D-1669 Confidentiality Agreement

Entity ID Code_______________

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
requirements 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 swear under penalty of perjury to maintain the confidentiality of 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, and that the penalty for wrongful
disclosure is 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. You must be at least 18 years of age to sign this agreement.

Your address – Please print
(If different from above)

Liaison’s name and telephone number

Printed Name

Telephone Number

Signature

Date

City

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

Printed Name

Telephone Number

Signature

Date

Printed Name

Telephone Number

Signature

Date

Printed Name

Telephone Number

Signature

Date

Printed Name

Telephone Number

Signature

Date

Printed Name

Telephone Number

Signature

Date

State

ZIP Code

Your address – Please print
(If different from above)

City

State

ZIP Code

City

State

ZIP Code

City

State

ZIP Code

City

State

ZIP Code

City

State

ZIP Code

If you require more signature blocks, you may duplicate this form.
D-1669
OMB No. 0607-0795