D-1 X1 2010 Experimental Questionnaire Version 1 (Census 2000 f

Draft 2 (4-8-2009)

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U.S. DEPARTMENT OF COMMERCE

This is the official form for all the people at this address. It is quick and
easy, and your answers are protected by law. Complete the Census and
help your community get what it needs - today and in the future.

Persons 7 – 12
If you didn’t have room to list everyone who lives
in this house or apartment, please list the others
below. You may be contacted by the Census Bureau
for the same information about these people.

Person 7 — Last Name

First Name

MI

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.

Start Here

U.S. CENSUS BUREAU

4. What is Person 1’s telephone number? We may call
this person if we don’t understand an answer.
Area Code + Number

1. How many people were living or staying in this

–

–

house, apartment, or mobile home on April 1, 2010?

5. What is Person 1’s sex? Mark I
J
K ONE box.
Number of people

Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management and
Budget.

Person 8 — Last Name

Please use a
black or blue pen.

Economics and Statistics Administration

Male

INCLUDE in this number:

Female

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

• foster children, roomers, or housemates

Age on April 1, 2010

• people staying here on April 1, 2010 who have
no other permanent place to stay.
First Name

Thank you for
completing your official
U.S. Census 2010 form.

Person 9 — Last Name

First Name

• people living here on most of the time while working,
even if they have another place to live

MI

DO NOT INCLUDE in this number:
• college students living away while attending college
• people in a correctional facility, nursing home, or
mental hospital on April 1, 2010
• Armed Forces personnel living somewhere else

MI

➜ NOTE: Please answer BOTH Questions 7 and 8.
J
K the "No"
7. Is Person 1 Spanish/Hispanic/Latino? Mark I
box if not Spanish/Hispanic/Latino.
Yes, Puerto Rican
No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, other Spanish/Hispanic/Latino — Print group. C
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• people who live or stay at another place most
of the time
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Print numbers in boxes.
Month
Day
Year of birth

2. Is this house, apartment, or mobile home —
Mark I
J
K ONE box.

Person 10 — Last Name

Owned by you or someone in this household with a
mortgage or loan?
First Name

MI

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

Person 11 — Last Name

First Name

person living in this house, apartment, or mobile
home. Start with the name of one of the people
living here who owns, is buying, or rents this
house, apartment, or mobile home. If there is no
such person, start with any adult living or staying
here. We will refer to this person as Person 1.

TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al
1-866-943-2010 entre las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La llamada telefónica
es gratis.

Last Name

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

JIC1

First Name

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

FOR OFFICE USE ONLY
JIC2

OMB No. XXXX-XXXX-X: Approval Expires XX/XX/XXXX

§p$"¤
790301
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Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

What is this person’s name? Print name below.

Person 12 — Last Name

First Name

indicate what this person considers himself/herself to be.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

3. Please answer the following questions for each

If you need help completing this form, call 1-866-948-2010 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.
MI

8. What is Person 1’s race? Mark I
J
K one or more races to

Form

Some other race — Print race. C
MI

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

D-1(X1) (4-8-2009)

USCENSUSBUREAU

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D-1(X1) – Prints Pantone PROCESS CYAN (10%, 25%,50% and 100%)
D-1(X1) – Base prints in BLACK

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Your answers are important!
Every person in the Census counts.

Person 2

1. What is Person 2’s name? Print name below.

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.
If NOT RELATED to Person 1:
Husband/wife
Natural-born son/daughter
Roomer, boarder
Adopted son/daughter
Housemate, roommate
Stepson/stepdaughter
Unmarried partner
Brother/sister
Foster child
Father/mother
Other nonrelative
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative — Print
exact relationship.
➤
3. What is this person’s sex? Mark I
J
K ONE box.
Male
Female

4. What is this person’s age and what is this person’s date of birth?
Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark I
J
K the "No"
box if not Spanish/Hispanic/Latino.
Yes, Puerto Rican
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino — Print group. C

6. What is this person’s race? Mark I
J
K one or more races to indicate
what this person considers himself/herself to be.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

Some other race — Print race. C

➜ If more people live here, continue with Person 3.

