Form D-1668 Registration Form (English)

OMB No. 0607-0795
FORM D-1668
(5-31-2007)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

ENTITY ID

U.S. CENSUS BUREAU

REGISTRATION FORM
LOCAL UPDATE OF CENSUS ADDRESSES (LUCA) PROGRAM
2010 Decennial Census
Please complete this form and return it to your U.S. Census Bureau Regional Office.
A. PARTICIPATION INFORMATION
1.
2.

YES! Our government would like to participate in the 2010 Decennial Census LUCA Program.
NO, we are not able to participate. Please mark (X) all that apply below.
a.
b.
c.
d.
e.

Insufficient staff
Lack of funds
No time/Too busy
No local address list available
Concerns about the security and
confidentiality of the Census Bureau’s list

f.
g.

Restrictions on the use of the Census Bureau’s
address list for other purposes
Other reason – Specify (Please print)

We rely on your comments to help us improve future LUCA programs.
B. HIGHEST ELECTED/APPOINTED OFFICIAL MAKING THIS COMMITMENT –
Please print
1. Name of participating government
2. Printed name of Highest Elected/Appointed Official – First, middle initial, last
3. Signature – First, middle initial, last
4. Position – Governor, Commissioner, Mayor, Supervisor, etc.
5. Telephone
Area code

6. E-mail address

7. Date

Number

–

Month Day

Year

–

C. LIAISON INFORMATION
Please designate your official 2010 Decennial Census LUCA Program liaison (work
contact) by providing the following information. Please print.
1. Name – First, middle initial, last
2. Position – Director, Assessor, Planner, etc.
3. Department, Organization, or Agency name
Number and street name
4. Mailing
address

City

State

ZIP Code

State

ZIP Code

Number and street name
5. Delivery
address

City

The Census Bureau will ship all materials via FedEx.
FedEx will not deliver to PO Box numbers or PO ZIP Codes.

USCENSUSBUREAU