2010 Questionnaire Info

Draft 6 (1-15-2009)
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U.S. DEPARTMENT OF COMMERCE
First Name
5. Please provide information for each person living here. Start with a
Use a blue or black pen.
MI
person living here who owns or rents this house, apartment, or mobile
home. If the owner or renter lives somewhere else, start with any adult
living here. This will be Person 1.
What is Person 1s name? Print name below.
Start here
Male
Children, such as newborn babies or foster children

Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in baby sitters
People staying here temporarily
No additional people
TDD Telephone display device for the hearing impaired. Call 1-866-783-2010 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
Yes
No
First Name
Month
Day
Female
Thank you for completing your official

2010 Census form.
Yes
No
Owned by you or someone in this household with a

mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
4. What is your telephone number? We may call if we

dont understand an answer.
Area Code + Number
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.
FOR OFFICIAL USE ONLY

JIC1
Mark I
J
K ONE box.
The U.S. Census Bureau estimates that, for the average household, this form will take about 10 minutes to
complete, including the time for reviewing the instructions and answers. Send comments regarding this burden
estimate or any other aspect of this burden to: Paperwork Reduction Project 0607-0919-C, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
<Paperwork@census.gov>; use "Paperwork Project 0607-0919-C" as the subject.
Related to Person 1?
Year
3. Is this house, apartment, or mobile home
NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al
1-866-928-2010 entre las 8:00 a.m. y 9:00 p.m., 7 das a la semana. La llamada telefnica
es gratis.
MI
Date of Birth
FO
Year
IN
Day
IN
Month
FO
Date of Birth
OMB No. 0607-0919-C: Approval Expires 12/31/2011.
JIC2
Form
D-61
Female
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
Age on April 1, 2010
NOTE: Please answer BOTH Question 8 about Hispanic origin and

Question 9 about race. For this census, Hispanic origins are not races.
8. Is Person 1 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 origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C
TI
April 1, 2010 that you did not include in Question 1?

Mark I
J
K all that apply.
MI
Male
7. What is Person 1s age and what is Person 1s date of birth?
O
C
L
A
N
O
2. Were there any additional people staying here
If you need help completing this form, call 1-866-872-6868 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.
Last Name
Sex
Yes
6. What is Person 1s sex? Mark I

J
K ONE box.
9. What is Person 1s race? Mark I

J
K one or more boxes.
Number of people =
If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
No
Female
Person 12
apartment, or mobile home on April 1, 2010?
TI
Year
1. How many people were living or staying in this house,
Day
If someone who has no permanent place to stay is staying

here on April 1, 2010, count that person. Otherwise, he or
she may be missed in the census.
MI
First Name
The Census must also include people without a permanent

place to stay, so:
PY
O
TI
A
FO
Male
No
First Name
Last Name
Yes
MI
Date of Birth
Male
Female
First Name
Month
Sex
Year
Do not count anyone living away either at college or in the

Armed Forces.
Do not count anyone in a nursing home, jail, prison,
detention facility, etc., on April 1, 2010.
Leave these people off your form, 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.
Last Name
(1-15-2009)
White
Black, African Am., or Negro
American Indian or Alaska Native Print name of enrolled or principal tribe. C
Japanese
Asian Indian
Chinese
Korean
Filipino
Vietnamese
Other Asian Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander Print
race, for example, Fijian, Tongan,
and so on. C
Some other race Print race. C
10. Does Person 1 sometimes live or stay somewhere else?

