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OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
TM
This is the official questionnaire for this address.
It is quick and easy to respond, and your answers are protected by law.
FOR OFFICIAL USE ONLY
ip
FOR
OFFICIAL
USE ONLY
ns
h
Address Number (For example: 5007)
ze
Street Name (For example: N Maple Ave) or Rural Route Address
ZIP Code
Start here
C
iti
Apt/Unit (For example: Apt A or Lot 3)
OR go online at XXXX.XXXX.gov to complete your 2020 Census questionnaire.
Use a blue or black pen.
o
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, 2020
that you did not include in Question 1?
Mark I
K all that apply.
J
N
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children
• Count all people, including babies, who live and sleep here
most of the time.
• If no one lives and sleeps at this address most of the time, go
online at XXXX.XXXX.gov or call the number on page 8.
Relatives, such as adult children, cousins, or in-laws
ft:
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:
ra
• If someone who does not have a permanent place to live is
staying here on April 1, 2020, count that person.
No additional people
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:
D
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, 2020.
• Leave these people off your questionnaire, 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.
1.
How many people were living or staying in this house,
apartment, or mobile home on April 1, 2020?
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
–
Number of people =
FORM
D-Q-UL (01-22-2019) Draft 18
11630019
–
§,‘!<¤
Person 1
5.
9.
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.
What is Person 1’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
What is Person 1’s name? Print name below.
MI
ip
First Name
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
What is Person 1’s sex? Mark K
J ONE box.
I
Female
ze
Male
7.
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
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.
Print numbers in boxes.
Month
Day
Year of birth
years
o
➜ NOTE: Please answer BOTH Question 8 about Hispanic
origin and Question 9 about race. For this census, Hispanic
origins are not races.
Native Hawaiian
Filipino
Korean
Samoan
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
N
Some other race – Print race or origin. C
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
ft:
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
ra
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
D
8.
Vietnamese
Asian Indian
C
Age on April 1, 2020
Chinese
iti
6.
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h
Last Name(s)
➜ If more people were counted in Question 1 on
the front page, continue with Person 2 on the
next page.
2
11630027
§,‘!D¤
1.
Person 2
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
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
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
iti
C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
Print numbers in boxes.
Month
Day
ft:
5.
Chinese
ze
Opposite-sex husband/wife/spouse
ns
h
Yes, at a seasonal or
second residence
o
4.
Yes, for a military assignment
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
N
3.
Yes, for college
Yes, with a parent or
other relative
ip
No
Age on April 1, 2020
Year of birth
ra
years
D
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 3 on the
next page.
3
11630035
§,‘!L¤
1.
Person 3
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Japanese
Chamorro
ze
Asian Indian
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
o
C
iti
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
ns
h
Yes, at a seasonal or
second residence
Female
N
4.
Yes, for a military assignment
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
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, 2020
Year of birth
ra
years
Print numbers in boxes.
Month
Day
ft:
3.
Yes, for college
Yes, with a parent or
other relative
ip
No
6.
D
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 4 on the
next page.
4
11630043
§,‘!S¤
1.
Person 4
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
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
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
iti
C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
Print numbers in boxes.
Month
Day
ft:
5.
Chinese
ze
Opposite-sex husband/wife/spouse
ns
h
Yes, at a seasonal or
second residence
o
4.
Yes, for a military assignment
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
N
3.
Yes, for college
Yes, with a parent or
other relative
ip
No
Age on April 1, 2020
Year of birth
ra
years
D
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 5 on the
next page.
5
11630050
§,‘!e¤
1.
Person 5
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Japanese
Chamorro
ze
Asian Indian
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
o
C
iti
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
ns
h
Yes, at a seasonal or
second residence
Female
N
4.
Yes, for a military assignment
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
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, 2020
Year of birth
ra
years
Print numbers in boxes.
Month
Day
ft:
3.
Yes, for college
Yes, with a parent or
other relative
ip
No
6.
D
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 6 on the
next page.
6
11630068
§,‘!m¤
1.
Person 6
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
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
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
iti
C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
Print numbers in boxes.
Month
Day
ft:
5.
Chinese
ze
Opposite-sex husband/wife/spouse
ns
h
Yes, at a seasonal or
second residence
o
4.
Yes, for a military assignment
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
N
3.
Yes, for college
Yes, with a parent or
other relative
ip
No
Age on April 1, 2020
Year of birth
ra
years
D
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 7 on the
next page.
7
11630076
§,‘!u¤
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 7
First Name
MI
Last Name(s)
Date of Birth
Age on April 1, 2020
Male
Female
Month
Day
Year of birth
years
Yes
MI
Last Name(s)
Date of Birth
Age on April 1, 2020
Male
Female
Month
years
Person 9
MI
Year of birth
No
Related to Person 1?
Yes
No
Last Name(s)
iti
First Name
Day
ze
Sex
ns
h
Person 8
First Name
Related to Person 1?
ip
Sex
Date of Birth
Age on April 1, 2020
Male
Female
years
MI
N
First Name
Year of birth
Related to Person 1?
Yes
No
Age on April 1, 2020
Last Name(s)
Date of Birth
Month
Day
Year of birth
ft:
Sex
Female
years
D
No
FOR OFFICIAL USE ONLY
Thank you for completing your 2020 Census questionnaire.
If your enclosed postage-paid envelope is missing,
please mail your completed questionnaire to:
Related to Person 1?
Yes
ra
Male
Day
o
Person 10
Month
C
Sex
JIC1
JIC2
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
If you need help completing this questionnaire, call toll-free 1-844-330-2020, Sunday through Saturday from 7:00 a.m. to 2:00 a.m. ET.
TDD — Telephone display device for the hearing impaired. Call toll-free 1-844-467-2020, Sunday through Saturday from 7:00 a.m. to 2:00 a.m. ET.
The U.S. Census Bureau estimates that completing the questionnaire will take 10 minutes on average. 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 email comments
to <[email protected]>. Use “Paperwork Reduction Project xxxx-xxxx” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number XXXX-XXXX confirms this
approval. If this number were not displayed, we could not conduct the census.
8
11630084
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |