Download:
pdf |
pdfPublished: 18-Feb-2014 14:58:06
11114121
11114014
U.S. DEPARTMENT OF COMMERCE
2014 Census Test
Use a blue or black pen.
Economics and Statistics Administration
U.S. CENSUS BUREAU
Or go to https://respond.census.gov/censustest to complete the 2014 Census Test.
Start here
Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• 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:
• 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 July 1, 2014.
• 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 Bureau must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on July 1, 2014, count that person.
1.
How many people were living or staying in this house, apartment, or mobile home on July 1, 2014?
Number of people =
If your enclosed postage-paid envelope is missing, please mail your completed form to:
2.
Mark I
K all that apply.
J
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
×
×
×
×
×
If you need help completing this form, call 1-866-226-2836, Monday through Saturday from 9:00 a.m. to
9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1-800-786-9448, Monday through Saturday
from 9:00 a.m. to 9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
3.
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
4.
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
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?
What is your telephone number? We may call if we don't understand an answer.
Area Code + Number
–
–
OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form
12
Children, such as newborn babies or foster children
Is this house, apartment, or mobile home — Mark I
K ONE box.
J
×
×
×
×
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-888-262-5931
de lunes a sábado entre las 9:00 a.m. y las 9:00 p.m. EST, y los domingos entre las 11:00 a.m. y 9:00 p.m.
EST. La llamada telefónica es gratis.
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 xxxx-xxxx,
U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project xxxx-xxxx" as the subject.
Were there any additional people staying here July 1, 2014 that you did not include in Question 1?
DC-1A (DRAFT)
Published: 18-Feb-2014 14:58:06
11114022
Person 1
5.
9.
Does Person 1 sometimes live or stay somewhere else?
×
×
Please provide information for each person living here.
Start with a 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.
Last Name
10.
MI
Yes — Mark I
K all that apply.
J
In college housing
In the military
For a job or business
For child custody
×
×
×
×
At a seasonal or second residence
In jail or prison
In a nursing home
If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays.
What is Person 1's sex? Mark I
K ONE box.
J
×
7.
Male
×
8.
Apartment Number
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Rural Route Address
×
Year of birth
×
×
Yes
No
First Name
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 12
First Name
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 13
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
First Name
Last Name
Sex
×
×
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 14
Where does Person 1 live or stay most of the time?
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
Some other race or origin — Print race(s) or origin(s).
Related to Person 1?
Day
ZIP Code
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
11.
×
×
×
×
×
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
a description in the boxes below.
×
Month
Female
Sex
City
County
×
MI
Date of Birth
Last Name
State
×
×
×
Age on July 1, 2014
Male
Sex
Print numbers in boxes.
Month
Day
Year of birth
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
Sex
Last Name
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.
×
First Name
Last Name
Person 11
Street Name
Female
Age on July 1, 2014
Person 10
For another reason
House Number
6.
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.
No ➜ SKIP to Person 2, if more people live here.
×
×
×
×
What is Person 1's name? Print name below.
First Name
11114113
12.
The address printed on the back of this questionnaire
The address or location you listed in Question 10
Both places equally
Some other place
Sex
×
×
Age on July 1, 2014
Male
Date of Birth
Month
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
FOR OFFICIAL USE ONLY
The address printed on the back of this questionnaire
The address or location you listed in Question 10
Some other place
➜ If more people were counted in Question 1, continue
Thank you for completing the
2014 Census Test.
with Person 2.
2
MI
On July 1, 2014, where was Person 1 staying?
×
×
×
➜ Continue to Question 9.
First Name
Last Name
11
JIC1
JIC2
Published: 18-Feb-2014 14:58:06
11114105
1.
Print name of
Person 9
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
Son-in-law or daughter-in-law
7.
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
8.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
page, continue with Person 10.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
10
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
The address or location you listed in Question 7
Some other place
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
For another reason
Street Name
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
➜ Continue to Question 6.
Where does this person live or stay most of the time?
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 2
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114030
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 3.
