D-1669 Confidentiality Agreement Form (English)

OMB No. 0607-0795
FORM D-1669
(5-31-2007)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

ENTITY ID

U.S. CENSUS BUREAU

CONFIDENTIALITY AGREEMENT
LOCAL UPDATE OF CENSUS ADDRESSES (LUCA) PROGRAM
2010 Decennial Census
PLEASE PRINT
1. Government name

2. Name of LUCA Liaison’s Office or Department (Assessor’s Office, Planning Department, etc.)

3. Address (House number and street name, RR, HC, or PO box number)

4. City, State, ZIP Code

Responsibilities for Participating in the 2010 Decennial Census LUCA Program
All 2010 Decennial Census LUCA Program liaisons, reviewers, and anyone with access to Title 13 materials must agree to
keep confidential the U.S. Census Bureau address information (including map structure points provided for feedback) they
review or to which they have access. They may use this information solely for suggesting improvements to the Census
Bureau’s address list and maps. All individuals who will be reviewing Census Bureau addresses or have access to Title 13
materials must sign below to indicate they have read and understand the Census Bureau’s results regarding restrictions
related to confidential information. By signing this agreement, your government agrees to return or destroy all Title 13,
Census Bureau confidential materials to the Census Bureau after the LUCA Program appeals process is complete. In
addition, those who sign the agreement indicate that they understand the penalty for disclosing information about
addresses or individuals obtained by the Census Bureau, including maps that contain structure points showing the location
of housing units or group quarters in a fine of not more than $250,000 or imprisonment for not more than 5 years, or both.
Although access to the data is temporary, this commitment is permanent.
Your address – Please print
(If different from above)

Liaison’s name and telephone number
Printed name

Telephone number

Area code

–
Signature

City

–

Date
Month

State
Day

Reviewer(s)/Person(s) with access to
Title 13 materials name(s) and telephone number(s)
Printed name

–
Signature

State
Day

–
Signature

State
Day

–
Signature

Date

–
Signature

Year

ZIP Code

City

–

Date
Month

USCENSUSBUREAU

City

State
Day

Telephone number

Area code

ZIP Code

–

Month

Printed name

Year

Telephone number

Area code

City

–

Date
Month

Printed name

ZIP Code

Year

Telephone number

Area code

City

–

Date
Month

Printed name

Your address – Please print
(If different from above)

Telephone number

Area code

ZIP Code

Year

State
Day

Year

ZIP Code

If you require more signature blocks, you may duplicate this form.