No
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
For child custody

In jail or prison
In a nursing home
For another reason
If more people were counted in Question 1, continue with Person 2.
USCENSUSBUREAU
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D-61- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
D-61- Base prints in BLACK
Last Name
Person 11
Day
Female
Sex
Date of Birth
Month
MI
First Name
IN
Fold Line
Last Name
Male
Person 10
Yes
No
Sex
Year
Person 9
Day
Count all people, including babies, who live and sleep here
most of the time.
The Census Bureau also conducts counts in institutions
and other places, so:
MI
Date of Birth
Month
Male
Female
The Census must count every person living in the United

States on April 1, 2010.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.
Yes
No
First Name
Sex
Year
Day
Last Name
Month
Male
Female
Person 8
Date of Birth
PY
Sex
Fold Line
Last Name
U.S. CENSUS BUREAU
PY
Person 7
Economics and Statistics Administration
This is the official form for all the people at this address.
It is quick and easy, and your answers are protected by law.
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.
Last Name
Last Name
First Name
2. How is this person related to Person 1? Mark I

J
K ONE box.
Male
Female
Male
4. What is this persons age and what is this persons date of birth?
Day
Year of birth
Month
Day
Year of birth
Year of birth

5. Is this person of Hispanic, Latino, or Spanish origin?
Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
6. What is this persons race? Mark I

J
White

J
White
White
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Native Hawaiian
Samoan
and so on. C
No
For child custody
In jail or prison
In a nursing home
For another reason
If more people were counted in Question 1 on the front page,

continue with Person 4.
No
For child custody
In jail or prison
In a nursing home
For another reason

7. Does this person sometimes live or stay somewhere else?
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
If more people
live here, turn
the page and
continue.
FO
IN
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Day
For child custody

In jail or prison
In a nursing home
For another reason
Month
TI

J
White
No

Year of birth
Day

Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Month
Month
No
Female
TI
Fold Line
Native Hawaiian
Samoan
and so on. C
Male
R
FO
IN
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Female

J
White
3. What is this persons sex? Mark I

J
K ONE box.


J
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

Yes, Puerto Rican
Yes, Cuban
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Year of birth
Day
Female

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Month

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
Male

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
Female
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
MI
TI
J
K ONE box.

J
K ONE box.
First Name
MI
Husband or wife
Brother or sister
Father or mother
Grandchild
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
PY
Husband or wife
Brother or sister
Father or mother
Grandchild
First Name
MI
FO
J
K ONE box.
First Name
MI
MI
Last Name
Last Name
IN
First Name
1. Print name of Person 6
Last Name
No
For child custody
In jail or prison
In a nursing home
For another reason
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

For child custody

In jail or prison
In a nursing home
For another reason
If more than six people were counted in Question 1 on

the front page, turn the page and continue.
Form D-61 (1-15-2009)
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D-61 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)

D-61 - Base prints BLACK
Fold Line
PY
Male
Fold Line
Fold Line
PY
Draft 6 (1-15-2009)
Last Name
Last Name
First Name

J
K ONE box.
Male
Female
Male
Day
Year of birth
Month
Day
Year of birth
Year of birth

Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese

J
White

J
White
White
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Native Hawaiian
Samoan
and so on. C
No
For child custody
In jail or prison
In a nursing home
For another reason

No
For child custody
In jail or prison
In a nursing home
For another reason

Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
If more people
live here, turn
the page and
continue.
FO
IN
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Day
For child custody

In jail or prison
In a nursing home
For another reason
Month
TI

J
White
No

Year of birth
Day

Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Month
Month
No
Female
TI
Fold Line
Native Hawaiian
Samoan
and so on. C
Male
R
FO
IN
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Female

J
White

J
K ONE box.


J
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

Yes, Puerto Rican
Yes, Cuban
Husband or wife
Brother or sister
Father or mother
Grandchild
Year of birth
Day
Female

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Month

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
Male

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
Female
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
MI
TI
J
K ONE box.