3
Published: 18-Feb-2014 14:58:06
11114048
1.
Print name of
Person 3
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 4.
4
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 8
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114097
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 9.
9
Published: 18-Feb-2014 14:58:06
11114089
1.
Print name of
Person 7
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 8.
8
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 4
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114055
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 5.
5
Published: 18-Feb-2014 14:58:06
11114063
1.
Print name of
Person 5
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 6.
6
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 6
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114071
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 7.
7
Published: 18-Feb-2014 14:58:06
11114063
1.
Print name of
Person 5
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 6.
6
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 6
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114071
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 7.
7
Published: 18-Feb-2014 14:58:06
11114089
1.
Print name of
Person 7
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 8.
8
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 4
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114055
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 5.
5
Published: 18-Feb-2014 14:58:06
11114048
1.
Print name of
Person 3
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Where does this person live or stay most of the time?
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
page, continue with Person 4.
4
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Street Name
The address or location you listed in Question 7
Some other place
For another reason
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 8
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114097
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 9.
9
Published: 18-Feb-2014 14:58:06
11114105
1.
Print name of
Person 9
6.
Last Name
×
×
First Name
2.
Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
Son-in-law or daughter-in-law
7.
Other relative
In college housing
In the military
For a job or business
For child custody
×
×
×
×
Male
×
In a nursing home
For another reason
2.
Street Name
Other nonrelative
3.
Apartment Number
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
Print numbers in boxes.
than 1 year old.
Day
Year of birth
4.
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Parent-in-law
7.
Son-in-law or daughter-in-law
Other relative
Foster child
×
American Indian or Alaska Native — Print name of enrolled or
×
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
8.
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
Male
×
Female
Apartment Number
Month
Day
Year of birth
Rural Route Address
×
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
City
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
State
County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
×
×
American Indian or Alaska Native — Print name of enrolled or
8.
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
9.
×
page, continue with Person 10.
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 7
Both places equally
Some other place
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
Some other place
➜ If more people were counted in Question 1 on the front
10
a description in the boxes below.
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
The address printed on the back of this questionnaire
The address or location you listed in Question 7
ZIP Code
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
The address or location you listed in Question 7
Some other place
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
The address printed on the back of this questionnaire
Both places equally
For another reason
Street Name
On July 1, 2014, where was this person staying?
×
×
×
Some other race or origin — Print race(s) or origin(s).
➜ Continue to Question 6.
Where does this person live or stay most of the time?
In a nursing home
Other nonrelative
a description in the boxes below.
×
For child custody
In jail or prison
Housemate or roommate
➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
For a job or business
At a seasonal or second residence
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
Print numbers in boxes.
than 1 year old.
×
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
In the military
×
×
×
×
House Number
Roomer or boarder
County
×
In college housing
Grandchild
Age on July 1, 2014
5.
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
Unmarried partner
×
×
×
×
×
×
×
Yes — Mark I
K all that apply.
J
×
×
×
×
MI
Husband or wife
No ➜ SKIP to the next person, if more people live here.
What is this person's sex? Mark I
K ONE box.
J
×
Rural Route Address
×
×
×
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.
Female
Month
Does this person sometimes live or stay somewhere else?
In jail or prison
Housemate or roommate
Foster child
6.
First Name
At a seasonal or second residence
House Number
Roomer or boarder
Person 2
Last Name
Grandchild
Age on July 1, 2014
5.
×
×
×
×
×
×
×
Print name of
Yes — Mark I
K all that apply.
J
What is this person's sex? Mark I
K ONE box.
J
×
4.
Husband or wife
1.
No ➜ SKIP to the next person, if more people live here.
×
×
×
×
MI
How is this person related to Person 1?
K ONE box.
J
Mark I
×
×
×
×
×
×
×
×
3.
Does this person sometimes live or stay somewhere else?
11114030
The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1 on the front
➜ Continue to Question 6.
page, continue with Person 3.
3
Published: 18-Feb-2014 14:58:06
11114022
Person 1
5.
9.
Does Person 1 sometimes live or stay somewhere else?
