Form DG-1D English paper questionnaire

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Start here

R
AF

T

2017 Census Test

OR go online at survey.census.gov to complete the 2017 Census Test.

Use a blue or black pen.

2.

Before you answer Question 1, count the people living in this
house, apartment, or mobile home using our guidelines.

Were there any additional people staying here on April 1, 2017
that you did not include in Question 1?
J
Mark I
K all that apply.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

D

• Count all people, including babies, who live and sleep here
most of the time.
• If no one lives or sleeps at this address, go online at
survey.census.gov or call the number on page 16.

Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily

The Census must also include people without a permanent
place to live, so:

3.

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

The Census Bureau also conducts counts in institutions and
other places, so:

Owned by you or someone in this household free and clear
(without a mortgage or loan)?

• Do not count anyone living away from here, either at college
or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention
facility, etc., on April 1, 2017.
• 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.

Rented?
Occupied without payment of rent?

4.

What is your telephone number?
We will only contact you if needed for official Census Bureau
business.
Telephone Number

1.

How many people were living or staying in this house,
apartment, or mobile home on April 1, 2017?

–

Number of people =
FORM

DG-1D (09-20-2016) Draft 2

–

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11457017

• If someone who does not have a permanent place to live is
staying here on April 1, 2017, count that person.

No additional people

Person 1
5.

8.

Please provide information for each person living here. If
there is someone living here who pays the rent or owns this
residence, start by listing him or her as Person 1. If the
owner or the person who pays the rent does not live here,
start by listing any adult living here as Person 1.

WHITE – Provide details below.

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

What is Person 1’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.

MI

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

Last Name(s)
HISPANIC, LATINO, OR SPANISH – Provide details below.

What is Person 1’s sex? Mark K
J ONE box.
I
Male

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.

What is Person 1’s age and what is Person 1’s 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, 2017
years

Print numbers in boxes.
Month
Day

African
American
Nigerian

T

7.

Puerto
Rican

Female

Jamaican

Haitian

Ethiopian

Somali

Print, for example, Ghanaian, South African, Barbadian, etc.

Year of birth

R
AF

6.

Mexican
or Mexican
American
Salvadoran

ASIAN – Provide details below.
Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

D

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

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MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

2

11457025

Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 1
9.

On April 1, 2017, was Person 1 enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

10.

On April 1, 2017, was Person 1 a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

11.

Does Person 1 usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457033

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D

➜ If more people were counted in Question 1
on the front page, continue with Person 2
on the next page.

3

1.

Person 2

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

4

11457041

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 2
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457058

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D

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

5

1.

Person 3

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

6

11457066

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 3
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457074

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D

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

7

1.

Person 4

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

8

11457082

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 4
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457090

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D

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

9

1.

Person 5

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

10

11457108

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 5
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457116

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D

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

11

1.

Person 6

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

12

11457124

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 6
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457132

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D

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

13

1.

Person 7

Print name of

5.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

Jamaican

Haitian

Ethiopian

Somali

T

2.

Print, for example, Ghanaian, South African, Barbadian, etc.

What is this person’s sex? Mark K
J ONE box.
I
Male

4.

Female

R
AF

3.

ASIAN – Provide details below.

What is this person’s age and what is this person’s 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, 2017

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

Year of birth

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

D

years

Print numbers in boxes.
Month
Day

Chinese

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

14

11457140

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Person 7
6.

On April 1, 2017, was this person enrolled in any
American Indian tribe or Alaska Native tribe or village?
No, not enrolled
Yes, enrolled ➔ Print enrolled tribe(s) or village(s) below.

7.

On April 1, 2017, was this person a shareholder of any
Alaska Native regional or village corporation?
No, not a shareholder
Yes, a shareholder ➔ Print Alaska Native regional or village
corporation(s) below.

8.

Does this person usually live or stay somewhere else?

No
Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

R
AF

Yes, for college

T

Mark K
J all that apply.
I

11457157

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D

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

15

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 8
First Name

MI

Last Name(s)

Date of Birth
Sex

Age on April 1, 2017
Male

Female

Month

Day

Year of birth

years

Related to Person 1?
Yes

No

Person 9
First Name

MI

Last Name(s)

Date of Birth
Age on April 1, 2017
Male

Female

Month

years

Person 10
MI

Year of birth

Related to Person 1?
Yes

No

Last Name(s)

R
AF

First Name

Day

T

Sex

Date of Birth

Sex

Age on April 1, 2017
Male

Female

Person 11

Sex

MI

Age on April 1, 2017

Male

Female

Day

Year of birth

years

D

First Name

Month

Related to Person 1?
Yes

No

Last Name(s)

Date of Birth
Month

Day

Year of birth

years

Related to Person 1?
Yes

No

Thank you for completing the 2017 Census Test.
If your enclosed postage-paid envelope is missing,
please mail your completed form to:

JIC1

JIC2

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

If you need help completing this form, call 1-844-330-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1-844-467-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET.
The telephone call is free.
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, DCMD-2H174,
4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to <[email protected]>; use "Paperwork Reduction Project xxxx-xxxx" as the
subject.
You 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.

16

11457165

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FOR OFFICIAL USE ONLY