D-1691(LG) Address List Add Page - local government

PAGE _________ OF ___________ PAGES

2010 CENSUS

Name of Preparer: _______________________
(Print Name)

Date Completed: _________________________
(MM/DD/YYYY)

LOCAL UPDATE OF CENSUS ADDRESSES PROGRAM
ADDRESS LIST ADD PAGE
Add Page For: ________________________________________________

Entity ID Code: _________________________

(Entity Name)

(Copy from Address List Page)

Census Geographic Location of Address (2)
Line
#
(1)

State
Code
Number
(2a)

County
Code
Number
(2b)

Census
Tract
Number
(2c)

Census
Block
Number
(2d)

Residential Address (4)
Group
Quarters?
(3)

House
Number
(4a)

Street or Road Name
(4b)
GQ Name
(4c)

Apartment/
Unit
Number
(4d)

City Style
Mailing ZIP
Code
(4e)

1

2

3

4

5

6

7
Form # D-1691

DISCLOSURE PROHIBITED BY TITLE 13, U.S.C.

U.S.. Department Of Commerce
U.S. Census Bureau