SC-921 Special Census Add Page

FORM

SC-921 (1-19-2023)

OMB No. 0607-0368

This listing contains confidential information, including Title 13 and Personally Identifiable Information (PII), the release of which is prohibited by the Privacy Act of 1974.
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

ADD PAGE
Special Census
Line
No.

Case ID
(from Form SC-Q)

Date Listed

(2)

(4)

Block No.
(1)

(3)

Address
Status

Address
No.

(6)

(7)

Address Status:
HU – Housing Unit
GQ – Group Quarters

AA:

TL – Transitory Location
GQ or TL Name/Facility Name

Location Address or Physical Location Description

Date SC-Q
Completed
(5)

SCID:

(12)

Street or Road Name

Apt/Unit No.

(8)

(10)

(13)

Physical Location Description

ZIP Code

GQ or TL Contact Telephone Number

(9)

(11)

(14)

GQ or TL Contact Name

FS
Use
Only

(15)