Form DC-1A 2014 Census Test

Published: 18-Feb-2014 14:58:06

11114121

11114014
U.S. DEPARTMENT OF COMMERCE

2014 Census Test
Use a blue or black pen.

Economics and Statistics Administration

U.S. CENSUS BUREAU

Or go to https://respond.census.gov/censustest to complete the 2014 Census Test.

Start here
Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• 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:
• 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 July 1, 2014.
• 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.
The Census Bureau must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on July 1, 2014, count that person.

1.

How many people were living or staying in this house, apartment, or mobile home on July 1, 2014?
Number of people =

If your enclosed postage-paid envelope is missing, please mail your completed form to:

2.

Mark I
K all that apply.
J

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

×
×
×
×
×

If you need help completing this form, call 1-866-226-2836, Monday through Saturday from 9:00 a.m. to
9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1-800-786-9448, Monday through Saturday
from 9:00 a.m. to 9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.

3.

Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

4.

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

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?

What is your telephone number? We may call if we don't understand an answer.
Area Code + Number
–

–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form

12

Children, such as newborn babies or foster children

Is this house, apartment, or mobile home — Mark I
K ONE box.
J

×
×
×
×

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-888-262-5931
de lunes a sábado entre las 9:00 a.m. y las 9:00 p.m. EST, y los domingos entre las 11:00 a.m. y 9:00 p.m.
EST. La llamada telefónica es gratis.

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 xxxx-xxxx,
U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project xxxx-xxxx" as the subject.

Were there any additional people staying here July 1, 2014 that you did not include in Question 1?

DC-1A (DRAFT)

Published: 18-Feb-2014 14:58:06

11114022

Person 1
5.

9.

Does Person 1 sometimes live or stay somewhere else?

×
×

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

Last Name

10.
MI

Yes — Mark I
K all that apply.
J
In college housing
In the military
For a job or business
For child custody

×
×
×
×

At a seasonal or second residence
In jail or prison
In a nursing home

If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays.

What is Person 1's sex? Mark I
K ONE box.
J

×
7.

Male

×

8.

Apartment Number

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

Rural Route Address

×

Year of birth

×
×

Yes
No

First Name

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 12
First Name

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 13

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

First Name

Last Name

Sex

×
×

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 14
Where does Person 1 live or stay most of the time?

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

Some other race or origin — Print race(s) or origin(s). 

Related to Person 1?

Day

ZIP Code

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

11.

×

×
×

×
×

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

a description in the boxes below.

×

Month

Female

Sex

City

County

×

MI

Date of Birth

Last Name

State

×

×
×

Age on July 1, 2014
Male

Sex

Print numbers in boxes.
Month
Day
Year of birth

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

Sex

Last Name

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.

×

First Name

Last Name

Person 11
Street Name

Female

Age on July 1, 2014

Person 10

For another reason

House Number

6.

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.

No ➜ SKIP to Person 2, if more people live here.

×
×
×
×

What is Person 1's name? Print name below.

First Name

11114113

12.

The address printed on the back of this questionnaire
The address or location you listed in Question 10
Both places equally
Some other place

Sex

×
×

Age on July 1, 2014
Male

Date of Birth
Month

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

FOR OFFICIAL USE ONLY

The address printed on the back of this questionnaire
The address or location you listed in Question 10
Some other place

➜ If more people were counted in Question 1, continue

Thank you for completing the
2014 Census Test.

with Person 2.

2

MI

On July 1, 2014, where was Person 1 staying?

×
×
×
➜ Continue to Question 9.

First Name

Last Name

11

JIC1

JIC2

Published: 18-Feb-2014 14:58:06

11114105

1.

Print name of

Person 9

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law
Son-in-law or daughter-in-law

7.

Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

8.

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

page, continue with Person 10.

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

10

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

The address or location you listed in Question 7

Some other place

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

For another reason

Street Name

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

➜ Continue to Question 6.

Where does this person live or stay most of the time?

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 2

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114030

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 3.

3

Published: 18-Feb-2014 14:58:06

11114048

1.

Print name of

Person 3

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 4.

4

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 8

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114097

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 9.

