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pdfDraft 3 (3-12-2009)
This is the official form for all the people at this address.
It is quick and easy, and your answers are protected by law.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
Use a blue or black pen.
Start Here
The Census must count every person living in the United States on April 1, 2010.
• 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:
Respondents are not required to respond to any information collection unless it displays a
valid approval number from the Office of Management and Budget.
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.
¿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.
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.
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.
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
If your enclosed postage-paid envelope is missing, please mail your completed form to:
Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• 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.
The Census must also include people without a permanent place to stay, so:
• 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.
1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2010?
Number of people =
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
3. Is this house, apartment, or mobile home — 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?
4. What is your telephone number? We may call if we don’t understand an answer.
Area Code + Number
–
–
OMB No. XXXX-XXXX-X: Approval Expires XX/XX/XXXX
Form D-1(X13) (3-12-2009)
12
§p0-¤
791512
D-1(X13) - Page 1 and 12 Overlay 1, - Prints Pantone Process Cyan, 10%, 20%, 25%, 50% and 100%
USCENSUSBUREAU
§p0"¤
791501
D-1(X13), Page 1 and 12 Base copy - Prints Black ink
Fold line
Draft 3 (3-12-2009)
Person 1
10. Does Person 1 sometimes live or stay somewhere else?
No ➞SKIP to Person 2, if more people live here.
5. Please provide information for each person living here. Start with a
In college housing
In the military
For a job or business
For child custody
What is Person 1’s name? Print name below.
Last Name
Person 10
Yes — Mark I
J
K all that apply.
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.
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.
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
Last Name
Sex
Age on April 1, 2010
11. IF you marked yes to Question 10, please provide the full address of
First Name
MI
Day
MI
Related to Person 1?
Year
Yes
No
Female
House Number
6. What is Person 1’s sex? Mark I
J
K ONE box.
Date of Birth
Month
Male
the other place where Person 1 sometimes lives or stays:
Male
First Name
Person 11
Female
Street Name
Last Name
First Name
MI
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 Question 8 about Hispanic origin and
Question 9 about race. For this census, Hispanic origins are not races.
9. What is Person 1’s 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
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Some other race — Print race. C
791502
➜ Continue to Question 10.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
Date of Birth
Month
Apartment Number
Day
Related to Person 1?
Year
Male
Yes
Female
No
Rural Route Address
Person 12
8. Is Person 1 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
Age on April 1, 2010
Sex
First Name
Last Name
City
Age on April 1, 2010
Sex
Date of Birth
Month
State
ZIP Code
Day
MI
Related to Person 1?
Year
Male
Yes
Female
No
Person 13
County
First Name
Last Name
MI
➜ NOTE: If there is no street address or if this is a facility, please print a
description in the boxes below.
Sex
Age on April 1, 2010
Date of Birth
Month
12. Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 11
Both places equally
Some other place
13. On April 1, 2010, where was Person 1 staying?
The address printed on the back of this questionnaire
The address or location you listed in Question 11
Some other place
➜ If more people were counted in Question 1, continue with
Day
Related to Person 1?
Year
Male
Yes
Female
No
Person 14
Last Name
Sex
First Name
Age on April 1, 2010
Date of Birth
Month
Day
MI
Related to Person 1?
Year
Male
Yes
Female
No
FOR OFFICIAL USE ONLY
Thank you for completing your official
2010 Census form.
JIC1
JIC2
Person 2.
2
§p0#¤
791502
§p0,¤
791511
11
D-1(X13), Page 2 & 11 Base copy - Prints Black ink
D-1(X13) - Pages 2 & 11 - Prints Pantone Process Cyan, 10%, 25%, 50% and 100%
Draft 3 (3-12-2009)
Fold line
1. Print name of
Person 9
No ➞SKIP to the next person, if more people live here.
Last Name
In college housing
In the military
For a job or business
For child custody
MI
2. How is this person related to Person 1? 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
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.
7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
Yes — Mark I
J
K all that apply.
