specify if power or hand tool.

DRY-CLEANING – Specify whether household item

(such as drapes) or apparel.

☛Mark the

last column of

parts 2, 3, & 4

if a purchase

was made for

someone not

on your list.

00

95

00

50

85

6

100 00

12 86

2 00

10

8

99

99

15

1

1

00

50

50

150 00

65 00

6

4 00

80

140 00

48

8

50

97

3 99

20 99

(see examples above and on the flap)

Black Ink (10%, 50%, & 100%) CE-801, Page 7, Pantone Blue 313 (20%, 40%, & 100%) CE-801, Page 7, Pantone Yellow 101 (70%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)")¤

080108

wine

beerother

8

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

1 2

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50% & 100%) CE-801, Page 8, Pantone Blue 313 (20%, 40%, & 100%)

3
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)"*¤

080109

9

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 9, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"+¤

080110

10

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 10, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)",¤

080111

11

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 11, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"-¤

080112

wine

beerother

12

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50%, & 100%) CE-801, Page 12, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)".¤

080113

13

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 13, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"/¤

080114

14

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 14, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"0¤

080115

15

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 15, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"1¤

080116

wine

beerother

16

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

1

Description

(see examples above

and on the flap)

4

234

Black Ink (50%, & 100%) CE-801, Page 16, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)"2¤

080117

17

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 17, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"3¤

080118

18

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50%, & 100%) CE-801, Page 18, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"4¤

080119

19

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 19, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"5¤

080120

wine

beerother

20

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50% & 100%) CE-801, Page 20, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)"6¤

080121

21

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 21, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"7¤

080122

22

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 22, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"8¤

080123

23

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 23, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"9¤

080124

wine

beerother

24

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50% & 100%) CE-801, Page 24, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)":¤

080125

25

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 25, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)";¤

080126

26

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 26, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"<¤

080127

27

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 27, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"=¤

080128

wine

beerother

28

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50% & 100%) CE-801, Page 28, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)">¤

080129

29

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 29, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"?¤

080130

30

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 30, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"@¤

080131

31

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 31, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

122

FR USE: None TR VC

FORM CE-801 (7-1-2005)

§)"A¤

080132

wine

beerother

32

117

118

119

120

121

If there are not enough lines in this part, please continue recording your expenses on pages 36–37.

1 2 34

1234

1 2 3

1 234

1234

1

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1234

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

1 2 34

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

123

1234

Description

(see examples above

and on the flap)

4

234

Black Ink (50% & 100%) CE-801, Page 32, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

Mark (X) If 

purchased for

someone not

on your list

219

220

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 38–41.

§)"B¤

080133

33

What did you buy or pay for?

221

222

223

224

225

bottled/

canned

Is this item:

fresh frozen other

12 4 3

Mark (X) one

12 4 3

2 4 3

12 4 3

1

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 33, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

Mark (X) If 

purchased for

someone not

on your list

319

320

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 41–42.

§)"C¤

080134

34

What did you buy or pay for? Age

Under

2 2–15

16 & 

Over

321

322

323

324

325

Was the 

item for:

male female

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 34, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

Mark (X) If 

purchased for

someone not

on your list

419

420

FORM CE-801 (7-1-2005)

If there are not enough lines in this part, please continue recording your expenses on pages 43–44.

§)"D¤

080135

35

What did you buy or pay for?

421

422

423

424

425

(see examples above and on the flap)

Black Ink (50% & 100%) CE-801, Page 35, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfastlunchdinnersnack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Description

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply

Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

FORM CE-801 (7-1-2005)

§)"E¤

080136

wine

beer

other

36

117

118

119

120

121

122

123

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

1 2 3 4 1 2 3 4 12 3

(see examples on the flap)

Total Cost

Black Ink (100%) CE-801, Page 36, Pantone Blue 313 (20%, 40%, & 100%)
Mark (X) one that

best describes 

the type of meal

breakfast lunch dinner snack/other

Fast-Food

Take-out

Delivery

Concession

Full 

Service

Places

Total Cost

with tax & tip

If alcoholic

beverages

included,

mark (X) all 

that apply Enter the

total cost of

the alcohol

Vending

Machines

or Mobile

Vendors

Employer 

or School

Cafeteria

Mark (X) one that best describes

where you made this purchase

124

125

126

127

128

129

130

131

132

133

134

135

FORM CE-801 (7-1-2005)

§)"F¤

080137

wine

beerother

37

142

143

144

145

146

136

137

138

139

140

141

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

1 2 3 4 1 2 3 4 123

Description

(see examples on the flap)

Black Ink (100%) CE-801, Page 37, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

Mark (X) if

purchased for

someone not 

on your list

FORM CE-801 (7-1-2005)

§)"G¤

080138

38

What did you buy or pay for?

227

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

220

221

222

223

224

225

226

bottled/

canned

Is this item:

fresh frozen other

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

1 34 2

1 34 2

(see examples on the flap)

Mark (X) one

Black Ink (100%) CE-801, Page 38, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

Mark (X) if

purchased for

someone not 

on your list

FORM CE-801 (7-1-2005)

§)"H¤

080139

39

What did you buy or pay for?

