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pdfDraft 5 (6-25-2009)
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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. Please provide information for each person living here. Start with a
Start here
Sex
Age on April 1, 2010
Male
Female
Month
Person 8
Last Name
Sex
Age on April 1, 2010
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Sex
Day
Related to Person 1?
Year
Related to Person 1?
Year
• 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.
Yes
No
Last Name
Age on April 1, 2010
First Name
MI
Date of Birth
Month
Male
Day
Related to Person 1?
Year
Female
The Census must also include people without a permanent
place to stay, so:
Yes
• 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.
No
Last Name
First Name
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
Related to Person 1?
Year
Female
Person 11
Yes
No
Last Name
First Name
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
2. Were there any additional people staying here
April 1, 2010 that you did not include in Question 1?
Mark I
J
K all 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
MI
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
Age on April 1, 2010
Date of Birth
Month
Male
Day
Related to Person 1?
Year
Female
Yes
No
Person 12
Last Name
Sex
Age on April 1, 2010
Male
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.
First Name
Month
Day
Female
Thank you for completing your official
2010 Census form.
Yes
No
JIC1
Last Name
First Name
MI
6. What is Person 1’s sex? Mark I
J
K ONE box.
Male
Female
7. What is Person 1’s age and what is Person 1’s 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
➜ NOTE: Please answer BOTH Questions 8 and 9 about race and origin.
8. What is Person 1’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
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
What is Person 1’s name? Print name below.
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 0607-0952, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project 0607-0952" as the subject.
Related to Person 1?
Year
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
3. Is this house, apartment, or mobile home —
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.
–
OMB No. 0607-0952: Approval Expires 12/31/2011
JIC2
Form
§4’"¤
190601
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D-1(X4)
(6-25-2009)
➜ 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
• 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
Person 9
Date of Birth
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
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Male
2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
J
K ONE box.
3. What is this person’s sex? Mark I
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
Male
2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
3. What is this person’s sex? Mark I
J
K ONE box.
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
Male
4. What is this person’s age and what is this person’s date of birth? 4. What is this person’s age and what is this person’s date of birth?
Female
Male
4. What is this person’s age and what is this person’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010
Age on April 1, 2010
Age on April 1, 2010
Day
Year of birth
Month
Day
Year of birth
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Month
Day
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
Male
Month
Day
Female
4. What is this person’s age and what is this person’s 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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
3. What is this person’s sex? Mark I
J
K ONE box.
4. What is this person’s age and what is this person’s date of birth?
Year of birth
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
3. What is this person’s sex? Mark I
J
K ONE box.
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
3. What is this person’s sex? Mark I
J
K ONE box.
MI
§4’#¤
190602
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Year of birth
Age on April 1, 2010
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Questions 5 and 6 about race and origin. ➜ NOTE: Please answer BOTH Questions 5 and 6 about race and origin.
➜ NOTE: Please answer BOTH Questions 5 and 6 about race and origin.
➜ NOTE: Please answer BOTH Questions 5 and 6 about race and origin.
➜ NOTE: 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
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,
principal tribe – For example, African Am., Argentinean, Chinese, Egyptian,
principal tribe – For example, African Am., Argentinean, Chinese, Egyptian,
principal tribe – For example, African Am., Argentinean, Chinese, Egyptian,
German, Marshallese, Mexican, Mexican Am., Mongolian, Native Hawaiian, Navajo,
Nigerian, Tlingit, and so on.
German, Marshallese, Mexican, Mexican Am., Mongolian, Native Hawaiian, Navajo,
Nigerian, Tlingit, and so on.
German, Marshallese, Mexican, Mexican Am., Mongolian, Native Hawaiian, Navajo,
Nigerian, Tlingit, and so on.
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
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.
➜
If more people were counted in Question 1 on the front page,
continue with Person 4.
➜
If more people were counted in Question 1 on the front page,
continue with Person 5.
➜
If more people were counted in Question 1 on the front page,
continue with Person 6.
➜
If more than six people were counted in Question 1 on
the front page, turn the page and continue.
Form D-1(X4) (6-25-2009)
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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 5 (6-25-2009)
| File Type | application/pdf |
| File Title | D-1(X4)_1_1.g |
| File Modified | 2010-04-12 |
| File Created | 2009-06-25 |