DX-10 Be Counted - English

Draft 8 (9-5-2007)

If you don’t have room to list everyone who lives with you and has not been counted, 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

Yes
No

Be Counted!
Who should be listed on this form?

• 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

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

Date of Birth
Month

Person 8

Day

Date of Birth
Month

Day

Last Name

• If you have more than one residence, provide the address of the place where you live most
of the time.
• If you do not have an address, complete this form and provide information on where you
stayed on April 1, 2008.

Age on April 1, 2008

Month

Day

Rural route BOX number

PO box number

Age on April 1, 2008

Yes
No

Month

¿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 las 11:00 a.m. y 9:00 p.m., los domingos. La
llamada telefónica es gratis.

Related to Person 1?

Date of Birth
Day

Year

Yes
No

FOR OFFICIAL USE ONLY

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

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 between 11:00 a.m. and 9:00 p.m., Sunday. The telephone call is free.
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 between 11:00 a.m. and 9:00 p.m., Sunday. The telephone
call is free.

Male
Female

MI

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

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

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

State or foreign country

Sex

First Name

Female

City

PHOTOCOPIES CANNOT BE ACCEPTED

Related to Person 1?

Last Name

Male

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

Male
Female

Year

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

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

Sex

Date of Birth

MI

First Name

Question 9 about race. For this census, Hispanic origins are not races.

Be sure to provide your complete address.

Yes
No

MI

Last Name

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

County

First Name

Person 10

Street name

Rural route type and number

Related to Person 1?
Year

Apartment number

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

Male
Female

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

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

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

Yes
No

MI

Age on April 1, 2008

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

Sex

Last Name

First Name

Person 9

Related to Person 1?
Year

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.
Street address number

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

Sex

First Name

PHOTOCOPIES CANNOT BE ACCEPTED

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

• Include yourself if you have not been counted in the 2008 Census Dress Rehearsal.
Last 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

JIC1

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-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.

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)?

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

Rented?
Occupied without payment of rent?

➜ 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
–

–

JIC2
Form

DX-10

(9-5-2007)

USCENSUSBUREAU

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

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800501

Draft 8 (9-5-2007)

1. Print name of

Person 2

1. Print name of

Last Name

1. Print name of

Last Name

First Name

MI

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

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

Person 3

First Name

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

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

➜ 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?
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

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

First Name

MI

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

3. What is this person’s sex? 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.
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.

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

Person 5

Last Name

Last Name

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

Female

Person 4

First Name

MI

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

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

Female

Male

4. What is this person’s age and what is this person’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 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.

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.

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.
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.

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.

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

Japanese
Asian Indian
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

➜ 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

➜ 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

➜ 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

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

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800502