J
K ONE box.
First Name
MI
Husband or wife
Brother or sister
Father or mother
Grandchild
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
PY
Husband or wife
Brother or sister
Father or mother
Grandchild
First Name
MI
FO
J
K ONE box.
First Name
MI
MI
Last Name
Last Name
IN
First Name
Last Name
No
For child custody
In jail or prison
In a nursing home
For another reason
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

For child custody

In jail or prison
In a nursing home
For another reason

Form D-61 (1-15-2009)
Fold Line
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Fold Line
PY
Male
Fold Line
Fold Line
PY
Draft 6 (1-15-2009)
Last Name
Last Name
First Name

J
K ONE box.
Male
Female
Male
Day
Year of birth
Month
Day
Year of birth
Year of birth

Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese

J
White

J
White
White
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Native Hawaiian
Samoan
and so on. C
No
For child custody
In jail or prison
In a nursing home
For another reason

No
For child custody
In jail or prison
In a nursing home
For another reason

Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Native Hawaiian
Samoan
and so on. C
If more people
live here, turn
the page and
continue.
FO
IN
Native Hawaiian
Samoan
and so on. C
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Day
For child custody

In jail or prison
In a nursing home
For another reason
Month
TI

J
White
No

Year of birth
Day

Yes, Puerto Rican
Yes, Cuban

Yes, Puerto Rican
Yes, Cuban
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
Month
Month
No
Female
TI
Fold Line
Native Hawaiian
Samoan
and so on. C
Male
R
FO
IN
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Female

J
White

J
K ONE box.


J
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

Yes, Puerto Rican
Yes, Cuban
Husband or wife
Brother or sister
Father or mother
Grandchild
Year of birth
Day
Female

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Month

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
Male

J
K ONE box.
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
Female
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative

J
K ONE box.
Husband or wife
Brother or sister
Father or mother
Grandchild
MI
TI
J
K ONE box.

J
K ONE box.
First Name
MI
Husband or wife
Brother or sister
Father or mother
Grandchild
Parent-in-law
Other relative
Roomer or boarder
Unmarried partner
Other nonrelative
PY
Husband or wife
Brother or sister
Father or mother
Grandchild
First Name
MI
FO
J
K ONE box.
First Name
MI
MI
Last Name
Last Name
IN
First Name
Last Name
No
For child custody
In jail or prison
In a nursing home
For another reason
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

For child custody

In jail or prison
In a nursing home
For another reason

Form D-61 (1-15-2009)
Fold Line
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Fold Line
PY
Male
Fold Line
Fold Line
PY
Draft 6 (1-15-2009)
Draft 6 (1-15-2009)
Fold line
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First Name
MI
Start here
Male

Yes
No
First Name
Month
Day
Female

2010 Census form.
Yes
No

Rented?

Area Code + Number

JIC1
Mark I
J
K ONE box.
Year
es gratis.
MI
Date of Birth
FO
Year
IN
Day
IN
Month
FO
Date of Birth
JIC2
Form
D-61
Female
Month
Day
Year of birth


Yes, Puerto Rican
Yes, Cuban
TI

Mark I
J
K all that apply.
MI
Male
O
C
L
A
N
O
Last Name
Sex
Yes

J
K ONE box.

J
Number of people =
U.S. Census Bureau
No
Female
Person 12
TI
Year
Day

MI
First Name

place to stay, so:
PY
O
TI
A
FO
Male
No
First Name
Last Name
Yes
MI
Date of Birth
Male
Female
First Name
Month
Sex
Year

Armed Forces.
Last Name
(1-15-2009)
White
Japanese
Asian Indian
Chinese
Korean
Filipino
Vietnamese
Native Hawaiian
Samoan
and so on. C

No
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
For child custody

In jail or prison
In a nursing home
For another reason
USCENSUSBUREAU
Fold line
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Last Name
Person 11
Day
Female
Sex
Date of Birth
Month
MI
First Name
IN
Fold Line
Last Name
Male
Person 10
Yes
No
Sex
Year
Person 9
Day
most of the time.
MI
Date of Birth
Month
Male
Female

Yes
No
First Name
Sex
Year
Day
Last Name
Month
Male
Female
Person 8
Date of Birth
PY
Sex
Fold Line
Last Name
U.S. CENSUS BUREAU
PY
Person 7
Draft 6 (1-15-2009)
Fold line
Fold line
First Name
MI
Start here
Male

Yes
No
First Name
Month
Day
Female

2010 Census form.
Yes
No

Rented?

