Other Public Use Forms

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

List A

INFORMATION SHEET
Your Answers Are Confidential
Your answers are confidential and protected by law.
All U.S. Census Bureau employees have taken an
oath and are subject to a jail term, a fine, or both if
they disclose ANY information that could identify you
or your household. Your answers will only be used for
statistical purposes, and for no other purpose. As
allowed by law, your census data become public after
72 years. This information can be used for family
history and other types of historical research.
You are required by law to provide the information
requested. These federal laws are found in the
United States Code, Title 13, (Sections 9, 141, 193,
214, and 221) and Title 44, (Section 2108). Please
visit our Web site at for
additional information.
Thank you for your cooperation. The U.S. Census
Bureau appreciates your help.
If you have any comments concerning the time it takes to complete
this form or any other aspect of the collection, send it to:
Paperwork Reduction Project 0607-0919-C, U.S. Census Bureau,
AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233.
You may e-mail comments to ; use
"Paperwork Project 0607-0919-C" as the subject.

WHO TO COUNT ON APRIL 1st
We need to count people where they live
and sleep most of the time.
Do NOT INCLUDE
these people: (They
will be counted at the
other place)

INCLUDE these people:

• College students who
live away from this
address most of the year
• Armed forces personnel
who live away
• People who, on
April 1, 2010, were in a:
– Nursing home,
mental hospital, etc.
– Jail, prison,
detention center, etc.

• Babies and children
living here, including
foster children
• Roommates
• Boarders
• People staying here
on April 1, 2010
who have no other
permanent place
to live

Respondents are not required to respond to any information
collection unless a valid approval number has been assigned
by the Office of Management and Budget. The approval number
for the 2010 Census is: OMB No. 0607-0919-C; Approval
Expires 12/31/2011.
D-1(F) (6-17-2008)

USCENSUSBUREAU

D-1(F) - Base prints Black Ink

D-1(F) - Tone prints Pantone Process Cyan 10% and 20%

List B

List C

RELATIONSHIP

HISPANIC, LATINO, OR
SPANISH ORIGIN

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

No, not of Hispanic, Latino, or
Spanish origin

Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative

Yes, Mexican, Mexican American,
or Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, of another Hispanic, Latino,
or Spanish origin – For example,
Argentinean, Colombian,
Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on.

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

List D
RACE
(Choose one or more races)
White
Black, African American, or Negro
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – For example,
Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – For
example, Fijian, Tongan,
and so on.
Some other race

D-1(F) (6-17-2008)

D-1(F) - Base prints Black Ink

D-1(F) - Tone prints Pantone Process Cyan 10% and 20%