D-1 X4 2010 Experimental Questionnaire Version 4 (Combined Race

Draft 1 (2-25-2009)

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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.

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

First Name

Use a blue or black pen.

MI

5.

Start here
Sex

Age on April 1, 2010

Male
Female

Person 8

Last Name

Sex

Age on April 1, 2010

Person 9

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Sex

Day

Year

Related to Person 1?
Year

Yes
No

Last Name

Age on April 1, 2010

First Name

MI

Date of Birth
Month

Male

Day

Related to Person 1?
Year

Female

Yes

First Name

• 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.
MI

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

Sex

Age on April 1, 2010

Date of Birth
Month

Male

Day

Female

Person 11

Yes
No

Last Name

First Name

Age on April 1, 2010

Month

Male

Day

Related to Person 1?
Year

Female

Last Name

Sex

Age on April 1, 2010

First Name

Month

Day

Year

Female

Yes
No

Thank you for completing your official
2010 Census form.

JIC1

Day

Year of birth

Please answer BOTH Questions 8 and 9 about race and origin.
What is Person 1’s race or origin? Mark I
J
K one or more boxes.

Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

9.

Write in Person 1’s specific race, origin, or enrolled or
principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.
Write in the specific race(s), origin(s) or tribe(s). C

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

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

FOR OFFICIAL USE ONLY

Month

Black, African Am., or Negro

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?

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.

Related to Person 1?

➜
8.

Mark I
J
K ONE box.

¿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.

MI

Date of Birth

Print numbers in boxes.
Age on April 1, 2010

3. Is this house, apartment, or mobile home —

No

Person 12

Male

Yes

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

White

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

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.

Female

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

April 1, 2010 that you did not include in Question 1?
Mark I
J
K all that apply.

MI

Date of Birth

7.

MI

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

2. Were there any additional people staying here

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.
Sex

6.

Number of people =

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

Related to Person 1?
Year

First Name

The Census must also include people without a permanent
place to stay, so:

No

Last Name

Last Name

JIC2

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

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790601
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D-1(X4)

(2-25-2009)

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If more people were counted in Question 1, continue with Person 2.

USCENSUSBUREAU

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D-1(X4) Base prints in BLACK
D-1(X4) Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)

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Person 10

• 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.

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.

• 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:

MI

Date of Birth
Day

The Census must count every person living in the United
States on April 1, 2010.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.

Yes
No

First Name

Month

Male
Female

Related to Person 1?

Date of Birth
Month

U.S. CENSUS BUREAU

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Person 7

Economics and Statistics Administration

1. Print name of Person 5

1. Print name of Person 4

1. Print name of Person 6

Last Name

Last Name

Last Name

Last Name

Last Name

First Name

First Name

First Name

First Name

First Name

MI

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

MI

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

MI

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

MI

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

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790602
MI

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

Husband or wife

Parent-in-law

Husband or wife

Parent-in-law

Husband or wife

Parent-in-law

Husband or wife

Parent-in-law

Husband or wife

Parent-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Biological son or daughter

Son-in-law or daughter-in-law

Adopted son or daughter

Other relative

Adopted son or daughter

Other relative

Adopted son or daughter

Other relative

Adopted son or daughter

Other relative

Adopted son or daughter

Other relative

Stepson or stepdaughter

Roomer or boarder

Stepson or stepdaughter

Roomer or boarder

Stepson or stepdaughter

Roomer or boarder

Stepson or stepdaughter

Roomer or boarder

Stepson or stepdaughter

Roomer or boarder

Brother or sister

Housemate or roommate

Brother or sister

Housemate or roommate

Brother or sister

Housemate or roommate

Brother or sister

Housemate or roommate

Brother or sister

Housemate or roommate

Father or mother

Unmarried partner

Father or mother

Unmarried partner

Father or mother

Unmarried partner

Father or mother

Unmarried partner

Father or mother

Unmarried partner

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Grandchild

Other nonrelative

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

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

Female

Male

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

Month

Day

Year of birth

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

Female

Male

What is this person’s date of birth and what is this person’s age?

4.

Female

Month

Day

Male

4. What is this person’s date of birth and what is this person’s age?

Print numbers in boxes.
Age on April 1, 2010

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

Print numbers in boxes.

Year of birth

Age on April 1, 2010

Month

Day

Year of birth

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

Female

Male

4. What is this person’s date of birth and what is this person’s age?

Female

4. What is this person’s date of birth and what is this person’s age?

Print numbers in boxes.
Age on April 1, 2010 Month

Day

Print numbers in boxes.

Year of birth

Age on April 1, 2010

Month

Day

Year of birth

➜ Please answer BOTH Questions 5 and 6 about race and origin.

➜ Please answer BOTH Questions 5 and 6 about race and origin.

➜ Please answer BOTH Questions 5 and 6 about race and origin.

➜ Please answer BOTH Questions 5 and 6 about race and origin.

➜ Please answer BOTH Questions 5 and 6 about race and origin.

J
K one or more boxes.
5. What is this person’s race or origin? Mark I

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

White
Black, African Am., or Negro
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

6. Write in this person’s specific race, origin, or enrolled or

White
Black, African Am., or Negro
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

White
Black, African Am., or Negro
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

6. Write in this person’s specific race, origin, or enrolled or

principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.

principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.

Write in the specific race(s), origin(s) or tribe(s). C

➜ If more people were counted in Question 1 on the
front page, continue with Person 3.

6. Write in this person’s specific race, origin, or enrolled or

White
Black, African Am., or Negro
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

White
Black, African Am., or Negro
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some other race or origin

6. Write in this person’s specific race, origin, or enrolled or

6. Write in this person’s specific race, origin, or enrolled or

principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.

principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.

principal tribe – For example, African Am., Argentinean, Chinese,
Egyptian, German, Marshallese, Mexican, Mexican Am., Mongolian,
Native Hawaiian, Navajo, Nigerian, Tlingit, and so on.

Write in the specific race(s), origin(s) or tribe(s). C

Write in the specific race(s), origin(s) or tribe(s). C

Write in the specific race(s), origin(s) or tribe(s). C

Write in the specific race(s), origin(s) or tribe(s). C

➜ If more people were counted in Question 1 on the

➜ If more people were counted in Question 1 on the

front page, continue with Person 4.

front page, continue with Person 5.

➜ If more people were counted in Question 1 on the

➜ If more than six people were counted in Question 1

front page, continue with Person 6.

on the front page, turn the page and continue.
Form D-1(X4) (2-25-2009)

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➜ If more people
live here, turn
the page and
continue.

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1. Print name of Person 3

D-1(X4) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)

1. Print name of Person 2

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D-1(X4) - Base prints BLACK

Draft 1 (2-25-2009)