Area Code + Number

JIC1
Mark I
J
K ONE box.
Year
es gratis.
MI
Date of Birth
FO
Year
IN
Day
IN
Month
FO
Date of Birth
JIC2
Form
D-61
Female
Month
Day
Year of birth


Yes, Puerto Rican
Yes, Cuban
TI

Mark I
J
K all that apply.
MI
Male
O
C
L
A
N
O
Last Name
Sex
Yes

J
K ONE box.

J
Number of people =
U.S. Census Bureau
No
Female
Person 12
TI
Year
Day

MI
First Name

place to stay, so:
PY
O
TI
A
FO
Male
No
First Name
Last Name
Yes
MI
Date of Birth
Male
Female
First Name
Month
Sex
Year

Armed Forces.
Last Name
(1-15-2009)
White
Japanese
Asian Indian
Chinese
Korean
Filipino
Vietnamese
Native Hawaiian
Samoan
and so on. C

No
Yes Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence
For child custody

In jail or prison
In a nursing home
For another reason
USCENSUSBUREAU
Fold line
Fold line
Last Name
Person 11
Day
Female
Sex
Date of Birth
Month
MI
First Name
IN
Fold Line
Last Name
Male
Person 10
Yes
No
Sex
Year
Person 9
Day
most of the time.
MI
Date of Birth
Month
Male
Female

Yes
No
First Name
Sex
Year
Day
Last Name
Month
Male
Female
Person 8
Date of Birth
PY
Sex
Fold Line
Last Name
U.S. CENSUS BUREAU
PY
Person 7

2010 Questionnaire Info

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Draft 6 (1-15-2009)

U.S. DEPARTMENT OF COMMERCE

Use a blue or black pen.

Children, such as newborn babies or foster children

Thank you for completing your official

Owned by you or someone in this household with a

4. What is your telephone number? We may call if we

FOR OFFICIAL USE ONLY

3. Is this house, apartment, or mobile home

OMB No. 0607-0919-C: Approval Expires 12/31/2011.

Age on April 1, 2010

NOTE: Please answer BOTH Question 8 about Hispanic origin and

8. Is Person 1 of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin

April 1, 2010 that you did not include in Question 1?

7. What is Person 1s age and what is Person 1s date of birth?

2. Were there any additional people staying here

Age on April 1, 2010

6. What is Person 1s sex? Mark I

9. What is Person 1s race? Mark I

apartment, or mobile home on April 1, 2010?

1. How many people were living or staying in this house,

If someone who has no permanent place to stay is staying

The Census must also include people without a permanent

Age on April 1, 2010

Do not count anyone living away either at college or in the

Some other race Print race. C

10. Does Person 1 sometimes live or stay somewhere else?

For child custody

If more people were counted in Question 1, continue with Person 2.

Age on April 1, 2010

Age on April 1, 2010

The Census must count every person living in the United

Age on April 1, 2010

Age on April 1, 2010

U.S. CENSUS BUREAU

Economics and Statistics Administration

2. How is this person related to Person 1? Mark I

Age on April 1, 2010

Age on April 1, 2010

NOTE: Please answer BOTH Question 5 about Hispanic origin and

No, not of Hispanic, Latino, or Spanish origin

6. What is this persons race? Mark I

6. What is this persons race? Mark I

If more people were counted in Question 1 on the front page,

If more people were counted in Question 1 on the front page,

7. Does this person sometimes live or stay somewhere else?

Some other race Print race. C

7. Does this person sometimes live or stay somewhere else?

Some other race Print race. C

Some other race Print race. C

7. Does this person sometimes live or stay somewhere else?

For child custody

NOTE: Please answer BOTH Question 5 about Hispanic origin and

6. What is this persons race? Mark I

If more people were counted in Question 1 on the front page,

No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

7. Does this person sometimes live or stay somewhere else?

Some other race Print race. C

Some other race Print race. C

Age on April 1, 2010

7. Does this person sometimes live or stay somewhere else?

6. What is this persons race? Mark I