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pdfOMB No. 0607-0795
U.S. DEPARTMENT OF COMMERCE
FORM D-1674
(5-31-2007)
Economics and Statistics Administration
U.S. CENSUS BUREAU
RETURN OR DESTRUCTION OF TITLE 13, U.S.C. MATERIALS
LOCAL UPDATE OF CENSUS ADDRESSES (LUCA) PROGRAM
2010 Decennial Census
1. Government name – Please Print
2. 2010 Decennial Census LUCA Program Liaison
Please print name
Signature
Date
Month Day
Year
has properly destroyed or returned to the U.S. Census Bureau, the original 2010 Decennial Census
Local Update of Census Addresses (LUCA) Program Title 13, U.S.C. materials and any copies using
the security requirements provided to us by the U.S. Census Bureau.
Mark (X) one.
Returned Title 13, U.S.C. materials
Destroyed Title 13, U.S.C. materials
2010 DECENNIAL CENSUS LUCA PROGRAM REVIEWERS
Program Reviewer
1. Please print name
Signature
Date
Month Day
Year
2. Please print name
Signature
Date
Month Day
Year
3. Please print name
Signature
Date
Month Day
Year
4. Please print name
Signature
Date
Month Day
If you require more signature blocks, you may duplicate this form.
All LUCA Program liaisons, reviewers, and anyone with access to Title 13 materials are required to sign
and date this form at the conclusion of the appeals process. Should any liaison, reviewer, or anyone
with access to Title 13 materials leave before the completion of the LUCA Program, they are required to
sign-out of the program by signing and dating this form. If any liaison, reviewer, or anyone with access
to Title 13 materials fails to sign and date this form, the current liaison can sign-out on their behalf.
USCENSUSBUREAU
Year
| File Type | application/pdf |
| File Title | d1674.g |
| File Modified | 2007-06-01 |
| File Created | 2007-06-01 |