dd-1_15_121014_d7

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

2015 Census Test
Use a blue or black pen.

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Or go to https://survey.census.gov/censustest to complete the 2015 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 April 1, 2015.
• Leave these people off your form, even if they will return to live here after they leave college, the nursing home,
the military, jail, etc. Otherwise, they may be counted twice.
The Census must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on April 1, 2015, count that person.

1.

How many people were living or staying in this house, apartment, or mobile home on April 1, 2015?
Number of people =

2.

Were there any additional people staying here April 1, 2015 that you did not include in Question 1?
Mark ✗ 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 babysitters
People staying here temporarily

3.

Is this house, apartment, or mobile home — Mark ✗ ONE box.
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.

11125010

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
–

FORM

DD-1 (12-10-2014) Draft 7

–

§,-S+¤

No additional people

Person 1
5.

9.

No ➔ SKIP to Person 2, if more people live here.

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.

Yes — Mark ✗ all that apply.
In college housing

At a seasonal or second residence

In the military

In jail or prison

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

For a job or business

In a nursing home

First Name

For child custody

For another reason

MI

10.
Last Name

6.

If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays:
Address Number (For example: 5007)

What is Person 1’s sex? Mark ✗ ONE box.
Male

7.

Does Person 1 sometimes live or stay somewhere else?

Street Name (For example: N Maple Ave)

Female

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.
Age on April 1, 2015

Print numbers in boxes.
Month
Day

Apt/Unit (For example: "Apt. A" or "Lot 3")

Year of birth

Rural Route Address

8.

What is Person 1’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

State

Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

County

➜ NOTE: If there is no street address or if this is a facility, please

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,

print a description in the boxes below.

C

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. C

11.

Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 10

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Both places equally

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

Some other place

12.

On April 1, 2015, where was Person 1 staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 10
Some other place

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

➜ Continue to Question 9.

2

11125028

§,-S=¤

Vietnamese, Korean, Japanese, and so on.

ZIP Code

1.

Person 2

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 3.

➜ Continue to Question 6.

3

§,-SE¤

11125036

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C

1.

Person 3

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 4.

➜ Continue to Question 6.

4

11125044

§,-SM¤

Vietnamese, Korean, Japanese, and so on.

1.

Person 4

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 5.

➜ Continue to Question 6.

5

§,-ST¤

11125051

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C

1.

Person 5

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜ Continue to Question 6.

6

11125069

§,-Sf¤

Vietnamese, Korean, Japanese, and so on.

1.

Person 6

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 7.

➜ Continue to Question 6.

7

§,-Sn¤

11125077

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C

1.

Person 7

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 8.

➜ Continue to Question 6.

8

11125085

§,-Sv¤

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C

1.

Person 8

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 9.

➜ Continue to Question 6.

9

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Vietnamese, Korean, Japanese, and so on.

1.

Person 9

Print name of

6.

First Name

Does this person sometimes live or stay somewhere else?

MI

No ➔ SKIP to the next person, if more people live here.
Yes — Mark ✗ all that apply.

Last Name

2.

How is this person related to Person 1? Mark ✗ ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or
daughter-in-law

Same-sex unmarried partner

Housemate or roommate

Stepson or stepdaughter

For a job or business

In a nursing home

For child custody

For another reason

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 (For example: N Maple Ave)

Foster child

Brother or sister

Other nonrelative

Father or mother

What is this person’s sex? Mark ✗ ONE box.
Male

Apt/Unit (For example: "Apt. A" or "Lot 3")

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, 2015

5.

In jail or prison

Roomer or boarder

Adopted son or daughter

4.

At a seasonal or second residence

In the military

Address Number (For example: 5007)

Other relative

Biological son or daughter

3.

7.

In college housing

Month

Day

Rural Route Address

Year of birth

What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C

City

State

Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C

ZIP Code

County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

8.

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. C

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

Native Hawaiian or Other Pacific Islander – Print origin(s), for

Some other place

example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1, on the front
page, continue with Person 10.

➜ Continue to Question 6.

10

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Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C

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.

Person 10
First Name

MI

Last Name

Date of Birth
Sex

Age on April 1, 2015
Male

Month

Day

Year of birth

Female

Related to Person 1?
Yes

No

Person 11
First Name

MI

Last Name

Date of Birth
Sex

Age on April 1, 2015
Male

Month

Day

Year of birth

Female

Related to Person 1?
Yes

No

Person 12
First Name

MI

Last Name

Date of Birth
Sex

Age on April 1, 2015
Male

Month

Day

Year of birth

Female

Related to Person 1?
Yes

No

Person 13
First Name

MI

Last Name

Date of Birth
Age on April 1, 2015
Male

Month

Day

Year of birth

Female

Related to Person 1?
Yes

No

Person 14
11125119

First Name

MI

Last Name

Date of Birth
Sex

Age on April 1, 2015
Male

Month

Day

Year of birth

Female

Related to Person 1?
Yes

No

FOR OFFICIAL USE ONLY

Thank you for completing the
2015 Census Test.
11

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JIC2

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Sex

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

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. and Sunday from 11:00 a.m. to 9:00 p.m. The telephone call is free.
¿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. y los domingos entre las 11:00 a.m. y 9:00 p.m.
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, DMD-3H174, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project xxxx-xxxx" as the subject.
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

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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. and Sunday from 11:00 a.m. to 9:00 p.m. The telephone call is free.