Form D-2005 Confidentiality Agreement Form

Form D-2005 (XX-XX-XXXX) OMB Control No. XXXX-XXXX

U.S. DEPARTMENT OF COMMERCE ECONOMICS AND STATISTICS ADMINSTRATION U.S. CENSUS BUREAU

CONFIDENTIALITY AGREEMENT FORM 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA)	Entity ID
	Government Name

1. Terms, Conditions, and Responsibilities for Participating in the LUCA OPERATION

All LUCA liaisons, reviewers, and anyone with access to Title 13, United State Code (U.S.C.) LUCA materials must agree to keep confidential the Title 13 materials to which they have access, including any maps that contain structure points showing the location of living quarters. They may use this information solely for suggesting improvements to the Census Bureau’s address list and maps.

All individuals who will review or have access to Census Bureau Title 13 materials must sign below to indicate they have read and understand the Census Bureau’s Confidentiality and Security Guidelines for LUCA. In addition, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality of Census Bureau materials protected under Title 13. Further, a signature indicates recognition that the penalty for wrongful disclosure is a fine of not more than $250,000 or imprisonment for not more than 5 years, or both. Although access to the data is temporary, this commitment is permanent. You must be at least 18 years of age to sign this agreement.

By signing this agreement, your government agrees to destroy all Census Bureau Title 13 materials or return them to the Census Bureau at the completion of LUCA.

2. LIAISON INFORMATION

Liaison’s Printed Name Area Code - Telephone number Ext

Liaison’s Signature Date – mm/dd/yyyy

Name of LUCA Liaison’s Office, Department, or Agency - (Assessor’s Office, Planning Department, Regional Planning Agency, etc.) – Please print

Address of LUCA Liaison’s Office, Department, or Agency - (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email Address

3. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS

Printed Name Area Code - Telephone number Ext

Signature Date – mm/dd/yyyy

Address, if different from Liaison – (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email Address

Section C continued on the back

Complete this form and return it along with the completed, signed copies of the Registration Form, Self-Assessment Checklist, and the Product Preference Form. Use the enclosed postage-paid envelope addressed to ATTN: Geography LUCA Materials 63-E, National Processing Center, 1201 East 10^th St , Jeffersonville IN 47132. Rather than mailing, you may scan your completed forms, including forms with signatures, and email them to us at [email protected].

Continued - Information for Reviewer(s) and Person(s) with Access to Title 13, United State Code Materials

Printed Name Area Code - Telephone number Ext

Signature Date – mm/dd/yyyy

Address, if different from Liaison – (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email address

Printed Name Area Code - Telephone number Ext

Signature Date – mm/dd/yyyy

Address, if different from Liaison – (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email address

Printed Name Area Code - Telephone number Ext

Signature Date – mm/dd/yyyy

Address, if different from Liaison – (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email address

Printed Name Area Code - Telephone number Ext

Signature Date – mm/dd/yyyy

Address, if different from Liaison – (House number and street name, RR, HC, or box number) – Please print

City State ZIP Code

Email address

If you require more signatures, you may duplicate this form.