D-10 Be Counted

Draft 4 (7-22-2008)

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

First Name

Date of Birth
Month

Person 7

U.S. CENSUS BUREAU

Be Counted!

Male
Female

MI

Age on April 1, 2010

Economics and Statistics Administration

Sex

Last Name

Day

This is an official census form for people who might not have been counted already.

Related to Person 1?
Year

Last Name

Who should be listed on this form?

Yes
No

• Include yourself if you have not been counted in the 2010 Census.
• Include anyone else who was living with you on April 1, 2010 who has not yet been counted.

Sex

First Name

Start here

1. If you are completing this form for ALL of the people living at this address, start
PHOTOCOPIES CANNOT BE ACCEPTED

1. What is the full address of the place you were living on April 1, 2010? If you have more
than one residence, provide the address of the place where you live most of the time.
Mark I
J
K this box if you had no address on Thursday, April 1, 2010. 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.

Date of Birth

Street name

Month

Person 8

Day

Related to Person 1?
Year

Last Name

First Name

Female

Please report babies as age 0 when the child is less than 1 year old.
Age on April 1, 2010

Print numbers in boxes.
Day
Year of birth
Month

Apartment number

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and Question 5

Rural route address

Male
Female

MI

MI

First Name

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

• Do NOT include anyone in a nursing home, jail, prison, detention facility, etc., on April 1.
We will count them at those places.

Sex

Last Name

• Do NOT include anyone who has already been counted in the 2010 Census.
• Do NOT include people living away at college or in the Armed Forces. We will count them
at those places.

Yes
No

What is Person 1’s name? Print name below.

Male

Who should NOT be listed on this form?
Age on April 1, 2010

with a person living here who owns or rents this house or apartment. Otherwise,
start with yourself.

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

House number

• 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

Person 1

U.S. DEPARTMENT OF COMMERCE

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

4. Is Person 1 of Hispanic, Latino, or Spanish origin?
Provide your complete address.

Age on April 1, 2010

Date of Birth
Month

Person 9

Day

Related to Person 1?
Year

Last Name

Yes
No

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

Sex

First Name

• Please do not provide a PO box address. The Census Bureau needs to know the
location of where each person was living or staying on April 1.

Male
Female

MI

• If you do not have an address, mark the box under Question 1 and provide as much
information as possible about the place you were staying on April 1.

City

State

ZIP Code

County

2. Is this house, apartment, or mobile home — Mark I
J
K ONE box.
Age on April 1, 2010

Month

Person 10

Related to Person 1?

Date of Birth
Day

Year

Last Name

Yes
No

Related to Person 1?

Date of Birth
Month

Day

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, IIame al
1-866-928-2010 entre las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La lIamada telefónica es gratis.

Male
Female

MI

Age on April 1, 2010

TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

Sex

First Name

Year

Yes
No

FOR OFFICIAL USE ONLY

Thank you for completing your official
2010 Census form.

If you need help completing this form, call 1-866-872-6868 between 8:00 a.m. and 9:00 p.m., 7 days
a week. The telephone call is free.

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-C, U.S.
Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments
to Paperwork@census.gov; use "Paperwork Project 0607-0919-C" 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.

JIC2
OMB No. 0607-0919-C: Approval Expires 12/31/2011.

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)?

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

5. What is Person 1’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

Rented?
Occupied without payment of rent?

3. What is your telephone number? We may call if we don’t understand an answer.
Area Code + Number
–

–

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

4. Are you filling out this form for ALL of the people who were living or staying
at this address on April 1, 2010?
Yes
No

Some other race — Print race. C

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

Form D-10 (7-21-2008)

USCENSUSBUREAU

D-10 Base Prints BLACK

D-10 Prints Pantone Process Cyan (10%, 20%, 25%, 50%, and 100%)

§l,"¤
751101

Draft 4 (7-22-2008)

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.
Day
Year of birth
Month
Age on April 1, 2010

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.
Month
Year of birth
Age on April 1, 2010

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, 2010
Month
Day
Year of birth

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, 2010
Month
Day
Year of birth

Day

➜ 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

➜ 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

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

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

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

Question 6 about race. For this census, Hispanic origins are not races.
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.

Question 6 about race. For this census, Hispanic origins are not races.
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

➜ Lift page up for Person 3 .....

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.

§l,#¤
751102

D-10 (7-22-2008)

D-10 Base Prints BLACK

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

D-10 Prints Pantone Process Cyan (10%, 20%, 25%, 50%, and 100%)