Other Public Use Forms

DRAFT #1 (1-29-2009)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

This is the official form for all people at this address.
It is easy, and your answers are protected by law.

Use a blue or black pen.

Start here
Do NOT mail this form, your completed form will be picked up by
a census worker.

The "Informational Copy"
shows the content of the
Census 2010 questionnaire
for American Samoa. Each
household will receive a
form, which includes
51 questions relating to
population characteristics
and 24 questions relating to
housing characteristics. The
content of the form resulted
from reviewing the 2000
census data, consulting with
federal and non-federal data
users, and conducting tests.
For additional information
about Census 2010 in
American Samoa, please
write to the Director, U.S.
Census Bureau,
Washington, DC 20233.

The Census must count every person living in
American Samoa on April 1, 2010.
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 April 1, 2010.
• Leave these people off your form, even if they will return to
live here after they leave college, the nursing home, the
military, jail, etc. Otherwise, they may be counted twice.
The Census must also include people without a
permanent place to stay, so:
• If someone who has no permanent place to stay is staying
here on April 1, 2010, count that person. Otherwise, he or
she may be missed in the census.

1. How many people were living or staying in this
house, apartment, or mobile home on April 1, 2010?
Number of people

➔

Please turn the page and print the names of all
the people living or staying here on April 1, 2010.
Please fill out your form promptly. A census worker
will visit your home to pick up your completed
questionnaire or assist you if you have questions.

The U.S. Census Bureau estimates that, for the average household, this form will take
about 64 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 0607-0000, U.S. Census Bureau, 4600 Silver
Hill Road, AMSD-3K138, Washington, DC 20233. You may email comments to
Paperwork@census.gov; use "Paperwork Project 0607-0000" 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.
OMB No. 0000-0000: Approval Expires 00/00/0000

Form

D-61 AS

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797001

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Form D-61 AS

List of Persons
Person 6 — Last Name

➜

Please be sure you answered Question 1 on the
front page before continuing.

2. Please print the names of all the people who
you indicated in Question 1 were living or
staying here on April 1, 2010.
Example — Last Name

MI

First Name

Person 7 — Last Name

C R U Z

J

PY

J O H N

MI

First Name

Start with the 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.

Person 8 — Last Name

First Name

Person 1 — Last Name

O

MI

MI

C

First Name

AL

Person 9 — Last Name
MI

First Name

N

First Name

IO

Person 2 — Last Name

MI

Person 10 — Last Name

MI

AT

First Name

R

M

Person 3 — Last Name

IN
FO

First Name

First Name

MI

Person 11 — Last Name
MI
First Name

MI

Person 4 — Last Name

First Name

Person 12 — Last Name
MI
First Name

MI

Person 5 — Last Name

➜
MI

First Name

Next, answer questions about Person 1. If you
did not have room to list everyone who lives in
this house, apartment, or mobile home, please
tell this to the census worker when you are
visited. The census worker will complete a
census form for the additional people.

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797002

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Form D-61 AS

Person 1
1. What is this person’s name? Print the name
of Person 1 from page 2.

7. Is this person a CITIZEN or NATIONAL of the
United States?

Last Name

Yes, born in this Area – SKIP to question 10a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)

MI

-

3. What is this person’s sex? Mark ✗ ONE box.
Male
Female

9.

N
AT

IO

Print numbers in boxes.
Month
Day
Year of birth

M

5. What is this person’s ethnic origin or race?

FO

R

(For example: Chamorro, Samoan, White, Black,
Carolinian, Filipino, Japanese, Korean, Palauan,
Tongan, and so on.)

6. Where was this person born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

IN

What was this person’s MAIN reason for
moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other

AL

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.
Age on April 1, 2010

O

-

When did this person come to this Area to
stay? If this person has entered the Area
more than once, what is the latest year?
Print numbers in boxes.
Year

PY

2. What is this person’s telephone number? We may
contact this person if we don’t understand an answer.
8.
Area Code + Number

C

First Name

10a. Where was this person’s mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.

b. Where was this person’s father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.

11.

Is this person a dependent of an active-duty
or retired member of the Armed Forces of the
United States or of the full-time military
Reserves or National Guard? Active duty does
NOT include training for the military Reserves or
National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No

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797003

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Form D-61 AS

Person 1 – Continued
12a. At any time since February 1, 2010, has this
person attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.

14.