Person 4

MI

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister
Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative — Print
exact relationship.
➤

If NOT RELATED to Person 1:
Roomer, boarder
Housemate, roommate
Unmarried partner
Foster child
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

2. How is this person related to Person 1? Mark I
J
K ONE box.
Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister
Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative — Print
exact relationship.
➤
Male

4. What is this person’s age and what is this person’s date of birth?
Age on April 1, 2010

MI

If NOT RELATED to Person 1:
Roomer, boarder
Housemate, roommate
Unmarried partner
Foster child
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

Female
Print numbers in boxes.
Month
Day
Year of birth

4. What is this person’s age and what is this person’s date of birth?
Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark I
J
K the "No"

box if not Spanish/Hispanic/Latino.

box if not Spanish/Hispanic/Latino.

No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, other Spanish/Hispanic/Latino — Print group. C

6. What is this person’s race? Mark I
J
K one or more races to indicate
what this person considers himself/herself to be.

6. What is this person’s race? Mark I
J
K one or more races to indicate
what this person considers himself/herself to be.

Person 6
1. What is Person 6’s name? Print name below.

MI

First Name

2. How is this person related to Person 1? Mark I
J
K ONE box.
Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister
Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative — Print
exact relationship.
➤

If NOT RELATED to Person 1:
Roomer, boarder
Housemate, roommate
Unmarried partner
Foster child
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

MI

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister
Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative — Print
exact relationship.
➤

If NOT RELATED to Person 1:
Roomer, boarder
Housemate, roommate
Unmarried partner
Foster child
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.
Male

Female

4. What is this person’s age and what is this person’s date of birth?
Age on April 1, 2010

§p$#¤
790302

2. How is this person related to Person 1? Mark I
J
K ONE box.

Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark I
J
K the "No"

Please turn
to go to
last page.

Female

4. What is this person’s age and what is this person’s date of birth?
Age on April 1, 2010

Print numbers in boxes.
Month
Year of birth
Day

➜ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark I
J
K the "No"

box if not Spanish/Hispanic/Latino.

No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, other Spanish/Hispanic/Latino — Print group. C

Your answers help
your community plan
for the future.

Last Name

First Name

Male

Female

Age on April 1, 2010

➜ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark I
J
K the "No"

Person 5
Last Name

First Name

2. How is this person related to Person 1? Mark I
J
K ONE box.

Knowing about age, race, and sex
helps your community better meet the
needs of everyone.

1. What is Person 5’s name? Print name below.

Last Name

First Name

Male

Information about children helps your
community plan for child care,
education, and recreation.

1. What is Person 4’s name? Print name below.

Last Name

First Name

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Person 3

1. What is Person 3’s name? Print name below.

Last Name

Age on April 1, 2010

Census information helps your
community get financial assistance for
roads, hospitals, schools, and more.

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Draft 2 (4-8-2009)

box if not Spanish/Hispanic/Latino.

No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, other Spanish/Hispanic/Latino — Print group. C

6. What is this person’s race? Mark I
J
K one or more races to indicate
what this person considers himself/herself to be.

No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, other Spanish/Hispanic/Latino — Print group. C

6. What is this person’s race? Mark I
J
K one or more races to indicate
what this person considers himself/herself to be.

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

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

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

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

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

Some other race — Print race. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

Some other race — Print race. C

➜ If more people live here, continue with Person 4.

➜ If more people live here, continue with Person 5.

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

Some other race — Print race. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print race. C

Some other race — Print race. C

➜ If more people live here, list their names on the back of this

➜ If more people live here, continue with Person 6.

page in the spaces provided.
Form D-1(X1) 4-8-2009

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D-1(X1) - Base prints BLACK
D-1(X1) - Prints Cyan (10%, 25%, 50% and 100%)