Census Forum Activity
1201 East 10th Street
First Name
First Name
Month
Month
First Name
YearDay
Last Name
Last Name
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Person 7
Person 8
Person 9
Person 10
Person 11
Person 12
Form D-61 (1-15-2009)
U S C E N S U S B U R E A U
D-61- Base prints in BLACK
D-61- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
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U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration
U.S. CENSUS BUREAUThis is the official form for all the people at this address. It is quick and easy, and your answers are protected by law.
Use a blue or black pen.
The Census must count every person living in the United States on April 1, 2010. Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• Count all people, including babies, who live and sleep here most of the time.
The Census Bureau also conducts counts in institutions and other places, so:
• Do not count anyone living away either at college or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention facility, etc., on April 1, 2010.
• Leave these people off your form, even if they will return to live here after they leave college, the nursing home, the military, jail, etc. Otherwise, they may be counted twice.
The Census must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on April 1, 2010, count that person. Otherwise, he or she may be missed in the census.
1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2010?
Number of people =
IJMark K all that apply.
No additional people
IJMark K ONE box.
Owned by you or someone in this household free and clear (without a mortgage or loan)? Rented? Occupied without payment of rent?
4. What is your telephone number? We may call if we don’t understand an answer. Area Code + Number
– –
5. Please provide information for each person living here. Start with a person living here who owns or rents this house, apartment, or mobile home. If the owner or renter lives somewhere else, start with any adult living here. This will be Person 1. What is Person 1’s name? Print name below.
Last Name
First Name MI
6. IJWhat is Person 1’s sex? Mark K ONE box. Male Female
➜
Day Year of birthAge on April 1, 2010
9. IJWhat is Person 1’s race? Mark K one or more boxes. White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian Chinese Filipino Other Asian — Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C
Japanese Korean Vietnamese
Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander — Print race, for example, Fijian, Tongan, and so on. C
Some other race — Print race. C
10. Does Person 1 sometimes live or stay somewhere else? No IJYes — Mark K all that apply.
In college housing In the military
At a seasonal or second residence
For child custody In jail or prison In a nursing home
For another reason ➜ If more people were counted in Question 1, continue with Person 2.
OMB No. 0607-0919-C: Approval Expires 12/31/2011.
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
Last Name First Name MI
Male Female
Day YearMonth Yes No
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
Last Name MI
Male
Female
Day YearMonth Yes
No
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
Last Name MI
Male
Female
Month Yes
No
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
MI
Male
Female
Day Year Yes
No
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
First Name MI
Male
Female
Day YearMonth Yes
No
Sex Age on April 1, 2010 Date of Birth Related to Person 1?
Last Name First Name MI
Male
Female
Day YearMonth Yes
No
Thank you for completing your official 2010 Census form.
FOR OFFICIAL USE ONLY
JIC1 JIC2
If your enclosed postage-paid envelope is missing, please mail your completed form to: U.S. Census Bureau National Processing Center
Jeffersonville, IN 47132
If you need help completing this form, call 1-866-872-6868 between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
Use this section to complete information for the rest of the people you counted in Question 1 on the front page. We may call for additional information about them.
Draft 6 (1-15-2009)
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TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-866-928-2010 entre las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La llamada telefónica es gratis.
The U.S. Census Bureau estimates that, for the average household, this form will take about 10 minutes to complete, including the time for reviewing the instructions and answers. Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project 0607-0919-C, U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to <Paperwork@census.gov>; use "Paperwork Project 0607-0919-C" as the subject.
Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget.
Start here
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2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1?
Children, such as newborn babies or foster children Relatives, such as adult children, cousins, or in-laws Nonrelatives, such as roommates or live-in baby sitters
3. Is this house, apartment, or mobile home —
People staying here temporarily
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
7. What is Person 1’s age and what is Person 1’s date of birth? Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
Yes, Puerto Rican Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
NOTE: Please answer BOTH Question 8 about Hispanic origin and Question 9 about race. For this census, Hispanic origins are not races.
8. Is Person 1 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin