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If you don’t have room to list everyone who lives with you and has not been counted, 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
Age on February 1, 2008
Sex
Male
Female
Person 8
Sex
Month
Last Name
Age on February 1, 2008
Male
Female
Person 9
Day
First Name
Day
Related to Person 1?
• 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 February 1, 2008.
• 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
Year
No
Last Name
Age on February 1, 2008
Male
First Name
MI
Date of Birth
Month
Day
Related to Person 1?
The Census must also include people without a permanent
place to stay, so:
Yes
Year
Female
• If someone who has no permanent place to stay
is staying here on February 1, 2008, count that person.
Otherwise, he or she may be missed in the census.
No
Last Name
First Name
MI
1. How many people were living or staying in this house,
Last Name
MI
First Name
6. What is Person 1’s sex? Mark I
J
K ONE box.
Male
Female
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.
Age on February 1, 2008
Month
Day
Year of birth
➜ 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
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
➞
➞
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 here on
February 1, 2008.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.
Yes
No
Year
apartment, or mobile home on February 1, 2008?
Age on February 1, 2008
Sex
Male
Month
Day
Yes
Year
Female
Person 11
No
Last Name
First Name
2. Were there any additional people staying here
February 1, 2008 that you did not include in Question 1?
Mark I
J
K all that apply.
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
MI
If you need help completing this form, call 1-866-872-6868 between 9:00 a.m. and 9:00 p.m.,
Monday through Saturday, and between 11:00 a.m. and 9:00 p.m., Sunday. The telephone call is free.
Sex
Age on February 1, 2008
Month
Male
Related to Person 1?
Date of Birth
Day
Year
No
Female
Person 12
Sex
Last Name
Age on February 1, 2008
Male
TDD — Telephone display device for the hearing impaired. Call 1-800-786-9448 between 9:00 a.m.
and 9:00 p.m., Monday through Saturday, and between 11:00 a.m. and 9:00 p.m., Sunday. The
telephone call is free.
Yes
3. Is this house, apartment, or mobile home —
Mark I
J
K ONE box.
If you need help completing this form, call 1-800-845-8243 between 9:00 a.m. and 9:00 p.m.,
Monday through Saturday, and between 11:00 a.m. and 9:00 p.m., Sunday. The telephone call is free.
First Name
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?
MI
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-DR, U.S. Census
Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments to
[email protected]; use "Paperwork Project 0607-0919-DR" as the subject.
Related to Person 1?
Date of Birth
Yes
Year
No
Female
Thank you for completing your official
2008 Census Test form.
JIC1
4. What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
FOR OFFICIAL USE ONLY
9. What is Person 1’s race? Mark I
J
K one or more boxes.
Number of people =
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
Related to Person 1?
Date of Birth
JIC2
–
OMB No. 0607-0919-DR: Approval Expires 8/30/2010.
Form
§q""¤
800101
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➞
D-1(TEST) (10-16-2007)
USCENSUSBUREAU
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➞
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 I
J
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.
D-1(TEST)- 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
2008 Census Test
D-1(TEST)- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
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Fold Line
Draft 2 10/16/07
Fold Line ➞
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First Name
First Name
MI
J
K ONE box.
2. How is this person related to Person 1? Mark I
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3. What is this person’s sex? Mark I
J
K ONE box.
Female
Male
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.
Age on February 1, 2008
Month
Day
Year of birth
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
Male
Female
Male
4. What is this person’s age and what is this person’s date of birth?
Fold Line ➞
2. How is this person related to Person 1? Mark I
J
K ONE box.
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 I
J
K ONE box.
Female
Male
4. What is this person’s age and what is this person’s date of birth?
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 February 1, 2008
Age on February 1, 2008
Age on February 1, 2008
Age on February 1, 2008
Month
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 I
J
K one or more boxes.
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?
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
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 I
J
K one or more boxes.
6. What is this person’s race? Mark I
J
K one or more boxes.
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
7. Does this person sometimes live or stay somewhere else?
No
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 3.
➜
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 4.
➜
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.
➜
7. Does this person sometimes live or stay somewhere else?
Yes — Mark I
J
K all that apply.
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
Some other race — Print race. C
7. Does this person sometimes live or stay somewhere else?
Yes — Mark I
J
K all that apply.
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
Some other race — Print race. C
7. Does this person sometimes live or stay somewhere else?
Yes — Mark I
J
K all that apply.
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
Some other race — Print race. C
7. Does this person sometimes live or stay somewhere else?
Yes — Mark I
J
K all that apply.
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
No
For child custody
In jail or prison
In a nursing home
For another reason
Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
If more people were counted in Question 1 on the
front page, continue with Person 6.
➜
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 D-1(TEST) (10-16-2007)
Fold Line ➞
§q"#¤
800102
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.
6. What is this person’s race? Mark I
J
K one or more boxes.
Some other race — Print race. C
➜
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 I
J
K one or more boxes.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3. What is this person’s sex? Mark I
J
K ONE box.
➜ 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
First Name
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
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 I
J
K ONE box.
4. What is this person’s age and what is this person’s date of birth?
First Name
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
Last Name
Last Name
First Name
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
J
K ONE box.
3. What is this person’s sex? Mark I
Male
Last Name
Last Name
1. Print name of Person 6
Fold Line ➞
➜ If more people
live here, turn
the page and
continue.
Fold Line ➞
Last Name
1. Print name of Person 5
1. Print name of Person 4
D-1(TEST) - Base prints BLACK
1. Print name of Person 3
D-1(TEST) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
1. Print name of Person 2
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2007-10-16 |
| File Created | 2007-10-16 |