D-21 Military Census Report

Draft 11 (10-14-2008)

OMB No. 0607-0919-C: Approval Expires 12/31/2011

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Military Census Report
Use a blue or black pen.

Start here
1. What is your name? Print name below.

6. What is the full name and address of the place
(barrack/dormitory, disciplinary barrack/jail, military
treatment facility) where you are assigned?

Last Name

Please complete all that apply.

MI

First Name

Military installation or Base name

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

Female

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, 2010
Month
Day
Year of birth

Barrack or dormitory name

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

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

Street number

Street name

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

Japanese
Asian Indian
Korean
Chinese
Vietnamese
Filipino
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

Some other race — Print race. C
Form D-21 (10-14-2008)

USCENSUSBUREAU

D-21 - Base Black ink

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777101

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DC

March 17, 2010

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

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

This is your official 2010 Census form. We need your help to count everyone in the United States.
It is important that everyone be counted, regardless of where they may be living at the time of the
census. This Military Census Report is to be used to count people who are assigned to military
group quarters, such as barracks, dormitories, disciplinary barracks or jails, or military treatment
facilities. Please follow the instructions you were given when you received this form for
returning it to the appropriate person.
Your answers are important. Census results are used to decide the number of representatives
each state has in the U.S. Congress. The amount of government money received also depends
on these answers. That money is used for services for children and the elderly, roads, and many
other local needs. As allowed by law, your census data becomes public after 72 years. This
information can be used for family history and other types of historical research.
Your answers are confidential. This means the Census Bureau cannot give out information that
identifies you. Your answers will only be used for statistical purposes, and no other purpose.
Please visit our Web site at and click on "Protecting Your
Answers" to learn more about our privacy policy and data protection.
Sincerely,

Steve H. Murdock
Director, U.S. Census Bureau

Thank you for completing your official 2010 Census 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-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.
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

B. JIC1

C. JIC2

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FORM D-21 (10-14-2008)

777102

D-21 - Base Black ink

D-21 - Tone Pantone Process Green # 368 - 10%, 40%, 50%, 65%, and 100%