Document
D-1 PR English Fulfillment PR
ICR 200910-0607-004 · OMB 0607-0919 · Object 14099001.
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0919 can be found here:
Document [pdf]
Download: pdf | txt
➞ Fold line ➞ U.S. DEPARTMENT OF COMMERCE 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 Last Name First Name Age on April 1, 2010 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 1’s name? Print name below. Male Female Person 8 Sex Month Last Name Age on April 1, 2010 Male Female Person 9 Day Year First Name Day Related to Person 1? 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. Yes No Last Name Age on April 1, 2010 Male First Name MI Date of Birth Month Day Related to Person 1? Year Female The Census must also include people without a permanent place to stay, so: Yes • 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. No Last Name First Name MI 1. How many people were living or staying in this house, Last Name MI First Name 6. What is Person 1’s sex? Mark I J K ONE box. Male Female 7. What is Person 1’s age and what is Person 1’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age on April 1, 2010 Month Day Year of birth ➜ 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 ➞ ➞ Person 10 • 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 The Census must count every person living in the Puerto Rico 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 apartment, or mobile home on April 1, 2010? Age on April 1, 2010 Sex Male Month Day Year Female Person 11 Yes No First Name Last Name 2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1? Mark I J K all that apply. 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 MI 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. Sex Age on April 1, 2010 Month Male Related to Person 1? Date of Birth Day Year Sex Last Name Age on April 1, 2010 Male 3. Is this house, apartment, or mobile home — Mark I J K ONE box. No Female Person 12 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 First Name Day Year Female Yes No JIC1 4. What is your telephone number? We may call if we don’t 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 Thank you for completing your official 2010 Census form. 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? 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? Date of Birth Month ¿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 días a la semana. La llamada telefónica es gratis. MI 9. What is Person 1’s 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 Related to Person 1? Date of Birth JIC2 – OMB No. 0607-0919-C: Approval Expires 12/31/2011. Form D-1 §j*"¤ 730901 Fold line ➞ PR (7-6-2008) USCENSUSBUREAU Fold line ➞ 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. D-1 PR - Base prints in BLACK Fold Line Sex Related to Person 1? Date of Birth U.S. CENSUS BUREAU 5. Please provide information for each person living here. Start with a Use a blue or black pen. MI Start here Sex 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. D-1 PR - Prints Pantone Process Green #320 (10%, 20%, 40%, 50%, 65% and 100%) Fold line Fold Line Draft 1 (7-6-2008) Last Name Last Name Last Name First Name First Name MI J K ONE box. 2. How is this person related to Person 1? Mark I Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild J K ONE box. 3. What is this person’s sex? Mark I 3. What is this person’s sex? Mark I J K ONE box. Female Male 4. What is this person’s age and what is this person’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age on April 1, 2010 Month Day Year of birth Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Female Male Fold Line ➞ 3. What is this person’s sex? Mark I J K ONE box. Female Male 4. What is this person’s age and what is this person’s date of birth? Female 4. What is this person’s age and what is this person’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age on April 1, 2010 Age on April 1, 2010 Age on April 1, 2010 Age on April 1, 2010 Month Day Year of birth Month Day Year of birth No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban 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 Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C 6. What is this person’s race? Mark I J K one or more boxes. Month Day Year of birth Month Day Year of birth ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this census, Hispanic origins are not races. 5. Is this person of Hispanic, Latino, or Spanish origin? 5. Is this person of Hispanic, Latino, or Spanish origin? Question 6 about race. For this census, Hispanic origins are not races. 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 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 6. What is this person’s race? Mark I J K one or more boxes. 6. What is this person’s race? Mark I J K one or more boxes. White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. C Asian Indian Japanese Chinese Korean Filipino Vietnamese Other Asian — Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Asian Indian Japanese Chinese Korean Filipino Vietnamese Other Asian — Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Asian Indian Japanese Chinese Korean Filipino Vietnamese Other Asian — Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Asian Indian Japanese Chinese Korean Filipino Vietnamese Other Asian — Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C Asian Indian Japanese 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 7. Does this person sometimes live or stay somewhere else? No 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 3. ➜ 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 If more people were counted in Question 1 on the front page, continue with Person 5. ➜ 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 Guamanian or Chamorro Samoan Other Pacific Islander — Print race, for example, Fijian, Tongan, and so on. C Some other race — Print race. C 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 Guamanian or Chamorro Samoan Other Pacific Islander — Print race, for example, Fijian, Tongan, and so on. C Some other race — Print race. C 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 Guamanian or Chamorro Samoan Other Pacific Islander — Print race, for example, Fijian, Tongan, and so on. C Some other race — Print race. C 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 Guamanian or Chamorro Samoan Other Pacific Islander — Print race, for example, Fijian, Tongan, and so on. C 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 If more people were counted in Question 1 on the front page, continue with Person 6. ➜ 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-1 PR (7-6-2008) Fold Line ➞ §j*#¤ 730902 Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. 6. What is this person’s race? Mark I J K one or more boxes. Some other race — Print race. C ➜ Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this census, Hispanic origins are not races. Question 6 about race. For this census, Hispanic origins are not races. Question 6 about race. For this census, Hispanic origins are not races. 5. Is this person of Hispanic, Latino, or Spanish origin? 5. Is this person of Hispanic, Latino, or Spanish origin? 5. Is this person of Hispanic, Latino, or Spanish origin? 6. What is this person’s race? Mark I J K one or more boxes. MI 2. How is this person related to Person 1? Mark I J K ONE box. Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative 3. What is this person’s sex? Mark I J K ONE box. Male ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 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 Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Female 4. What is this person’s age and what is this person’s date of birth? First Name MI 2. How is this person related to Person 1? Mark I J K ONE box. Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative 3. What is this person’s sex? Mark I J K ONE box. 4. What is this person’s age and what is this person’s date of birth? Last Name First Name MI 2. How is this person related to Person 1? Mark I J K ONE box. Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative 1. Print name of Person 6 Last Name First Name MI 2. How is this person related to Person 1? Mark I J K ONE box. Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative 1. Print name of Person 5 1. Print name of Person 4 Fold Line ➞ ➜ If more people live here, turn the page and continue. Fold Line ➞ 1. Print name of Person 3 D-1 PR - Pantone Process green # 320 (10%, 40%, 65% and 100%) 1. Print name of Person 2 Male Fold Line ➞ Fold Line ➞ D-1 PR- Base prints BLACK Draft 1 (7-6-2008)
| File Type | application/pdf |
| File Title | D-1PR_1_1.g |
| File Modified | 2008-07-07 |
| File Created | 2008-07-07 |