No, has not attended since February 1 – SKIP to
question 13

Has this person completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or
place of work? Do not include academic college
courses.
No
Yes, in this Area
Yes, not in this Area

Yes, public school, public college
Yes, private school, private college, home school

15a. Does this person speak a language other
than English at home?

What is the highest degree or level of school
this person has COMPLETED? Mark ✗ ONE
box. If currently enrolled, mark the previous grade or
highest degree received.

PY

O

b. What is this language?

(For example: Chamorro, Samoan, Carolinian, Tongan)

c. Does this person speak this language at home
more frequently than English?

N

13.

Yes
No – SKIP to question 16a

C

Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)

AL

b. What grade or level was this person
attending? Mark ✗ ONE box.

IO

NO SCHOOLING COMPLETED
No schooling completed

M

Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA

AT

PRE-KINDERGARTEN THROUGH GRADE 12

R

HIGH SCHOOL GRADUATE

Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English

16a. Did this person live in this house or
apartment 1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house

b. Where did this person live 1 year ago?
Print the name of the island, U.S. state, commonwealth,
territory, or foreign country. If outside this Area, print the
answer below and SKIP to question 17.

FO

Regular high school diploma
GED or alternative credential

COLLEGE OR SOME COLLEGE

c. Name of city, town, or village

IN

Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

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Form D-61 AS

Person 1 – Continued
19c. Does this person have difficulty dressing or
Is this person CURRENTLY covered by any
of the following types of health insurance or
bathing?
health coverage plans? Mark "Yes" or "No" for
Yes
EACH type of coverage in items a–h.
Yes No
No
a. Insurance through a current or former
employer or union (of this person or
Answer question 20 if this person is 15 years old or over.
another family member) . . . . . . . . . . .
Otherwise, SKIP to question 49.
b. Insurance purchased directly from an
insurance company (by this person or
20. Because of a physical, mental, or emotional
another family member) . . . . . . . . . . .
condition, does this person have difficulty
doing errands alone such as visiting a
c. Medicare, for people 65 and older, or
doctor’s office or shopping?
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . .

21.

.

What is this person’s marital status?

O

e. TRICARE or other military health care

Yes
No

Now married
Widowed
Divorced
Separated
Never married

C

f. VA (including those who have ever
used or enrolled for VA health care) . . .
h. Any other type of health insurance or
health coverage plan – Specify

If this person is female, how many babies
has she ever had, not counting stillbirths?
Do not count stepchildren or children she has
adopted.

AT

IO

N

22.

AL

g. Local medical programs for indigents . .

18a. Is this person deaf or does he/she have
serious difficulty hearing?
Yes
No

M

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

FO

R

Yes
No

Answer questions 19a–c if this person is 5 years old or
over. Otherwise, SKIP to question 49.

IN

19a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No

PY

17.

None OR Number of children

23a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No – SKIP to question 24

b. Is this grandparent currently responsible
for most of the basic needs of any
grandchild(ren) under the age of 18 who
live(s) in this house or apartment?
Yes
No – SKIP to question 24

c. How long has this grandparent been
responsible for the(se) grandchild(ren)? If
the grandparent is financially responsible for more
than one grandchild, answer the question for the
grandchild for whom the grandparent has been
responsible for the longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

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Form D-61 AS

Person 1 – Continued

Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 26a
No, never served in the military – SKIP to
question 27a

Yes, worked for pay; did NO subsistence
activity – SKIP to question 28
Yes, worked for pay AND did subsistence
activity – SKIP to question 28
No, did NOT work for pay at a job or business
(or was retired)

b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour? Mark ✗
ONE box.

When did this person serve on active duty
in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if
just for part of the period.

O

C

28.

At what location did this person work LAST
WEEK? Do not include subsistence activity. If this
person worked at more than one location, print where
he or she worked most last week.

a. Name of the island, U.S. state,
commonwealth, territory, or foreign country

AT

IO

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

Yes, worked for pay; did NO subsistence activity
Yes, worked for pay AND did subsistence activity
No, did NOT work for pay; did subsistence
activity – SKIP to question 33a
No, did NOT work for pay; did NO
subsistence activity – SKIP to question 33a

AL

25.

27a. LAST WEEK, did this person work for pay
at a job (or business)? If "Yes," also indicate
whether the person did subsistence activity last
week, such as fishing, growing crops, etc., NOT
primarily for commercial purposes. Mark ✗ ONE
box.

