DX-20 Individual Census Report - English

OMB No. 0607-0919-DR: Approval Expires 8/30/2010

2008 Census Dress Rehearsal
Individual Census Report

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Use a blue or black pen.

Start here
6. Do you live or stay in this facility MOST OF

1. What is your name? Print name below.

THE TIME?
Yes ➜ This completes the questionnaire.
No

Last Name

MI

➜

First Name

7. (If No) What is the full address of the place where
you live or stay MOST OF THE TIME?

2. What is your sex? Mark I
J
K ONE box.
Male

Please complete all that apply.

Female

Street address number

3. What is your age and what is your date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2008
Day
Year of birth
Month

Apartment number

Street name

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and
Question 5 about race. For this census, Hispanic origins are not races.

4. Are you 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

Rural route type and number

Rural route BOX number

PO box number

5. What is your 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

City

County
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

State or foreign country

ZIP Code

Some other race — Print race. C
Form DX-20 (9-21-2007)

USCENSUSBUREAU

DX-20 - Base Black ink

§q@"¤
803101
Draft 14 (9/21/2007)
DX-20 - Tone Pantone Process Cyan - 10%, 25%, 50% and 100%

DC

March 17, 2008

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

Dear Resident:
The U.S. Constitution requires that a census of the United States be conducted every 10 years.
To prepare for the 2010 Census, the U.S. Census Bureau is conducting the 2008 Census Dress
Rehearsal. The results will be used to develop better methods that will make the 2010 Census easier,
more convenient, and less costly for taxpayers.
It is important that everyone be counted, regardless of where they may be living at the time of the
census. This Individual Census Report is to be used to count people who are currently living or
staying in group quarters, such as college or university dormitories, nursing homes, group homes,
emergency and transitional shelters for people experiencing homelessness, and other such locations.
Your answers are confidential. That means the Census Bureau cannot give out information that
identifies you. Your survey answers will only be used for statistical purposes, and for no other
purpose. As allowed by law, census forms become public after 72 years (Title 44, United States
Code, Section 2108).
Please follow the instructions you were given when you received this form for returning it to the
appropriate person.
Sincerely,

Charles Louis Kincannon
Director, U.S. Census Bureau

www.census.gov/2010census

Thank you for completing your official
2008 Census Dress Rehearsal form.
FOR OFFICIAL USE ONLY
The U.S. Census Bureau estimates that, for the average respondent,
this form will take about 5 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.
Respondents are not required to respond to any information
collection unless it displays a valid approval number from the Office
of Management and Budget.

GQ Control Number

A. PN

C. JIC2

§q@#¤
803102

FORM DX-20 (9-21-2007)

DX-20 - Base Black ink

B. JIC1

DX-20 - Tone Pantone Process Cyan - 10%, 25%, 50%, and 100%