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 the U.S. Virgin Islands.
Each household will receive
a form, which includes
46 questions relating to
population characteristics
and 25 questions relating to
housing characteristics. The
content of the form resulted
from reviewing the 2000
census data, consulting with
federal and nonfederal data
users, and conducting tests.
For additional information
about Census 2010 in the
U.S. Virgin Islands, please
write to the Director, U.S.
Census Bureau,
Washington, DC 20233.

The Census must count every person living in the
U.S. Virgin Islands 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 42 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

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D-61 VI

797301

(1-29-2009)

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Form D-61 VI

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 O H N

J

MI

First Name

PY

MI

Person 8 — Last 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.

O

First Name

MI

C

First Name

Person 1 — Last 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

MI

Person 11 — Last Name
MI
First Name

FO

First Name

First Name

MI

IN

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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797302

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Form D-61 VI

Person 1
6. What is this person’s race? Mark ✗ one or more
boxes.

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

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

MI

First Name

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

-

PY

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

-

O

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

C

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.
Age on April 1, 2010

AL
N

AT

IO

Print numbers in boxes.
Month
Day
Year of birth

➔

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

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

M

5. Is this person of Hispanic, Latino, or Spanish
origin?

7. Where was this person born? Print St. Croix,
St. John, or St. Thomas if in the U.S. Virgin Islands, or
the name of the U.S. state, commonwealth, territory,
or foreign country.

IN

FO

R

No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican Am., Chicano
Yes, another Hispanic, Latino, or Spanish origin –
Print origin, for example, Argentinean, Colombian,
Cuban, Nicaraguan, Salvadoran, Spaniard, and
so on.

Some other race – Print race.

8. Is this person a CITIZEN of the United States?
Yes, born in the U.S. Virgin Islands – SKIP to
question 10a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)

9.

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

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Form D-61 VI

Person 1 – Continued
10a. Where was this person’s mother born? Print
12.
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.

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.
NO SCHOOLING COMPLETED
No schooling completed

b. Where was this person’s father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.

NURSERY SCHOOL OR PRESCHOOL
THROUGH GRADE 12

PY

Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11

11a. At any time since February 1, 2010, has this
person attended school or college? Include
only nursery school or preschool, kindergarten,
elementary school, home school, and schooling which
leads to a high school diploma or a college degree.

12th grade – NO DIPLOMA

O

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

C

No, has not attended since February 1 – SKIP to
question 12
Yes, public school, public college
Yes, private school, private college, home school

FO

R

M

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)

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)

AL

AT

IO

Nursery school, preschool
Kindergarten
Grade 1 through 12 –
Specify grade 1–12

N

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

COLLEGE OR SOME COLLEGE

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)

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 the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands

14a. Does this person speak a language other
than English at home?
Yes
No – SKIP to question 15a

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Form D-61 VI

Person 1 – Continued
14b. What is this language?

(For example: French, Spanish, Chinese, Italian)

17a. Is this person deaf or does he/she have
serious difficulty hearing?
Yes
No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Yes
No

PY

18a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

b. Where did this person live 1 year ago?

c. Name of city, town, or village

AL
Yes
No

IO

c. Does this person have difficulty dressing or
bathing?

AT

Is this person CURRENTLY covered by any
of the following types of health insurance or
health coverage plans? Mark "Yes" or "No" for
EACH type of coverage in items a–g.
Yes No
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . .

FO

c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .

19.

20.

IN

g. Any other type of health insurance or
health coverage plan – Specify

What is this person’s marital status?
Now married
Widowed
Divorced
Separated
Never married

.

f. VA (including those who have ever
used or enrolled for VA health care) . . .

Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No

d. Medicaid, Medical Assistance, or any
kind of federal government-assistance
plan for those with low incomes or a
disability . . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care

Yes
No

Answer question 19 if this person is 15 years old or over.
Otherwise, SKIP to question 47.

R

M

16.

b. Does this person have serious difficulty
walking or climbing stairs?

N

Name of the Island in the U.S. Virgin Islands,
or the name of U.S. State, commonwealth,
territory, or foreign country

O

Person is under 1 year old – SKIP to question 16
Yes, this house – SKIP to question 16
No, different house

Answer questions 18a–c if this person is 5 years old or
over. Otherwise, SKIP to question 47.

C

15a. Did this person live in this house or
apartment 1 year ago (on April 1, 2009)?

21.

