Various Demographic Pretesting Activities

OMB No. 0607-0725
Approval Expires 08/31/2013

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

Address Verification and
Update Form
Survey of Income and Program Participation

PREPRINTED ADDRESS LABEL ABOUT HERE

Use a blue or black pen
Start here
1) Is the above preprinted address information correct?
If no, please provide correct address below.

Yes

No

Street:__________________________________________________________________
City:___________________________State:_____ ZIP-Code:_____________-_______
2) Has anyone moved out of the above address since January 2011 or is planning to
move?
Yes (Please continue with question 3)
No (Thank you, please return the form with the enclosed envelope)
3) What is the new address?
If a full address is unavailable, please complete as much of the information as possible. If
household members have moved or are moving to more than one address, please fill out
the second address on next page.
Street:__________________________________________City:____________________
State:______ ZIP-Code:_________________Phone number : _____________________
E-mail _________________________Date moved or Moving date:_________________
MM/DD/YY
PLEASE TURN OVER

Please list the full names for those who have moved since January 2011 or are planning to
move to the new address listed on the previous page.
First Name
M.I. Last Name
1
2
3
4

If applicable, please fill out the second address below.
Street:__________________________________________City:___________________
State:______ ZIP-Code:_________________Phone number : __________________
E-mail _________________________Date moved or Moving date:_______________
MM/DD/YY
Please list the full names for those who have moved since January 2011 or are planning
to move to the above address.
First Name
M.I. Last Name
1
2
3
4

The U.S. Census Bureau estimates that, for the
average household, 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 06070919-C, U.S. Census Bureau, AMSD-3K138, 4600
Silver Hill Road, Washington, DC 20233. You may email comments to ; 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.

OMB No. 0607-0725 Approval Expires 08/31/2013

Thank you for your assistance.
Please return this page in the enclosed
postage-paid envelope to:

U.S. Census Bureau
ATTN: RESIPP
1201 E. 10th Street
Jeffersonville, IN 37132-0001
Form AVU-1 (01-26-2011)