9

Published: 18-Feb-2014 14:58:06

11114089

1.

Print name of

Person 7

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 8.

8

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 4

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114055

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 5.

5

Published: 18-Feb-2014 14:58:06

11114063

1.

Print name of

Person 5

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 6.

6

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 6

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114071

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 7.

7

Published: 18-Feb-2014 14:58:06

11114063

1.

Print name of

Person 5

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 6.

6

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 6

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114071

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 7.

7

Published: 18-Feb-2014 14:58:06

11114089

1.

Print name of

Person 7

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 8.

8

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 4

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114055

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 5.

5

Published: 18-Feb-2014 14:58:06

11114048

1.

Print name of

Person 3

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

page, continue with Person 4.

4

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Street Name

The address or location you listed in Question 7

Some other place

For another reason

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 8

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114097

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 9.

9

Published: 18-Feb-2014 14:58:06

11114105

1.

Print name of

Person 9

6.

Last Name

×
×

First Name

2.

Unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law
Son-in-law or daughter-in-law

7.

Other relative

In college housing
In the military
For a job or business
For child custody

×
×
×
×

Male

×

In a nursing home
For another reason

2.

Street Name

Other nonrelative

3.
Apartment Number

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
Print numbers in boxes.
than 1 year old.
Day

Year of birth

4.

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

Parent-in-law

7.

Son-in-law or daughter-in-law
Other relative

Foster child

×

American Indian or Alaska Native — Print name of enrolled or

×

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

8.

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

Male

×

Female
Apartment Number

Month

Day

Year of birth

Rural Route Address

×

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

City

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

State

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

×
×

American Indian or Alaska Native — Print name of enrolled or

8.

principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

9.

×

page, continue with Person 10.

Where does this person live or stay most of the time?

×
×
×
×

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Both places equally
Some other place

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

Some other place

➜ If more people were counted in Question 1 on the front

10

a description in the boxes below.

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

The address printed on the back of this questionnaire
The address or location you listed in Question 7

ZIP Code

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

The address or location you listed in Question 7

Some other place

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

The address printed on the back of this questionnaire

Both places equally

For another reason

Street Name

On July 1, 2014, where was this person staying?

×
×
×

Some other race or origin — Print race(s) or origin(s). 

➜ Continue to Question 6.

Where does this person live or stay most of the time?

In a nursing home

Other nonrelative

a description in the boxes below.

×

For child custody

In jail or prison

Housemate or roommate

➜ NOTE: If there is no street address or if this is a facility, please print
Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

For a job or business

At a seasonal or second residence

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
Print numbers in boxes.
than 1 year old.

×

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

In the military

×
×
×
×

House Number

Roomer or boarder

County

×

In college housing

Grandchild

Age on July 1, 2014

5.

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

Unmarried partner

×
×
×
×
×
×
×

Yes — Mark I
K all that apply.
J

×
×
×
×

MI

Husband or wife

No ➜ SKIP to the next person, if more people live here.

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

×

Rural Route Address

×

×
×

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

×
×
×
×
×
×
×
×

If you marked yes to Question 6, please provide the full
address of the other place where this person sometimes
lives or stays.

Female

Month

Does this person sometimes live or stay somewhere else?

In jail or prison

Housemate or roommate
Foster child

6.

First Name

At a seasonal or second residence

House Number

Roomer or boarder

Person 2

Last Name

Grandchild

Age on July 1, 2014

5.

×
×
×
×
×
×
×

Print name of

Yes — Mark I
K all that apply.
J

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

×
4.

Husband or wife

1.

No ➜ SKIP to the next person, if more people live here.

×
×
×
×

MI

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

×
×
×
×
×
×
×
×
3.

Does this person sometimes live or stay somewhere else?

11114030

The address printed on the back of this questionnaire
The address or location you listed in Question 7
Some other place

➜ If more people were counted in Question 1 on the front

➜ Continue to Question 6.

page, continue with Person 3.

3

Published: 18-Feb-2014 14:58:06

11114022

Person 1
5.

9.

Does Person 1 sometimes live or stay somewhere else?