If this person is female, how many babies
has she ever had, not counting stillbirths?
Do not count stepchildren or children she has
adopted.
None OR Number of children

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Form D-61 VI

Person 1 – Continued
22a. 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 23

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?

25a. Does this person have a VA
service-connected disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 26a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

26a. LAST WEEK, did this person work for pay
at a job (or business)?

O

Yes – SKIP to question 27
No, did not work (or retired)

C

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.

PY

Yes
No – SKIP to question 23

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

Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last week.

AT

IO

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

27.
23.

AL

Yes
No – SKIP to question 32a

b. Name of city, town, or village

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.

IN

24.

FO

R

M

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 25a
No, never served in the military – SKIP to
question 26a

a. Name of the island in the U.S. Virgin Islands,
or name of U.S. state, commonwealth,
territory, or foreign country

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

28.

How did this person usually get to work
LAST WEEK? 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 van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 36
Other method

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Form D-61 VI

Person 1 – Continued

30.

31.

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

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

When did this person last work, even for a
few days?
2005 to 2010
2004 or earlier, or never worked – SKIP to
question 45

36–41.

CURRENT OR MOST RECENT JOB
ACTIVITY

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.
36.

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

Was this person –
Mark ✗ ONE box.

O

29.

35.

PY

Answer question 29 if you marked "Car, truck, or van"
in question 28. Otherwise, SKIP to question 30.

An employee of a PRIVATE FOR-PROFIT
company or business or of an individual, for
wages, salary, or commissions?

C

Minutes

AL

IO

Yes – SKIP to question 32c
No

N

Answer questions 32–35 if this person did NOT work last
week. Otherwise, SKIP to question 36.

32a. LAST WEEK, was this person on layoff from
a job?

AT

b. LAST WEEK, was this person TEMPORARILY 37.
absent from a job or business?

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

R

M

Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 35
No – SKIP to question 33

An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local GOVERNMENT employee (territorial, 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?

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?

33.

IN

Yes – SKIP to question 34
No
During the LAST 4 WEEKS, has this person
been ACTIVELY looking for work?
Yes
No – SKIP to question 35

34.

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 VI

Person 1 – Continued
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

44.

During 2009, in the WEEKS WORKED, how
many hours did this person usually work
each WEEK?
Usual hours worked each WEEK

45.

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 45d and 45e). Mark ✗ the
"No" box if the income source was not received.

O

PY

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

40.

43b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

C

39.

What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto repair shop, bank)

What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)

AL

38.

What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

42.

IN

FO

R

M

41.

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?
Yes
No – SKIP to question 45

43a. During 2009 (all 52 weeks), did this person
work 50 or more weeks? Count paid time off as
work.
Yes – SKIP to question 44
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 VI

Person 1 – Continued
48.

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

Annual amount – Dollars
Yes
No

$

,

.00

e. Any public assistance or welfare payments
from the state or local welfare office,
including Supplemental Security Income
(SSI).
Annual amount – Dollars
Yes
No

$

,

49.

.00

,

O

C

$

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

f. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Annual amount – Dollars
Yes
No

About when was this building first built?

PY

45d. Social Security or Railroad Retirement.

.00

IO

N

AL

Answer questions 50–52 if this is a HOUSE or a
MOBILE HOME. Otherwise, SKIP to question 52.
g. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, 50. How many acres is this house or mobile
or alimony. Do NOT include lump-sum payments
home on?
such as money from an inheritance or sale of a home.
Less than 1 acre – SKIP to question 52
Annual amount – Dollars
1 to 9.9 acres
10 or more acres
,
$
.00
Yes

$

,

.00

Please answer questions 47–71 about your household.

IN

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
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 or more apartments
A boat or houseboat
RV, van, etc.

In 2009, what were the actual sales of all
agricultural products from this property?
None
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more

Loss

FO

None OR

R

Annual amount – Dollars

47.

51.

What was this person’s total income during
2009? Add entries in questions 45a–45g; subtract
any losses. If net income was a loss, enter the amount
and mark ✗ the "Loss" box next to the dollar amount.

M

46.

AT

No

52.

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

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Form D-61 VI

Person 1 – Continued
53a. How many separate rooms are in this house,
apartment, or mobile home? Rooms must be
separated by built-in archways or walls that extend out
at least 6 inches and go 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

PY

O

C

AL

Yes
No

N
IO

AT

Does this house, apartment, or mobile home
have –
.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

.
.
.
.
.
.

FO

R

M

Hot and cold running water?
A flush toilet? . . . . . . . . . .
A bathtub or shower? . . . . .
A sink with a faucet?. . . . . .
A stove or range? . . . . . . .
A refrigerator? . . . . . . . . . .

