DE-1 Initial and replacement questionnaire

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2007 Census Bilingual Form Study

If you didn’t have room to list everyone who lives in this house or apartment, please list the others
below. You may be contacted by the Census Bureau for the same information about these people.

Person 7

Last Name

First Name

This is the official form for all the people at this address.
It is quick and easy, and your answers are protected by law.

5. Please provide information for each person living here. Start with a

Use a blue or black pen.

MI

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.

Start here
Sex

Age on July 1, 2007

Male
Female

Person 8

Sex

Month

Last Name

Age on July 1, 2007

Male
Female

Person 9

Day

Year

First Name

Day

Related to Person 1?
Year

• 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 July 1, 2007.
• 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.

Yes
No

Last Name

Age on July 1, 2007

Male

First Name

MI

Date of Birth
Month

Day

Related to Person 1?
Year

Female

➞

Person 10

• 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:

MI

Date of Birth
Month

The Census must count every person living in the
United States on July 1, 2007.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.

Yes
No

The Census must also include people without a permanent
place to stay, so:

Yes

• If someone who has no permanent place to stay is staying
here on July 1, 2007, count that person. Otherwise, he or
she may be missed in the census.

No

Last Name

First Name

MI

Last Name
MI

First Name

6. What is Person 1’s sex? Mark G
F ONE box.
E
Male

Female

7. What is this person’s age and what is this person’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on July 1, 2007

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 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
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

1. How many people were living or staying in this house,
apartment, or mobile home on July 1, 2007?

Sex

Age on July 1, 2007

Male

Month

Day

Year

Female

Person 11

Sex

Age on July 1, 2007

First Name

Day

Male

that you did not include in Question 1?
Mark G
F all that apply.
E

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

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
People staying here temporarily
No additional people

Related to Person 1?
Year

If you need help completing this form, call 1-877-XXX-XXXX between 8:00 a.m. and 9:00 p.m.
Central Time, 7 days a week (except federal holidays). The telephone call is free.

Yes
No

Female

Sex

2. Were there any additional people staying here July 1, 2007

MI

Date of Birth
Month

Male

Person 12

Yes
No

Last Name

3. Is this house, apartment, or mobile home —
Mark G
F ONE box.
E

TDD—Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX between 8:00 a.m.
and 9:00 p.m. Central Time, 7 days a week (except federal holidays). The telephone call is free.
Last Name

Age on July 1, 2007

First Name

MI

Month

Day

Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, IIame al
1-800-XXX-XXXX entre las 8:00 a.m. y 9:00 p.m., Hora Central, 7 días a la semana (excepto los
días feriados). La IIamada telefónica es gratis.

Related to Person 1?

Date of Birth
Year

Female

Yes
No

FOR OFFICIAL USE ONLY

Thank you for completing your official
2007 Census Bilingual Form Study
questionnaire.

JIC1

9. What is Person 1’s race? Mark G
F one or more boxes.
E

Number of people =

Related to Person 1?

Date of Birth

JIC2

The 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-XXXX, U.S. Census Bureau, 4600 Silver
Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments to [email protected]; use
"Paperwork Project 0607-XXXX" 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.

4. What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–

–

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Japanese
Asian Indian
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

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

Yes — Mark G
F all that apply.
E
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

OMB No. 0607-XXX: Approval Expires XX/31/20XX

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Form

DE-1 (12-18-2006)

200101

USCENSUSBUREAU

➜ If more people were counted in Question 1, continue with Person 2.

DE-1- Base prints in BLACK

Fold Line

Sex

Related to Person 1?

Date of Birth

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

DX-1- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)

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Last Name
MI

F ONE box.
E
2. How is this person related to Person 1? Mark G
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

F ONE box.
E
3. What is this person’s sex? Mark G
Female

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on July 1, 2007

First Name

Month

Day

Year of birth

MI

2. How is this person related to Person 1? Mark G
F ONE box.
E
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark G
F ONE box.
E
Male

4. What is this person’s age and what is this person’s date of birth?

1. Print name of Person 5

Last Name

Last Name

First Name

Male

1. Print name of Person 4

Female

MI

2. How is this person related to Person 1? Mark G
F ONE box.
E
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark G
F ONE box.
E

MI

2. How is this person related to Person 1? Mark G
F ONE box.
E
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark G
F ONE box.
E
Female

First Name

2. How is this person related to Person 1? Mark G
F ONE box.
E
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Female

4. What is this person’s age and what is this person’s date of birth?

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Age on July 1, 2007

Age on July 1, 2007

Age on July 1, 2007

Age on July 1, 2007

Day

Year of birth

Month

Day

Year of birth

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s race? Mark G
F one or more boxes.
E

6. What is this person’s race? Mark G
F one or more boxes.
E

Month

Day

Year of birth

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin?

5. Is this person of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s race? Mark G
F one or more boxes.
E

Question 6 about race. For this census, Hispanic origins are not races.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s race? Mark G
F one or more boxes.
E

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

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

Yes — Mark G
F all that apply.
E
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 on
the front page, continue with Person 3.

7. Does this person sometimes live or stay somewhere else?
No

Yes — Mark G
F all that apply.
E
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

Yes — Mark G
F all that apply.
E
In college housing
In the military
At a seasonal
or second residence

Yes — Mark G
F all that apply.
E
In college housing
In the military
At a seasonal
or second residence

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

7. Does this person sometimes live or stay somewhere else?
No

For child custody
In jail or prison
In a nursing home
For another reason

➜ If more people were counted in Question 1 on
the front page, continue with Person 6.

➜ If more people
live here, turn
the page and
continue.

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
No

For child custody
In jail or prison
In a nursing home
For another reason

➜ If more people were counted in Question 1 on
the front page, continue with Person 5.

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

7. Does this person sometimes live or stay somewhere else?
No

➜ If more people were counted in Question 1 on
the front page, continue with Person 4.

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

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
No

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

200102

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Month

§5"#¤

3. What is this person’s sex? Mark G
F ONE box.
E
Male

4. What is this person’s age and what is this person’s date of birth?

MI

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
Question 6 about race. For this census, Hispanic origins are not races.
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin?
5. Is this person of Hispanic, Latino, or Spanish origin?
5. Is this person of Hispanic, Latino, or Spanish origin?

6. What is this person’s race? Mark G
F one or more boxes.
E

First Name

Male

Female

4. What is this person’s age and what is this person’s date of birth?

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Last Name

Last Name

First Name

Male

4. What is this person’s age and what is this person’s date of birth?

1. Print name of Person 6

DE-1 - Base prints BLACK

1. Print name of Person 3

DE-1 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)

1. Print name of Person 2

Yes — Mark G
F all that apply.
E
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 than six people were counted in Question 1 on
the front page, turn the page and continue.

Form DE-1 (12-18-2006)