×
×

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

Last Name

10.
MI

Yes — Mark I
K all that apply.
J
In college housing
In the military
For a job or business
For child custody

×
×
×
×

At a seasonal or second residence
In jail or prison
In a nursing home

If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays.

What is Person 1's sex? Mark I
K ONE box.
J

×
7.

Male

×

8.

Apartment Number

What is this person's race or origin? Mark I
K one or more
J
boxes AND write in the specific race(s) or origin(s).

×

Hispanic, Latino, or Spanish origin — Print origin(s), for example,

Rural Route Address

×

Year of birth

×
×

Yes
No

First Name

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 12
First Name

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 13

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. 

➜ NOTE: If there is no street address or if this is a facility, please print

American Indian or Alaska Native — Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee
(Creek) Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on. 

First Name

Last Name

Sex

×
×

Age on July 1, 2014

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

Person 14
Where does Person 1 live or stay most of the time?

×
×
×
×

Native Hawaiian or Other Pacific Islander — Print origin(s), for
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. 

Some other race or origin — Print race(s) or origin(s). 

Related to Person 1?

Day

ZIP Code

Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somalian, and so on. 

11.

×

×
×

×
×

Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. 

a description in the boxes below.

×

Month

Female

Sex

City

County

×

MI

Date of Birth

Last Name

State

×

×
×

Age on July 1, 2014
Male

Sex

Print numbers in boxes.
Month
Day
Year of birth

White — Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. 

Sex

Last Name

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.

×

First Name

Last Name

Person 11
Street Name

Female

Age on July 1, 2014

Person 10

For another reason

House Number

6.

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.

No ➜ SKIP to Person 2, if more people live here.

×
×
×
×

What is Person 1's name? Print name below.

First Name

11114113

12.

The address printed on the back of this questionnaire
The address or location you listed in Question 10
Both places equally
Some other place

Sex

×
×

Age on July 1, 2014
Male

Date of Birth
Month

Related to Person 1?

Day

Year of birth

Female

×
×

Yes
No

FOR OFFICIAL USE ONLY

The address printed on the back of this questionnaire
The address or location you listed in Question 10
Some other place

➜ If more people were counted in Question 1, continue

Thank you for completing the
2014 Census Test.

with Person 2.

2

MI

On July 1, 2014, where was Person 1 staying?

×
×
×
➜ Continue to Question 9.

First Name

Last Name

11

JIC1

JIC2

Published: 18-Feb-2014 14:58:06

11114121

11114014
U.S. DEPARTMENT OF COMMERCE

2014 Census Test
Use a blue or black pen.

Economics and Statistics Administration

U.S. CENSUS BUREAU

Or go to https://respond.census.gov/censustest to complete the 2014 Census Test.

Start here
Before you answer Question 1, count the people living in this house, apartment, or mobile home using our guidelines.
• 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:
• 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 July 1, 2014.
• 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.
The Census Bureau must also include people without a permanent place to stay, so:
• If someone who has no permanent place to stay is staying here on July 1, 2014, count that person.

1.

How many people were living or staying in this house, apartment, or mobile home on July 1, 2014?
Number of people =

If your enclosed postage-paid envelope is missing, please mail your completed form to:

2.

Mark I
K all that apply.
J

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

×
×
×
×
×

If you need help completing this form, call 1-866-226-2836, Monday through Saturday from 9:00 a.m. to
9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1-800-786-9448, Monday through Saturday
from 9:00 a.m. to 9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.

3.

Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

4.

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

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?

What is your telephone number? We may call if we don't understand an answer.
Area Code + Number
–

–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form

12

Children, such as newborn babies or foster children

Is this house, apartment, or mobile home — Mark I
K ONE box.
J

×
×
×
×

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-888-262-5931
de lunes a sábado entre las 9:00 a.m. y las 9:00 p.m. EST, y los domingos entre las 11:00 a.m. y 9:00 p.m.
EST. La llamada telefónica es gratis.

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 xxxx-xxxx,
U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project xxxx-xxxx" as the subject.

Were there any additional people staying here July 1, 2014 that you did not include in Question 1?

DC-1A (DRAFT)