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U.S. DEPARTMENT OF COMMERCE
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
5. Please provide information for each person living here. Start with a
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.
Start here
Age on April 1, 2010
Sex
Date of Birth
Day
Month
What is Person 1’s name? Print name below.
Related to Person 1?
Year
Male
The Census must count every person living in the
United States on April 1, 2010.
Yes
No
Sex
Last Name
Age on April 1, 2010
First Name
Date of Birth
Month
Day
• 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
Related to Person 1?
Year
Male
Yes
No
• 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.
Female
Person 9
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Sex
Last Name
Age on April 1, 2010
Male
First Name
Date of Birth
Month
Day
Female
Last Name
MI
7.
Female
Male
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
AND write in the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
The Census must also include people without a permanent
place to stay, so:
Yes
No
• 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
First Name
First Name
6. What is Person 1’s sex? Mark I
J
K ONE box.
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
1. How many people were living or staying in this house,
If your enclosed postage-paid envelope is missing, please mail your completed form to:
Sex
Age on April 1, 2010
Date of Birth
Month
Day
Related to Person 1?
Year
Male
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
Yes
No
Female
Person 11
Last Name
Age on April 1, 2010
Sex
First Name
Date of Birth
Day
Month
Year
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.
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.
Yes
No
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
Person 12
Last Name
Sex
Age on April 1, 2010
First Name
Date of Birth
Month
Day
¿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
Related to Person 1?
Year
Male
Female
FOR OFFICIAL USE ONLY
Thank you for completing your
official 2010 Census form.
JIC1
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
JIC2
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
Asian Indian
Chinese
Filipino
Korean
Vietnamese
Japanese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
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
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.
Yes
No
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
Number of people =
MI
Related to Person 1?
Male
apartment, or mobile home on April 1, 2010?
–
Native Hawaiian
Guamanian or Chamorro
Samoan
040401
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Some other race or origin — Print race(s) or origin(s). C
–
OMB No. XXXX-XXXX-X: Approval Expires XX/XX/XXXX
Form D-1(X2) (3-13-2009)
USCENSUSBUREAU
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If more people were counted in Question 1, continue with Person 2.
§p%"¤
790401
D-1(X2) – Prints Pantone PROCESS Cyan (10%, 20%, 25%, 50%, and 100%)
D-1(X2)- Base prints in BLACK
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Person 10
MI
Related to Person 1?
Year
Last Name
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.
Female
Person 8
U.S. CENSUS BUREAU
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Person 7
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.
1.
Person 2
Print name of
1.
Last Name
How is this person related to Person 1? Mark I
J
K ONE box.
4.
2.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
What is this person’s sex? Mark I
J
K ONE box.
Male
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.
Month
Day
Year of birth
Age on April 1, 2010
3.
How is this person related to Person 1? Mark I
J
K ONE box.
4.
Person 4
Print name of
1.
2.
Female
How is this person related to Person 1? Mark I
J
K ONE box.
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.
Month
Day
Year of birth
Age on April 1, 2010
5. What is this person’s race or origin? Mark I
J
K one or more boxes
AND write in the specific race(s) or origin(s).
4.
2.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
What is this person’s sex? Mark I
J
K ONE box.
Male
1.
5. What is this person’s race or origin? Mark I
J
K one or more boxes
4.
2.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
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
3.
What is this person’s sex? Mark I
J
K ONE box.
Female
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.
Month
Day
Year of birth
Age on April 1, 2010
4.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
What is this person’s sex? Mark I
J
K ONE box.
Male
J
K one or more boxes
5. What is this person’s race or origin? Mark I
AND write in the specific race(s) or origin(s).
§p%#¤
790402
MI
First Name
How is this person related to Person 1? Mark I
J
K ONE box.
Male
Female
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
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3.
Person 6
Print name of
Last Name
First Name
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3.
Person 5
Print name of
Last Name
First Name
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative
What is this person’s sex? Mark I
J
K ONE box.
Male
AND write in the specific race(s) or origin(s).
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MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Female
5. What is this person’s race or origin? Mark I
J
Kone or more boxes
➜
1.
Last Name
First Name
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
3.
Person 3
Print name of
Last Name
First Name
2.
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Female
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.
Month
Day
Year of birth
Age on April 1, 2010
5. What is this person’s race or origin? Mark I
J
K one or more boxes
AND write in the specific race(s) or origin(s).
AND write in the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
Black, African Am., or Negro — Print origin(s), for example,
African American, Haitian, Nigerian, and so on. C
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin(s), for
example, Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on. C
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo, Mayan, Tlingit, and so on. C
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian — Print origin(s), for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print origin(s), for example, Fijian,
Tongan, and so on. C
Some other race or origin — Print race(s) or origin(s). C
Some other race or origin — Print race(s) or origin(s). C
Some other race or origin — Print race(s) or origin(s). C
Some other race or origin — Print race(s) or origin(s). C
Some other race or origin — Print race(s) or origin(s). 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,
If more people were counted in Question 1 on the front page,
continue with Person 3.
➜
continue with Person 5.
➜
➜
If more people were counted in Question 1 on the front page,
continue with Person 6.
➜ If more people
live here, turn the
page and continue.
If more than six people were counted in Question 1 on the front page,
turn the page and continue.
Form D-1(X2) (3-12-2009)
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D-1(X2) - Base prints BLACK
D-1(X2) - Pantone PROCESS Cyan (10%, 25%, 50%, and 100%)
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Draft 2 (3-13-2009)
| File Type | application/pdf |
| File Title | D-1(X2)_2_1.g |
| File Modified | 2009-03-13 |
| File Created | 2009-03-13 |