PY

Has this person ever served on active
duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty
does not include training for the Reserves or
National Guard, but DOES include activation, for
example, for the Persian Gulf War.

N

24.

R

M

26a. Does this person have a VA
service-connected disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a

FO

b. What is this person’s service-connected
disability rating?

IN

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

b. Name of city, town, or village

29.

How did this person usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip,
mark ✗ the box of the one used for most of the
distance.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 37
Other method

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Form D-61 AS

Person 1 – Continued
36.

31.

What time did this person usually leave
home to go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.

32.

37–42.

Describe clearly this person’s chief job activity or
business last week. If this person had more than
one job, describe the one at which this person
worked the most hours. If this person had no job
or business last week, give information for
his/her last job or business since 2005.

How many minutes did it usually take this
person to get from home to work LAST
WEEK?
Minutes

IO

N

Answer questions 33–36 if this person did NOT work last
week. Otherwise, SKIP to question 37.

AT

Yes – SKIP to question 33c
No

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

R

M

Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 36
No – SKIP to question 34

FO

c. Has this person been informed that he or
she will be recalled to work within the next
6 months OR been given a date to return to
work?

34.

38.

An employee of a PRIVATE FOR-PROFIT
company or business or of an individual, for
wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business or farm?

For whom did this person work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other
employer

IN

Yes – SKIP to question 35
No

Was this person – Mark ✗ ONE box.

AL

37.

33a. LAST WEEK, was this person on layoff from
a job?

CURRENT OR MOST RECENT JOB
ACTIVITY

PY

How many people, including this person,
usually rode to work in the car, truck, or
private van/bus LAST WEEK?
Person(s)

2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 46
1999 or earlier – SKIP to question 46
Never worked; or did subsistence only – SKIP to
question 46

O

30.

When did this person last work, even for a
few days? Do not include subsistence activity.

C

Answer question 30 if you marked "Car, truck, or
private van/bus" in question 29. Otherwise, SKIP to
question 31.

During the LAST 4 WEEKS, has this person
been ACTIVELY looking for work?
Yes
No – SKIP to question 36

35.

LAST WEEK, could this person have started
a job if offered one, or returned to work if
recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

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Form D-61 AS

Person 1 – Continued
39.

What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, fish cannery, watchmaker,
auto repair shop, bank)

44b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
During 2009, in the WEEKS WORKED, how
many hours did this person usually work
each WEEK? Do not include subsistence activity.
Usual hours worked each WEEK

46.

INCOME IN 2009
Mark ✗ the "Yes" box for each income source
received during 2009, and enter the total amount
received during 2009 to a maximum of $999,999
($99,999 for questions 46d and 46e). Mark ✗ the
"No" box if the income source was not received.

What kind of work was this person doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)

O

PY

45.

C

41.

Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?

AL

40.

What were this person’s most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)

43.

IN

FO

R

M

42.

AT

IO

N

If net income was a loss, enter the amount and mark ✗
the "Loss" box next to the dollar amount.

LAST YEAR, 2009, did this person work at a
job or business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 46

44a. During 2009 (all 52 weeks), did this person
work 50 or more weeks? Count paid time off as
work. Do not include subsistence activity.
Yes – SKIP to question 45
No

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark ✗ the "No" box for the other person. If exact
amount is not known, please give best estimate.

a. Wages, salary, commissions, bonuses, or
tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Annual amount – Dollars
Yes
No

$

,

.00

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report NET
income after business expenses.
Annual amount – Dollars
Loss
Yes
No

$

,

.00

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Annual amount – Dollars
Loss
Yes
No

$

,

.00

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Form D-61 AS

Person 1 – Continued
46d. Social Security or Railroad Retirement.

Please answer questions 49–75 about your household.

Annual amount – Dollars
Yes
No

$

,

49.

.00

Which best describes this building? Include all
apartments, flats, etc., even if vacant.
A mobile home
A one-family house detached from any other house
A one-family house attached to one or more houses
Two houses – Applies only in American
Samoa
Three or more houses – Applies only in
American Samoa
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
A container
Boat, RV, van, etc.

e. Any public assistance or welfare payments
from the state or local welfare office,
including Supplemental Security Income
(SSI).
Annual amount – Dollars

$

,

.00

PY

Yes
No

,

C

$

.00

50.