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
First Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number
Street Name
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.
Male
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
Apartment Number
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
City
State
ZIP Code
City
State
ZIP Code
County
6. What is this person’s race? Mark I
J
K one or more boxes.
6. What is this person’s 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
➜ NOTE: If there is no street address or if this is a facility, please print a
description in the boxes below.
Asian Indian
Japanese
Korean
Chinese
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
9. Where does this person live or stay most of the time?
The address or location you listed in Question 8
The address printed on the back of this questionnaire
Both places equally
Some other place
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
10. On April 1, 2010, where was this person staying?
10. On April 1, 2010, where was this person staying?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
Some other race — Print race. C
➜ Continue to Question 7.
➜ If more people were counted in Question 1 on the front page,
continue with Person 10.
10
Apartment Number
5. Is this person of Hispanic, Latino, or Spanish origin?
County
➜ Continue to Question 7.
Street Name
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin?
Some other race — Print race. C
House Number
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
the other place where this person sometimes lives or stays:
Rural Route Address
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Asian Indian
Japanese
Korean
Chinese
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
8. IF you marked yes to Question 7, please provide the full address of
Female
Rural Route Address
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
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?
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
In college housing
In the military
For a job or business
For child custody
MI
2. How is this person related to Person 1? Mark I
J
K ONE box.
Female
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
Person 2
Last Name
Yes — Mark I
J
K all that apply.
First Name
Male
1. Print name of
7. Does this person sometimes live or stay somewhere else?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 3.
§p0+¤
791510
§p0$¤
791503
3
D-1(X-13), Page 3 & 10 Base copy - Prints Black ink
Fold line
D-1(X13) - Page 3 & 10 Overlay 1, - Prints Pantone Process Cyan, 10%, 25%, 50%, and 100%
Fold line
Draft 3 (3-12-2009)
1. Print name of
Person 3
7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
Last Name
First Name
Yes — Mark I
J
K all that apply.
In college housing
In the military
For a job or business
For child custody
MI
2. How is this person related to Person 1? 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
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.
Male
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number
Street Name
1. Print name of
7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
Last Name
2. How is this person related to Person 1? 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
Male
4. What is this person’s age and what is this person’s date of birth?
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
Apartment Number
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
City
State
ZIP Code
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
State
ZIP Code
6. What is this person’s race? Mark I
J
K one or more boxes.
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 4.
§p0%¤
791504
City
County
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C
Asian Indian
Japanese
Korean
Chinese
Vietnamese
Filipino
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
10. On April 1, 2010, where was this person staying?
4
Apartment Number
5. Is this person of Hispanic, Latino, or Spanish origin?
6. What is this person’s race? Mark I
J
K one or more boxes.
➜ Continue to Question 7.
Street Name
Rural Route Address
County
Some other race — Print race. C
House Number
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin?
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
the other place where this person sometimes lives or stays:
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
Asian Indian
Japanese
Korean
Chinese
Vietnamese
Filipino
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
8. IF you marked yes to Question 7, please provide the full address of
4. What is this person’s age and what is this person’s date of birth?
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
Female
Rural Route Address
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
Yes — Mark I
J
K all that apply.
In college housing
In the military
For a job or business
For child custody
MI
First Name
3. What is this person’s sex? Mark I
J
K ONE box.
Female
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
Person 8
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
10. On April 1, 2010, where was this person staying?
Some other race — Print race. C
➜ Continue to Question 7.
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 9.
§p0*¤
791509
9
D-1(X13) - Pages 4 & 9 - Prints Pantone Process Cyan, 10%, 25%, 50% and 100%
D-1(X13), Page 4 & 9 Base copy - Prints Black ink
Fold line
Draft 3 (3-12-2009)
1. Print name of
Person 7
7. Does this person sometimes live or stay somewhere else?
1. Print name of
Person 4
7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
Last Name
Yes — Mark I
J
K all that apply.
