P4-02 118th CD Verification Form

OMB Number: 0607-0988
Expiration Date: XX-XX-2024

118^th CONGRESSIONAL DISTRICT BOUNDARY

VERIFICATION FORM FOR ________________________

(state name)

I have reviewed the 118^th congressional district boundaries and identifying numbers, and I certify that the boundaries and numbers are correct as shown.

I have reviewed the 118^th congressional district boundaries and identifying numbers, and I certify that the boundaries are correct as shown, except for the following block assignments specified below:

I have reviewed the 118^th congressional district boundaries and identifying numbers. I verify that the boundaries are correct as shown, except for the identified block assignments. In lieu of specifying the incorrect block assignments and/or codes, we are providing corrections by sending a new block equivalency file via e-mail to [email protected].

Date ___________ Signature ____________________________________

Name ___________________________________________________________

Title ___________________________________________________________

Address ___________________________________________________________

City _______________________ State ___________ Zip Code __________

E-mail ___________________________________________________________

Fax ___________________________________________________________

County (code)	Census Tract	Census Block	Incorrect CD	Correct CD

Please return this form by e-mail to [email protected] or by FAX at 301-763-4348.