Form DX-10 2008 Census Dress Rehearsal Be Counted Form

Draft 3 (7-16-2007)

If you didn’t have room to list everyone who lives in this house or apartment, please list the others
below. You may be contacted by the Census Bureau for the same information about these people.

Person 6

Sex

Last Name

First Name

Date of Birth
Month

Person 7

Day

Last Name

Yes
No

Be Counted!

Date of Birth
Month

Person 8

Day

Related to Person 1?
Year

Who should be listed on this form?
• Include yourself if you have not been counted in the 2008 Census Dress Rehearsal.

Street address number

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

First Name

Date of Birth
Month

Person 9

Day

Last Name

Age on April 1, 2008

Day

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

Rural route BOX number

PO box number

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

County

State or foreign country

The 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-DR, U.S.
Census Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments
to Paperwork@census.gov; use "Paperwork Project 0607-0919-DR" as the subject.
Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

Male
Female

Year

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

ZIP Code

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

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

Rented?

Related to Person 1?

Date of Birth
Month

TDD—Telephone display device for the hearing impaired. Call 1-800-786-9448 between 9:00 a.m. and
9:00 p.m., Monday through Saturday and 11:00 a.m. and 9:00 p.m., Sunday. The telephone call is free.

Yes
No

MI

First Name

➜ NOTE: Please answer BOTH Question 8 about Hispanic origin and

9. What is Person 1’s race? Mark I
J
K one or more boxes.

If you need help completing this form, call 1-866-872-6868 between 9:00 a.m. and 9:00 p.m., Monday
through Saturday, and 11:00 a.m. and 9:00 p.m., Sunday. The telephone call is free.

Sex

Last Name

Street name

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al
1-800-845-8243 entre las 9:00 a.m. y 9:00 p.m., de lunes a sábado, y entre 11:00 a.m. y 9:00 p.m.,
los domingos. La llamada telefónica es gratis.

Year

Female

City

Related to Person 1?

Date of Birth
Day

• If you do not have an address, complete this form and provide information on where you
stayed on April 1, 2008.
PHOTOCOPIES CANNOT BE ACCEPTED

Male
Female

MI

Month

Person 10

Yes
No

Sex

First Name

Age on April 1, 2008

• If you have more than one residence, provide the address of the place where you live most
of the time.

Related to Person 1?
Year

Apartment number

Rural route type and number

Be sure to provide your complete address.

Male

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2008
Month
Day
Year of birth

• Exclude anyone in a nursing home, jail, prison, detention facility, etc., on April 1, 2008.
They will be counted elsewhere.

Male
Female

MI

Age on April 1, 2008

• Exclude anyone who has already been counted in the 2008 Census Dress Rehearsal.

Sex

Last Name

MI

First Name

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

• Exclude people living away at college or in the Armed Forces.

Yes
No

Last Name

Print address below. Please complete all that apply.
Mark I
J
K this box if you had no address on Tuesday, April 1, 2008. Use the boxes below to
identify the location where you stayed. Include city, county, state, ZIP Code, and any other
information such as street or park name.

Who should NOT be listed on this form?
Age on April 1, 2008

to this person as Person 1.
What is Person 1’s name? Print name below.

more than one residence, provide the address of the place where you live most of the time.

• Include family members, nonrelatives, and anyone else who lives and sleeps at your address
most of the time and has not been counted. Do not forget babies!

Male
Female

MI

PHOTOCOPIES CANNOT BE ACCEPTED

• Include anyone else who was living with you on April 1, 2008 who has not yet been counted.

Sex

First Name

5. Start with yourself or any person living with you who was not counted. We will refer

Start here

1. What is the full address of the place you were living on April 1, 2008? If you have

Related to Person 1?
Year

Use a blue or black pen.

2008 Census Dress Rehearsal

Male
Female

MI

Age on April 1, 2008

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Occupied without payment of rent?

Yes
No

➜ Continue with information about the next person who has not been counted.

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

FOR OFFICIAL USE ONLY

Thank you for completing your official
2008 Census Dress Rehearsal form.

JIC1

–

–

JIC2
Form

DX-10

(7-16-2007)

4. Are you filling out this form for ALL of the people who were living or staying
OMB No. 0607-0919-DR: Approval Expires 8/30/2010

at this address on April 1, 2008?
Yes
No

USCENSUSBUREAU
20 Digit Census barcode box
5/8" tall x 4" wide

20 Digit Census barcode readable box
1/8" tall x 1 3/4" wide

20 Digit Census barcode box
5/8" tall x 4" wide

20 Digit Census barcode readable box
1/8" tall x 1 3/4" wide

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800501

Draft 2 (7-16-2007)

1. Print name of

Person 2

1. Print name of

Last Name

1. Print name of

Last Name

First Name

MI

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

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

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

3. What is this person’s sex? 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

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, 2008
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.

➜ 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?
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

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

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

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

Person 5

Last Name
MI

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

MI

First Name

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

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

Male

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.
Month
Day
Year of birth
Age on April 1, 2008

1. Print name of

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

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

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

Female

Person 4

Last Name

First Name

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

Male

Person 3

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.

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.
Month
Day
Age on April 1, 2008
Year of birth

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Age on April 1, 2008
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?

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

5. Is this person 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

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

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.

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

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

Some other race — Print race. C

➜ Continue with information about the next person who has not been counted.

20 Digit Census barcode box
5/8" tall x 4" wide

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

20 Digit Census barcode readable box
1/8" tall x 1 3/4" wide

➜ Continue with information about the next person who has not been counted.

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

Some other race — Print race. C

➜ Continue with information about the next person who has not been counted.

20 Digit Census barcode box
5/8" tall x 4" wide

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

20 Digit Census barcode readable box
1/8" tall x 1 3/4" wide

➜ Continue with information about the next person who has not been counted.

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800502