$

,

.00

IO

Yes
No

,

.00

R

IN

Annual amount – Dollars

None OR

48.

$

,

Loss

2009 or 2010
2000 to 2008
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

When did PERSON 1 (listed on page 2) move
into this living quarters?
2009 or 2010
2000 to 2008
1990 to 1999
1980 to 1989
1970 to 1979
1969 or earlier

What was this person’s total income during
2009? Add entries in questions 46a–46h; subtract
any losses. If net income was a loss, enter the amount
and mark ✗ the "Loss" box next to the dollar amount.

FO

47.

$

M

AT

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support,
or alimony. Do NOT include lump-sum payments
such as money from an inheritance or sale of a home.
51.
Annual amount – Dollars
Yes
No

About when was this building first built?

N

g. Any remittances. Include money from relatives
outside the household or in the military.
Annual amount – Dollars

AL

Yes
No

O

f. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Annual amount – Dollars

Answer question 52 if this is a HOUSE or a MOBILE
HOME. Otherwise, SKIP to question 53a.

.00

52.

During 2009, did this person GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable contributions
or money given to charitable organizations. If exact
amount is not known, please give best estimate.

Is there a business (such as a store or shop)
or a medical office on this property?
Yes
No

Annual amount – Dollars
Yes
No

$

,

.00

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Form D-61 AS

Person 1 – Continued
53a. How many separate rooms are in this living
quarters? Rooms must be separated by built-in
archways or walls that extend from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.
1 room
2 rooms
3 rooms
4 rooms
5 rooms
6 rooms
7 rooms
8 rooms
9 or more rooms

55a. Are your MAIN cooking facilities located
inside or outside this building? Mark ✗ ONE
box.
Inside this building
Outside this building
No cooking facilities – SKIP to question 55c

b. What type of cooking facilities are these?
Mark ✗ ONE box.

No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 or more bedrooms

c. Do you have a refrigerator in this building?
Yes
No

C

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this
living quarters were for sale or rent. If this is an
efficiency/studio apartment, mark ✗ "No bedroom."

O

PY

Electric stove
Kerosene stove
Gas stove
Microwave oven and non-portable burners
Microwave oven only
Other (fireplace, hotplate, etc.)

AL

d. Do you have a sink with piped water in this
building?

N

Yes
No

54a. Do you have hot and cold piped water?

IO

56.

57.

b. Do you have a bathtub or shower?

IN

FO

Yes, in this unit
Yes, in this building, not in unit
Yes, outside this building
No

c. Do you have a flush toilet?
Yes, in this unit – SKIP to question 55a
Yes, in this building, not in unit – SKIP to
question 55a
Yes, outside this building – SKIP to question 55a
No

d. What type of toilet facilities do you have?

Yes, a cell or mobile phone only
Yes, a landline only
Yes, both a cell or mobile phone and a landline
No
Do you have air conditioning?
Yes, a central air-conditioning system
(includes split-type)

R

M

AT

Yes, in this unit
Yes, in this building, not in unit
No, only cold piped water in this unit
No, only cold piped water in this building
No, only cold piped water outside this building
No piped water

Does this living quarters have telephone
service from which you can both make and
receive calls?

Yes, 1 individual room unit
Yes, 2 or more individual room units
No

58.

How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?
None
1
2
3
4
5
6 or more

Outhouse or privy
Other or none

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11

Form D-61 AS

Person 1 – Continued
Do you or any member of this household
have a battery-operated radio? Count car
radios, transistors, and other battery-operated sets in
working order or needing only a new battery for
operation.

66.

What is the MAIN type of material used for
the foundation of this building? Mark ✗ ONE
box.
Concrete
Wood pier or pilings
Other

Yes
No

60a. Do you or any member of this household
have a home computer or laptop? Count only
if computer is in working condition.

67a. What is the average monthly cost for
electricity for this living quarters?
Average monthly cost – Dollars

Yes
No – SKIP to question 61

$

O

Included in rent or condominium fee
No charge or electricity not used

C

b. What is the average monthly cost for gas for
this living quarters?

Do you get water from – Mark ✗ ONE box.

AL
$

AT

62.

Is this building connected to a public sewer?

M

$

R

FO

What is the MAIN type of material used for
the outside walls of this building?
Mark ✗ ONE box.

