Various Pretesting Activities (see attached list)

Draft 1 (10-2-2008)

OMB No. 0607-0919-C: Approval Expires 12/31/2011
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

This is your official U.S. Census form. It is quick, easy, and your answers are protected by law. Please complete your form in the
language most comfortable for you and return it today.

Start here
Use a blue or black pen.

Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• Count all people, including babies, who live and sleep here most of the time.
The Census Bureau also conducts counts in institutions and other places, so:
Respondents are not required to respond to any information collection unless it displays a valid
approval number from the Office of Management and Budget.

The U.S. Census Bureau estimates that, for the average household, this form will take about 10 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-C, U.S.
Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments
to ; use "Paperwork Project 0607-0919-C" as the subject.

TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between 8:00 a.m. and 9:00
pm. 7 days a week. The telephone call is free.

If you need help completing this form, call 1-866-872-6868 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

If your enclosed postage-paid envelope is missing, please mail your completed form to:

The Census must count every person living in the United States on April 1, 2010.

• Do not count anyone living away either at college or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention facility, etc., on April 1, 2010.
• Leave these people off your form, even if they will return to live here after they leave college, the nursing home, the military, jail,
etc. Otherwise, they may be counted twice.
The Census must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on April 1, 2010, count that person. Otherwise, he or she may be
missed in the census.

1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2010?
Number of people =

2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1?
Mark I
J
Kall that apply.
Children, such as newborn babies or foster children
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in baby sitters
People staying here temporarily
No additional people
J
KONE box.
3. Is this house, apartment, or mobile home — Mark I
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.

Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

4. What is your telephone number? We may call if we don’t understand an answer.
Area Code + Number
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USCENSUSBUREAU

Form D-Y1(X13)

(10-2-2008)

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Fold line

Draft 1 (10-2-2008)

Person 1

10. Does Person 1 sometimes live or stay somewhere else?
No ➤ SKIP to Person 2
Yes — Mark I
J
K all that apply.

5. Please provide information for each person living here. Start with a
person living here who owns or rents this house, apartment, or
mobile home. If the owner or renter lives somewhere else, start with
any adult living here. This will be Person 1.
What is Person 1’s name? Print name below.
Last Name

Person 10

In college housing

At a seasonal or second residence

In the military
For a job or business

In jail or prison
In a nursing home
For another reason

For child custody

Use this section to complete information for the rest of the people you counted in Question 1 on the front page. We may call
for additional information about them.

Last Name

Male
Female

sometimes lives or stays:
MI

House Number

7. What is Person 1’s age and what is Person 1’s date of birth?

First Name

Age on April 1, 2010

Sex
Male
Female

Print numbers in boxes.
Day

No

MI

Street Name

Please report babies as age 0 when the child is less than 1 year old.
Month

Related to Person 1?
Year
Yes

Last Name

Female

Age on April 1, 2010

Date of Birth
Month
Day

MI

Person 11

6. What is Person 1’s sex? Mark I
J
K ONE box.
Male

Age on April 1, 2010

Sex

11. Please provide the full address of the place where Person 1

First Name

First Name

Year of birth

Date of Birth
Month
Day

Related to Person 1?
Year
Yes
No

Apartment number

Person 12

➜ NOTE: Please answer BOTH Question 8 about Hispanic origin and
Question 9 about race. For this census, Hispanic origins are not races.

Last Name

First Name

MI

Rural route address

8. Is Person 1 of Hispanic, Latino, or Spanish origin?
Age on April 1, 2010

Sex

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

Male
Female

Yes, Puerto Rican

Date of Birth
Month
Day

Yes
No

City

Yes, Cuban

Person 13

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
Zip Code

State

9. What is Person 1’s race? Mark I
J
K one or more boxes.

Last Name

Male
Female

Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

If there is no street address or if this is a facility, please provide further
description in the boxes below.

First Name

Age on April 1, 2010

Sex
County

White

Date of Birth
Month
Day

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Some other race — Print race. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C

➜

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First Name

Age on April 1, 2010
Male
Female

12. Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire

Date of Birth
Month
Day

MI

Related to Person 1?
Year
Yes
No

Both places equally

Person 15

Some other place

Last Name

First Name

MI

13. On April 1, where was Person 1 staying?
The address printed on the back of this questionnaire

Continue to question 10.

Related to Person 1?
Year

Person 14

Sex

The address or location you listed in Question 11

MI

Yes
No

Last Name

2

Related to Person 1?
Year

The address or location you listed in Question 11
Some other place

Age on April 1, 2010

Sex
Male
Female

Date of Birth
Month
Day

Related to Person 1?

FOR OFFICIAL USE ONLY

Year
Yes
No

JIC1

JIC2

➜ If more people live here, continue with Person 2.

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