DX-21 Military Census Report - English

OMB No. 0607-0919-DR: Approval Expires 8/30/2010

2008 Census Dress Rehearsal
Military Census Report

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

Use a blue or black pen.

Start here
6. What is the full name and address of the

1. What is your name? Print name below.

place (barrack/dormitory, disciplinary
barrack/jail, military treatment facility)
where you are assigned?

Last Name

First Name

MI

Please complete all that apply.
Military installation or Base name

2. What is your sex? Mark I
J
K ONE box.
Male

Female

3. What is your age and what is your 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

Barrack or dormitory name

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and
Question 5 about race. For this census, Hispanic origins are not races.

4. Are you 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

Barrack or dormitory number

Street number

Street name

5. What is your 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

Some other race — Print race. C
Form DX-21 (8-30-2007)

§qB"¤
803301

USCENSUSBUREAU

Draft 10 (8-30-2007)
DX-21 - Pantone Green 368 - 10%, 40%, 50%, 65% and 100%,

DX-21 - Base Black ink
Barcode Box
7/16" tall, 1 7/8" wide

Eye Readable Box
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DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

March 17, 2008

The U.S. Constitution requires that a census of the United States be conducted every 10 years.
To prepare for the 2010 Census, the U.S. Census Bureau is conducting the 2008 Census Dress
Rehearsal. The results will be used to develop better methods that will make the 2010 Census easier,
more convenient, and less costly for taxpayers.
It is important that everyone be counted, regardless of where they may be living at the time of the
census. This Military Census Report is to be used to count people who are assigned to military
group quarters, such as barracks, dormitories, disciplinary barracks or jails, or military treatment
facilities.
Your answers are confidential. That means the Census Bureau cannot give out information that identifies
you. Your survey answers will only be used for statistical purposes, and for no other purpose. As allowed
by law, census forms become public after 72 years (Title 44, United States Code, Section 2108).
Please follow the instructions you were given when you received this form for returning it to the
appropriate person.
Sincerely,

Charles Louis Kincannon
Director, U.S. Census Bureau

www.census.gov/2010census

Thank you for completing your official
2008 Census Dress Rehearsal form.
FOR OFFICIAL USE ONLY
The U.S. Census Bureau estimates that, for the average respondent,
this form will take about 5 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.

FORM DX-21 (8-30-2007)

DX-21 - Base Black ink

GQ Control Number

A. PN

B. JIC1

C. JIC2

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803302

DX-21 - Pantone Green 368 - 10%, 40%, 50%, 65%, and 100%