Form DF-20

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

2016 Individual Census Report

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

Use blue or black pen.

Start here
1.

5.

What is your name? Print name below.
First Name

Do you live or stay here MOST OF THE TIME?

MI

Yes
No

Last Name(s)

6.
What is your sex? Mark I
J
K ONE box.
Male

3.

Address Number (For example: 5007)

Female

What is your age and what is your date of birth?
For babies less than 1 year old, do not write the age in months.
Write 0 as the age.
Age on April 1, 2016

Print numbers in boxes.
Month
Day

Year of birth

years

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

Which categories describe you?
Mark all boxes that apply AND print details in the spaces below.
Note, you may report more than one group.

AF

4.

Street Name (For example: N Maple Ave)

T

2.

BESIDES HERE, what is the full address of a place
where you sometimes live or stay?

Rural Route Address (if there is no street address)

White – Print, for example, German, Irish, English, Italian, Polish,
French, etc.

R

Hispanic, Latino, or Spanish – Print, for example, Mexican or Mexican
American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

D

Black or African Am. – Print, for example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc.

City

State

ZIP Code

County, Parish, or Borough

Asian – Print, for example, Chinese, Filipino, Asian Indian, Vietnamese,
Korean, Japanese, etc.

➜ NOTE: Please provide a location description below if there is no
address or if this is a facility.

Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc

11366010

§,E]+¤

American Indian or Alaska Native – Print, for example, Navajo Nation,

Middle Eastern or North African – Print, for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, etc.

Native Hawaiian or Other Pacific Islander – Print, for example,
Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

Some other race, ethnicity, or origin – Print details.

FORM

DF-20 (02-17-2016) Draft 4

DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

May 1, 2016
A message from the Director, U.S. Census Bureau
This is your official 2016 Individual Census Report. The Census Bureau is researching modern and cost
efficient methods for the population to exercise its civic obligation to be counted in the 2020 Census,
and your participation in this test will help pave the way for a more accurate count of all populations in
the 2020 Census.
This Individual Census Report is to be used to count people who are currently living or staying in group
quarters, such as college or university dormitories, nursing homes, group homes, emergency and
transitional shelters for people experiencing homelessness, and other such locations. Please follow
the instructions you were given when you received this form for returning it to the appropriate
person.

AF

T

Completing the 2016 Individual Census Report is important, because your participation allows the
Census Bureau to try out, on a smaller scale, a number of distribution, collection, and processing
methods that we can use on a national scale in four years. That means information from this census
test will help the Census Bureau carry out the census in 2020 more effectively and accurately, saving
taxpayer dollars while ensuring everyone gets counted.

Sincerely,

D

John H. Thompson
Director

R

Your answers are confidential. This means the Census Bureau cannot give out information that
identifies you. Your answers will only be used for statistical purposes, and no other purpose. For more
information about how we protect your information, please visit our website at: www.census.gov and
click on “Data Protection & Privacy Policy” at the bottom of the homepage.

Thank you for completing your official 2016 Individual Census Report.
The U.S. Census Bureau estimates that, for the average
respondent, this form will take about 5 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, DCMD-2H174,
4600 Silver Hill Road, Washington, DC 20233. You may
e-mail comments to <[email protected]>;
use "Paperwork Project xxxx-xxxx" as the subject.
Respondents are not required to respond to this collection of
information if it does not display a valid approval number from
the Office of Management and Budget (OMB). The eight-digit
OMB number is xxxx-xxxx.

GQ Control Number

11366028

§,E]=¤

FOR OFFICIAL USE ONLY

A. PN

D. Answered By:

B. JIC1

Respondent
Observation

FORM DF-20 (02-17-2016) Draft 4

C. JIC2

Administrative
Records