D-1 X3 2010 Experimental Questionnaire Version 3 (Combined Race

Draft 1 (2-24-2009)

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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

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.
What is Person 1’s name? Print name below.

Start here
Sex
Male
Female

Person 8

Sex

Age on April 1, 2010

Last Name

Age on April 1, 2010

Male
Female

Person 9

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Sex

Age on April 1, 2010

Male
Female

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:

Year

Related to Person 1?
Yes
No

First Name

• 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.

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

MI

Date of Birth

Month

Last Name

Year

Related to Person 1?
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

Last Name
MI

First Name

6. What is Person 1’s sex? Mark I
J ONE box.
K
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
Day
Year of birth
Month

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

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,
apartment, or mobile home on April 1, 2010?

Sex
Male
Female

Age on April 1, 2010

Person 11

Last Name

Month

Day

Year

Yes
No

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

Related to Person 1?

Date of Birth

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

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

Male
Female

Person 12

Sex
Male
Female

Last Name

Age on April 1, 2010

Date of Birth
Month
Day

Related to Person 1?
Year

First Name

Date of Birth
Month
Day

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.

Yes
No

¿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

Year

Thank you for completing your official
2010 Census form.

Related to Person 1?
Yes
No

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.

FOR OFFICIAL USE ONLY

Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

JIC1

–

JIC2

–

Hispanic, Latino, or Spanish origin — Print origin(s), for example, Mexican,
Mexican Am., Puerto Rican, Cuban, 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

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
Fijian, Tongan, and so on. C

Some other race or origin — Print race(s) or origin(s). C

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX.
Form

§p&"¤
790501
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D-1(X3)

(2-24-2009)

➜ If more people were counted in Question 1, continue with Person 2.

USCENSUSBUREAU

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D-1(X3)- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
D-1(X3)- Base prints in BLACK

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Person 10

Day

First Name

Month

Last Name

Related to Person 1?

Date of Birth
Month

U.S. CENSUS BUREAU

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Person 7

Economics and Statistics Administration

1. Print name of Person 2

1. Print name of Person 3

Last Name

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

J
K ONE box.
3. What is this person’s sex? Mark I
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.
Year of birth
Age on April 1, 2010
Day
Month

5. What is this person’s race or origin? Mark I
J
K one or more boxes

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Last Name

First Name
MI
2. How is this person related to Person 1? Mark I
J ONE box.
K
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

1. Print name of Person 5

1. Print name of Person 4

Last Name

First Name
MI
J ONE box.
K
2. How is this person related to Person 1? Mark I

Male

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Female

First Name
MI
2. How is this person related to Person 1? Mark I
J ONE box.
K
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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

5. What is this person’s race or origin? Mark I
J
K one or more boxes

Last Name

Last 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.

4. What is this person’s age and what is this person’s date of birth?

1. Print name of Person 6

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
Month
Day
Year of birth

5. What is this person’s race or origin? Mark I
J
K one or more boxes

First Name
MI
2. How is this person related to Person 1? Mark I
J ONE box.
K
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

§p&#¤
790502

First Name
MI
2. How is this person related to Person 1? Mark I
J ONE box.
K
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

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

5. What is this person’s race or origin? Mark I
J
K one or more boxes

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
Month
Day
Year of birth

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).
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C

AND write in the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C

AND write in the specific race(s) or origin(s).
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

Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Mexican, Mexican Am., Puerto Rican, Cuban, 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 — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
Fijian, Tongan, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
Fijian, Tongan, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
Fijian, Tongan, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
Fijian, Tongan, and so on. C

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Guamanian or Chamorro, Samoan,
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

AND write in the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, Lebanese,
Egyptian, and so on. C

AND write in the specific race(s) or origin(s).
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

➜ 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

➜ If more people were counted in Question 1 on the front

page, continue with Person 4.

page, continue with Person 5.

➜ If more people
live here, turn
the page and
continue.

➜ If more than six people were counted in Question 1 on

➜ If more people were counted in Question 1 on the front
page, continue with Person 6.

the front page, turn the page and continue.
Form D-1(X3)
(2-24-2009)

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D-1(X3) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
D-1(X3) - Base prints BLACK

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Draft 1 (2-24-2009)