D-2012 Destruction or Return Form

FORM D-2012 U.S. DEPARTMENT OF COMMERCE

(XX-XX-XXXX) ECONOMICS AND STATISTICS ADMINISTRATION

OMB Control No. XXXX-XXXX U.S. CENSUS BUREAU

DESTRUCTION OR RETURN OF TITLE 13, UNITED STATES CODE MATERIALS FORM 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA)	Entity ID
	Government Name

Please complete this form and return it via email to [email protected] or in the enclosed postage paid, preaddressed envelope. Keep the original completed, signed form for your records.

All LUCA Operation liaisons, reviewers, and anyone with access to Title 13, United States Code LUCA materials must sign and date this form at the conclusion of your government’s participation in LUCA. Should any liaison, reviewer, or anyone with access to Title 13 LUCA materials leave before the completion of LUCA, they must sign and date this form. If any liaison, reviewer, or anyone with access to Title 13 LUCA materials are unable to sign and date this form, the current liaison must sign and date on their behalf.

1. LUCA liaison destruction or return of Title 13, materials

I certify by my signature that I have properly destroyed or returned to the U.S. Census Bureau, the original LUCA Title 13 materials, and any copies, using the security requirements provided to my government by the Census Bureau.

Check one:  Destroyed Title 13 LUCA materials (Preferred method)

 Returned Title 13 LUCA materials

Printed Name of LUCA Liaison

Signature of LUCA Liaison Date - mm/dd/yyyy

2. LUCA reviewers and anyone With Access to Title 13 materials

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Section B continued on the back

Continued - LUCA reviewers and anyone with access to Title 13 materials

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

Printed Name

Signature Date - mm/dd/yyyy

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