×
×
Please provide information for each person living here.
Start with a 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.
Last Name
10.
MI
Yes — Mark I
K all that apply.
J
In college housing
In the military
For a job or business
For child custody
×
×
×
×
At a seasonal or second residence
In jail or prison
In a nursing home
If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays.
What is Person 1's sex? Mark I
K ONE box.
J
×
7.
Male
×
8.
Apartment Number
What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).
×
Hispanic, Latino, or Spanish origin — Print origin(s), for example,
Rural Route Address
×
Year of birth
×
×
Yes
No
First Name
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 12
First Name
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 13
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.
➜ NOTE: If there is no street address or if this is a facility, please print
American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.
First Name
Last Name
Sex
×
×
Age on July 1, 2014
Date of Birth
Month
Male
MI
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
Person 14
Where does Person 1 live or stay most of the time?
×
×
×
×
Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on.
Some other race or origin — Print race(s) or origin(s).
Related to Person 1?
Day
ZIP Code
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on.
11.
×
×
×
×
×
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on.
a description in the boxes below.
×
Month
Female
Sex
City
County
×
MI
Date of Birth
Last Name
State
×
×
×
Age on July 1, 2014
Male
Sex
Print numbers in boxes.
Month
Day
Year of birth
White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on.
Sex
Last Name
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.
×
First Name
Last Name
Person 11
Street Name
Female
Age on July 1, 2014
Person 10
For another reason
House Number
6.
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.
No ➜ SKIP to Person 2, if more people live here.
×
×
×
×
What is Person 1's name? Print name below.
First Name
11114113
12.
The address printed on the back of this questionnaire
The address or location you listed in Question 10
Both places equally
Some other place
Sex
×
×
Age on July 1, 2014
Male
Date of Birth
Month
Related to Person 1?
Day
Year of birth
Female
×
×
Yes
No
FOR OFFICIAL USE ONLY
The address printed on the back of this questionnaire
The address or location you listed in Question 10
Some other place
➜ If more people were counted in Question 1, continue
Thank you for completing the
2014 Census Test.
with Person 2.
2
MI
On July 1, 2014, where was Person 1 staying?
×
×
×
➜ Continue to Question 9.
First Name
Last Name
11
JIC1
JIC2
Published: 18-Feb-2014 14:58:06
11114121
11114014
U.S. DEPARTMENT OF COMMERCE
2014 Census Test
Use a blue or black pen.
Economics and Statistics Administration
U.S. CENSUS BUREAU
Or go to https://respond.census.gov/censustest to complete the 2014 Census Test.
Start here
Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• 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:
• 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 July 1, 2014.
• 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 Bureau must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on July 1, 2014, count that person.
1.
How many people were living or staying in this house, apartment, or mobile home on July 1, 2014?
Number of people =
If your enclosed postage-paid envelope is missing, please mail your completed form to:
2.
Mark I
K all that apply.
J
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
×
×
×
×
×
If you need help completing this form, call 1-866-226-2836, Monday through Saturday from 9:00 a.m. to
9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1-800-786-9448, Monday through Saturday
from 9:00 a.m. to 9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
3.
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
4.
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
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?
What is your telephone number? We may call if we don't understand an answer.
Area Code + Number
–
–
OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form
12
Children, such as newborn babies or foster children
Is this house, apartment, or mobile home — Mark I
K ONE box.
J
×
×
×
×
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-888-262-5931
de lunes a sábado entre las 9:00 a.m. y las 9:00 p.m. EST, y los domingos entre las 11:00 a.m. y 9:00 p.m.
EST. La llamada telefónica es gratis.
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 xxxx-xxxx,
U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project xxxx-xxxx" as the subject.
Were there any additional people staying here July 1, 2014 that you did not include in Question 1?
DC-1A (DRAFT)
| File Type | application/pdf |
| File Title | C:\Users\cogan300\AppData\Local\Temp\tmp9FC2.tmp |
| Author | cogan300 |
| File Modified | 2014-02-18 |
| File Created | 2014-02-18 |