What is the MAIN type of material used for
the roof of this building? Mark ✗ ONE box.
Poured concrete
Metal
Wood
Other

.00

Included in rent or condominium fee
No charge

d. What is the average monthly cost for oil, coal,
kerosene, wood, etc. for this living quarters?
Average monthly cost – Dollars

$

Poured concrete
Concrete blocks
Metal
Wood
Other

65.

,
OR

IN

64.

Included in rent or condominium fee
Included in electricity payment entered above
No charge or gas not used

Average monthly cost – Dollars

Is this living quarters part of a condominium?
Yes
No

.00

c. What is the average monthly cost for water
and sewer for this living quarters?

Yes, connected to a public sewer
No, connected to a septic tank or cesspool
No, use other means

63.

,

OR

IO

A public system only?
A public system and catchment?
A village water system only? – Applies only in
American Samoa
An individual well?
A catchment, tanks, or drums only?
Some other source (a standpipe, spring, river,
creek, etc.)?

Average monthly cost – Dollars

N

61.

.00

OR

b. Do you or any member of this household
have an Internet connection at this living
quarters?
Yes
No

,

PY

59.

,

.00

OR
Included in rent or condominium fee
No charge or these fuels not used

68.

Is this living quarters – Mark ✗ 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)?
Rented?
Occupied without payment of rent?

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Form D-61 AS

Person 1 – Continued
Answer question 69 if this living quarters is RENTED.
Otherwise, SKIP to question 70.
69.

73b. How much is the regular monthly mortgage
payment on THIS property? Include payment only
on FIRST mortgage or contract to purchase.

What is the monthly rent for this living
quarters?

Monthly amount – Dollars

Monthly amount – Dollars

$

,

$

,

.00

OR

.00

No regular payment required – SKIP to question 74a

70–75. Answer questions 70–75 if you or someone else
in this household OWNS or IS BUYING this living
quarters. Otherwise, SKIP to the questions for
Person 2.

PY

Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required

About how much do you think this house and
lot, apartment, or mobile home (and lot, if
owned) would sell for if it were for sale?

d. Does the regular monthly mortgage payment
include payments for fire, hazard, typhoon,
or flood insurance on THIS property?

O

70.

c. Does the regular monthly mortgage payment
include payments for real estate taxes on
THIS property?

71.

,

,

.00

What were the real estate taxes on THIS
property last year?
Annual amount – Dollars

,

.00

IO

OR
None

What was the annual payment for fire,
hazard, typhoon, and flood insurance on
THIS property?

AT

72.

74a. Do you or any member of this household
have a second mortgage or home equity
loan on THIS property?

N

$

Yes, insurance included in mortgage payment
No, insurance paid separately or no insurance

AL

$

C

Amount – Dollars

,

.00

OR

FO

None

Monthly amount – Dollars

$

R

$

b. How much is the regular monthly payment
on all second or junior mortgages and all
home equity loans on THIS property?

M

Annual amount – Dollars

73a. Do you or any member of this household
have a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?

IN

Yes, mortgage, deed of trust, or similar debt
Yes, contract to purchase
No – SKIP to question 74a

Yes, a home equity loan
Yes, a second mortgage
Yes, both second mortgage and home equity loan
No – SKIP to question 75

,

.00

OR
No regular payment required
Answer question 75 ONLY if this is a CONDOMINIUM.

75.

What is the monthly condominium fee?
Monthly amount – Dollars

$

➔

,

.00

Are there more people living here? If YES,
continue with Person 2 on the next page.

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Form D-61 AS

Person 2
PY

1. What is this person’s name? Print the name
of Person 2 from page 2.

C

O

Last Name

MI

N

AL

First Name

IN

FO

R

M

AT

IO

2. How is this person related to Person 1? Mark ✗
ONE box.
Son-in-law or
Husband or wife
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or
Brother or sister
roommate
Father or mother
Unmarried partner
Grandchild
Other nonrelative
Parent-in-law

For Persons 3–6,
repeat questions
1–46 of Person 2.

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Form D-61 AS

Person 3

For Persons 3–6, repeat
questions 1–51 of Person 2.
NOTE – The content for Question 2
varies between Person 1 and Persons
2–6.
Thank you for completing your
official Census 2010 form. If
there are more than six people
living in this house or
apartment, please make sure
you have completed the form for
the first six people. When the
census worker visits your
residence, he/she will obtain the
information for the additional
people.

(1-29-2009)

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