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pdfDraft 5 (6-26-2009)
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U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
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.
U.S. CENSUS BUREAU
5. Please provide information for each person living here. Start with a
Last Name
First Name
Use a blue or black pen.
MI
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.
Start here
Sex
Age on April 1, 2010
Month
Male
Female
Person 8
Sex
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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
MI
Day
Year
Date of Birth
The Census Bureau also conducts counts in institutions
and other places, so:
• 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
MI
Related to Person 1?
Day
Year
The Census must also include people without a permanent
place to stay, so:
Yes
No
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,
Last Name
First Name
MI
J
K ONE box.
6. What is Person 1’s sex? Mark I
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
8. What is Person 1’s race or origin? Mark I
J
K one or more boxes.
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
apartment, or mobile home on April 1, 2010?
Sex
Age on April 1, 2010
Month
Male
Female
Person 11
Date of Birth
Day
Last Name
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
Yes
No
First Name
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
Day
Related to Person 1?
Male
Female
Person 12
Sex
Yes
No
Last Name
Age on April 1, 2010
Male
Female
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.
Year
First Name
Month
Day
Year
Yes
No
FOR OFFICIAL USE ONLY
Thank you for completing your official
2010 Census form.
JIC1
Mark I
J
K ONE box.
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.
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
Related to Person 1?
Date of Birth
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
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
3. Is this house, apartment, or mobile home —
¿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
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Number of people =
Some other race or origin — Print race or origin. C
4. What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–
–
OMB No. 0607-0952: Approval Expires 12/31/2011
JIC2
Form D-1(X5) (6-26-2009)
§4("¤
190701
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➜ If more people were counted in Question 1, continue with Person 2.
USCENSUSBUREAU
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D-1(X5) – Prints Pantone PROCESS Cyan (10%, 20%, 25%, 50%, and 100%)
D-1(X5)- Base prints in BLACK
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Last Name
• Count all people, including babies, who live and sleep here
most of the time.
Related to Person 1?
First Name
Month
Male
Female
Person 10
Date of Birth
Last Name
Age on April 1, 2010
Sex
Year
First Name
Month
Male
Female
Related to Person 1?
Day
Last Name
Age on April 1, 2010
Person 9
Date of Birth
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Person 7
Last Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3. What is this person’s sex? Mark I
J
K ONE box.
Female
Male
4. What is this person’s age and what is this person’s date of birth?
3. What is this person’s sex? Mark I
J
K ONE box.
Male
4. What is this person’s age and what is this person’s date of birth?
First Name
MI
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
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
Last Name
First Name
MI
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
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
1. Print name of Person 6
Last Name
First Name
MI
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.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
2. How is this person related to Person 1? Mark I
J
K ONE box.
Male
4. What is this person’s age and what is this person’s date of birth?
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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.
Female
MI
3. What is this person’s sex? Mark I
J
K ONE box.
Female
Male
4. What is this person’s age and what is this person’s date of birth?
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.
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.
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
Age on April 1, 2010
Age on April 1, 2010
Month
Day
Year of birth
Month
Day
Year of birth
5. What is this person’s race or origin? Mark I
J
K one or more boxes.
Month
Day
Year of birth
5. What is this person’s race or origin? Mark I
J
K one or more boxes.
Month
Day
Year of birth
5. What is this person’s race or origin? Mark I
J
K one or more boxes.
Month
Day
Year of birth
5. What is this person’s race or origin? Mark I
J
K one or more boxes.
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
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 or origin — Print race or origin. C
If more people were counted in Question 1 on the front page,
continue with Person 3.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C
Some other race or origin — Print race or origin. C
➜
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C
Some other race or origin — Print race or origin. C
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.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
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 or origin — Print race or origin. C
Some other race or origin — Print race or origin. C
➜
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(X5) (6-26-2009)
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190702
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
5. What is this person’s race or origin? Mark I
J
K one or more boxes.
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First Name
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
➜
Last Name
Last Name
First Name
1. Print name of Person 5
1. Print name of Person 4
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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(X5) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
1. Print name of Person 2
Male
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D-1(X5) - Base prints BLACK
Draft 5 (6-26-2009)
| File Type | application/pdf |
| File Title | D-1(X5)_1_1.g |
| File Modified | 2010-04-12 |
| File Created | 2009-06-26 |