First Name
In college housing
In the military
For a job or business
For child custody
MI
2. How is this person related to Person 1? 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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number
Street Name
3. What is this person’s sex? Mark I
J
K ONE box.
Male
No ➞SKIP to the next person, if more people live here.
Last Name
First Name
MI
2. How is this person related to Person 1? 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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
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.
Age on April 1, 2010
Month
Day
Year of birth
Apartment Number
House Number
Street Name
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
Rural Route Address
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person 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
5. Is this person of Hispanic, Latino, or Spanish origin?
City
State
ZIP Code
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
County
6. What is this person’s race? Mark I
J
K one or more boxes.
City
State
ZIP Code
County
6. What is this person’s 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
➜ NOTE: If there is no street address or if this is a facility, please print
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
9. Where does this person live or stay most of the time?
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
Apartment Number
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
a description in the boxes below.
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
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, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
10. On April 1, 2010, where was this person staying?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 5.
§p0)¤
791508
the other place where this person sometimes lives or stays:
4. What is this person’s age and what is this person’s date of birth?
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
8
8. IF you marked yes to Question 7, please provide the full address of
Female
Rural Route Address
➜ Continue to Question 7.
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
3. What is this person’s sex? Mark I
J
K ONE box.
Female
Some other race — Print race. C
Yes — Mark I
J
K all that apply.
In college housing
In the military
For a job or business
For child custody
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
10. On April 1, 2010, where was this person staying?
Some other race — Print race. C
➜ Continue to Question 7.
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 8.
§p0&¤
791505
5
D-1(X13), Page 5 & 8 Base copy - Prints Black ink
D-1(X13) - Pages 5 & 8 - Prints Pantone Process Cyan, 10%, 25%, 50% and 100%
Fold line
Draft 3 (3-12-2009)
1. Print name of
Person 5
7. Does this person sometimes live or stay somewhere else?
1. Print name of
Person 6
7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
No ➞ SKIP to the next person, if more people live here.
Last Name
Last Name
Yes — Mark I
J
K all that apply.
First Name
In college housing
In the military
For a job or business
For child custody
MI
2. How is this person related to Person 1? 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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number
Street Name
3. What is this person’s sex? Mark I
J
K ONE box.
Male
Yes — Mark I
J
K all that apply.
First Name
2. How is this person related to Person 1? 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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
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.
Age on April 1, 2010
Month
Day
Year of birth
Apartment Number
Street Name
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
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
Rural Route Address
5. Is this person of Hispanic, Latino, or Spanish origin?
City
ZIP Code
State
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
6. What is this person’s race? Mark I
J
K one or more boxes.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
City
State
ZIP Code
County
County
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C
Apartment Number
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin?
6. What is this person’s race? Mark I
J
K one or more boxes.
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
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, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 6.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander —
Print race, for example,
Fijian, Tongan, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.
9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place
10. On April 1, 2010, where was this person staying?
10. On April 1, 2010, where was this person staying?
§p0’¤
791506
House Number
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
6
the other place where this person sometimes lives or stays:
4. What is this person’s age and what is this person’s date of birth?
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
➜ Continue to Question 7.
8. IF you marked yes to Question 7, please provide the full address of
Female
Rural Route Address
Some other race — Print race. C
At a seasonal or second residence
In jail or prison
In a nursing home
For another reason
3. What is this person’s sex? Mark I
J
K ONE box.
Female
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
In college housing
In the military
For a job or business
For child custody
MI
Some other race — Print race. C
➜ Continue to Question 7.
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place
➜ If more people were counted in Question 1 on the front page,
continue with Person 7.
§p0(¤
791507
7
D-1(X13), Page 6 & 7 Base copy - Prints Black ink
D-1(X13) - Pages 6 & 7 - Prints Pantone Process Cyan, 10%, 25%, 50% and 100%
| File Type | application/pdf |
| File Title | D-1(X13)_1_1.g |
| File Modified | 2009-03-12 |
| File Created | 2009-03-12 |