254

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

bottled/

canned

Is this item:

fresh frozen other

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

1 34 2

1 34 2

Mark (X) one

(see examples on the flap)

Black Ink (100%) CE-801, Page 39, Pantone Blue 313 (20%, 40%, & 100%)
Total Cost

without tax

Mark (X) if

purchased for

someone not 

on your list

FORM CE-801 (7-1-2005)

§)"I¤

080140

40

281

256

257

258

259

260

261

262

263

264

265

266

267

268

269

270

271

272

273

274

275

276

277

278

279

280

What did you buy or pay for?

bottled/

canned

Is this item:

fresh frozen other

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

1 34 2

1 34 2

Mark (X) one

(see examples on the flap)

255

Black Ink (100%) CE-801, Page 40, Pantone Blue 313 (20%, 40%, & 100%)
3. Clothing, Shoes, Jewelry, and Accessories

Total Cost

without tax

Mark (X) if

purchased for

someone not 

on your list

FORM CE-801 (7-1-2005)

§)"J¤

080141

41

What did you buy or pay for?

309

282

283

284

285

286

287

288

289

290

291

292

293

294

295

301

302

303

304

305

306

307

308

Mark (X) if

purchased for

someone not 

on your list

Total Cost

without tax

Was the

item for: Under

2

16 & 

Over male female 2–15

What did you buy or pay for? Age:

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

bottled/

canned

Is this item:

fresh frozen other

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

12 4 3

Mark (X) one

(see examples on the flap)

(see examples on the flap)

Black Ink (100%) CE-801, Page 41, Pantone Blue 313 (20%, 40%, & 100%)
FORM CE-801 (7-1-2005)

§)"K¤

080142

42

336

310

311

312

313

314

315

316

317

Mark (X) if

purchased for

someone not 

on your list

Total Cost

without tax

Was the

item for: Under

2

16 & 

Over

2–15 male female

What did you buy or pay for?

318

319

320

321

322

323

324

325

326

327

328

329

330

331

332

333

334

335

Age:

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

1 2 123

(see examples on the flap)

Black Ink (100%) CE-801, Page 42, Pantone Blue 313 (20%, 40%, & 100%)
FORM CE-801 (7-1-2005)

§)"L¤

080143

43

427

401

402

403

404

405

406

407

408

Mark (X) if

purchased for

someone not 

on your list

Total Cost

without tax

409

410

411

412

413

414

415

416

417

418

419

420

421

422

423

424

425

426

What did you buy or pay for?

(see examples on the flap)

Black Ink (100%) CE-801, Page 43, Pantone Blue 313 (20%, 40%, & 100%)
FORM CE-801 (7-1-2005)

§)"M¤

080144

44

454

428

429

430

431

432

433

434

435

Mark (X) if

purchased for

someone not 

on your list

Total Cost

without tax

436

437

438

439

440

441

442

443

444

445

446

447

448

449

450

451

452

453

What did you buy or pay for?

(see examples on the flap)

Black Ink (100%) CE-801, Page 44, Pantone Blue 313 (20%, 40%, & 100%)
Keep your records in this pocket.

(These records are only for your reference; we will not keep them.)

FORM CE-801 (7-1-2005)

Receipts

Bank Statements

Credit Card Statements

Pay Stubs

Catalog/Internet Order Invoices

Utility Bills

Telephone bills

■

■

■

■

■

■

■

Black Ink (100%)
Daily Reminder List

Did you or anyone on your list pay for . . .

Please review the list of expenses below with the people on your list at the end of each day.

If you have forgotten to record any expense, please do so on the appropriate page.

■

catered events or meal plans?

food & drinks from a grocery store or other speciality food store

FORM CE-801 (7-1-2005)

clothing, shoes, jewelry, accessories or clothing services such as dry cleaning?

personal care items or services such as cosmetics, soaps, haircuts, etc.?

housekeeping supplies or services for home decoration/maintenance?

toys, books, electronics, hobby supplies, etc.?

cigarettes, tobacco, or other smoking supplies?

commuting costs such as public transportation, parking fees, gasoline, or tolls?

medicine or medical/dental services?

entertainment or recreational activities?

typical bills such as utility bills, cable bills, telephone bills, etc.?

automatic deductions from a paycheck such as insurance premiums?

bank/ATM service fees?

credit card interest or finance charges?

internet or catalog orders?

fees for lessons or instructions?

gifts, contributions, donations?

For more specific examples of expenses, please refer to the flap attached to the front cover.

vending machines, concession stands, etc.?

such as a bakery, candy shop, or liquor store?

meals, drinks, or snacks from restaurants, fast food, cafeterias,

■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

RO 

code

Spinoff 

Indicator

Control Number Week

PSU code Segment No. Segment No.

Suffix

Sample

Designation

Serial No. Serial No.

Suffix

HH No. CU No.

1 2

Black Ink (100%)