Does this house, apartment, or mobile home
have telephone service from which you can
both make and receive calls?

IN

Yes, a cell or mobile phone only
Yes, a landline only
Yes, both a cell or mobile phone and a landline
No

56.

b. Do you or any member of this household
have an Internet connection at this house,
apartment, or mobile home?

59a. Do you get water from – Mark ✗ ONE box.

Yes No

55.

Gas: bottled or tank
Electricity
Fuel oil, kerosene, etc.
Wood or charcoal
Other fuel
No fuel used

Yes
No – SKIP to question 59a

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

a.
b.
c.
d.
e.
f.

Which FUEL is used MOST for cooking in this
house, apartment, or mobile home?
Mark ✗ ONE box.

58a. Do you or any member of this household
have a home computer or laptop? Count only
if computer is in working condition.

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."

54.

57.

How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home
for use by members of your household?

A public system only?
A public system and cistern?
A cistern, tanks, or drums only?
A public standpipe?
Some other source (an individual well or
spring)?

b. During the past month, did anyone in this
house, apartment, or mobile home purchase
any water from – Mark ✗ all that apply.
A water delivery vendor?
A supermarket or grocery store?
Neither of the above

60.

Is this building connected to a public sewer?
Yes, connected to a public sewer
No, connected to a septic tank or cesspool
No, use other means

61.

Is this living quarters part of a condominium?
Yes
No

None
1
2
3
4
5
6 or more

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Form D-61 VI

Person 1 – Continued
62a. What is the average monthly cost for
electricity for this house, apartment, or
mobile home?
Average monthly cost – Dollars
.00

$

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

Yes

.00

No

PY

Average monthly cost – Dollars

65–71. Answer questions 65–71 if you or someone else
in this household OWNS or IS BUYING this
house, apartment, or mobile home. Otherwise,
SKIP to the questions for Person 2.
65.

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

$

,

Amount – Dollars

$

.00

AT

OR

M

.00

OR

$

63.

,

.00

OR
None

67.

What was the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars

$

,

.00

OR
None

IN

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

.00

Annual amount – Dollars

R

,

FO

$

,

What were the real estate taxes on THIS
property last year?

Included in rent or condominium fee
No charge

d. What is the average monthly cost for oil,
coal, kerosene, wood, etc. for this house,
apartment, or mobile home?
Average monthly cost – Dollars

,

N

66.

IO

c. What is the average monthly cost for water
and sewer for this house, apartment, or
mobile home?
Average monthly cost – Dollars

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?

C

,

.00

b. Does the monthly rent include any meals?

b. What is the average monthly cost for gas for
this house, apartment, or mobile home?

$

,

O

,

64a. What is the monthly rent for this house,
apartment, or mobile home?
Monthly amount – Dollars

AL

$

Answer questions 64a and 64b if this house, apartment, or
mobile home is RENTED. Otherwise, SKIP to question 65.

Is this house, apartment, or mobile home –
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 VI

Person 1 – Continued
68a. Do you or any member of this household
have a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?

Answer question 70 ONLY if this is a CONDOMINIUM.

70.

Yes, mortgage, deed of trust, or similar debt
Yes, contract to purchase
No – SKIP to question 69a

Monthly amount – Dollars

$

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

OR
No regular payment required – SKIP to question 69a

Annual amount – Dollars

$

.00

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

IO

N

➔

,

C

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

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

O

.00

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

What was the total annual cost for
installment loan payments, personal
property taxes, site rent, marina fee,
registration fees, and license fees on THIS
mobile home or boat and its site/slip last
year? Exclude real estate taxes.

PY

71.

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

.00

AL

,

,

Answer question 71 if this is a MOBILE HOME or a
BOAT. Otherwise, SKIP to the questions for Person 2 on
page 13.

Monthly amount – Dollars

$

What is the monthly condominium fee?

AT

69a. Do you or any member of this household
have a second mortgage or home equity
loan on THIS property?

R

M

Yes, a home equity loan
Yes, a second mortgage
Yes, both second mortgage and home equity loan
No – SKIP to question 70

FO

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

$

IN

,

.00

OR

No regular payment required

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Form D-61 VI

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

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

IN

FO

R

Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law

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

Other relative
Roomer or boarder
Housemate or
roommate
Unmarried partner
Other nonrelative

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Form D-61 VI

Person 3

For Persons 3–6, repeat
questions 1–46 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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