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Form D-61 Informational Copy of MOMB Questionnaire

ICR 201006-0607-003 · OMB 0607-0919 · Object 18140901.

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Draft 2 (9-25-2008)

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U.S. DEPARTMENT OF COMMERCE

5. Please provide information for each person living here. Start with a

Use a blue or black pen.

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.

Start here

Sex
Male

Related to Person 1?

Date of Birth
Month

Day

Year

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

Year

Female

Yes
No

JIC1

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
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.

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
; use "Paperwork Project 0607-0919-C" as the subject.

Related to Person 1?

Date of Birth

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 días a la semana. La llamada telefónica
es gratis.

JIC2

–

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

§,,"¤
111101
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D-61(9-25-2008)

USCENSUSBUREAU

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➞

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.
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.

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

9. What is Person 1’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

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.

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

A
N
TI

April 1, 2010 that you did not include in Question 1?
Mark I
J
K all that apply.

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

Age on April 1, 2010

2. Were there any additional people staying here

Female

Person 12

Yes

First Name

Number of people =

Male

Age on April 1, 2010

Year

apartment, or mobile home on April 1, 2010?

Sex

Day

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

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?
No

Last Name

Person 11

Month

Female

Date of Birth

• 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.

First Name

Male

First Name

➞

Last Name

Age on April 1, 2010

Sex

Yes

Female

Person 10

Year

The Census must also include people without a permanent
place to stay, so:

Day

Related to Person 1?

Month

Male

Date of Birth

Age on April 1, 2010

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Sex

Last Name

First Name

• 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

Yes

Year

Day

Month

Male
Female

Person 9

Related to Person 1?

Date of Birth

Age on April 1, 2010

• 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:

First Name

Last Name

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

Year

Day

Sex

Month

Male
Female

Person 8

Related to Person 1?

Date of Birth

Age on April 1, 2010

Sex

D-61- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)

D-61- Base prints in BLACK

First Name

U.S. CENSUS BUREAU

Last Name

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.

Month

Day

Year of birth

➜

Yes — Mark I
J
K all that apply.

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, 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 3.

➜

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

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.

➜

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

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

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

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
No

Question 6 about race. For this census, Hispanic origins are not races.

6. What is this person’s race? Mark I
J
K one or more boxes.

Some other race — Print race. C

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Year of birth

5. Is this person of Hispanic, Latino, or Spanish origin?

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Day

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Month

Question 6 about race. For this census, Hispanic origins are not races.
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.

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

Age on April 1, 2010

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
In college housing
In the military
At a seasonal
or second residence

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Day

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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

A
N

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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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

6. What is this person’s race? Mark I
J
K one or more boxes.

Month

Year of birth

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-61 (9-25-2008)

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➜ If more people
live here, turn
the page and
continue.

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Age on April 1, 2010

Day

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

D-1 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)

Age on April 1, 2010

Month

4. What is this person’s age and what is this person’s date of birth?

D-1 - Base prints BLACK

Age on April 1, 2010

Female

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.

Male

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

Female

4. What is this person’s age and what is this person’s date of birth?

Male

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.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Year of birth

Female

4. What is this person’s age and what is this person’s date of birth?

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Male

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.

Day

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?

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Female

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

Male

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

Female

Age on April 1, 2010

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?

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

§,,#¤
111102

J
K ONE box.
3. What is this person’s sex? Mark I

2. How is this person related to Person 1? Mark I
J
K ONE box.

First Name

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

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

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

First Name

2. How is this person related to Person 1? Mark I
J
K ONE box.

J
K ONE box.
2. How is this person related to Person 1? Mark I

First Name

Last Name

First Name

1. Print name of Person 6

Last Name

1. Print name of Person 5

1. Print name of Person 4

1. Print name of Person 3

1. Print name of Person 2

Male

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Draft 2 (9-25-2008)

File Type	application/pdf
File Title	D-61p1.g
File Modified	2008-09-25
File Created	2008-09-25