Census Household Form
GENERAL INSTRUCTIONS
Use this census form or respond online to provide information for:
Anyone who, on October 1, 2012, was living or staying at the address printed on this form.
Anyone who lives and sleeps most of the time at the address printed on this form.
You MUST RESPOND ONLINE if:
You moved into this address after October 1, 2012.
The address printed on the back of the form was vacant on October 1.
The address printed on the back of the form is a seasonal home which is mostly vacant
You may use this census form or respond online:
If you moved into this address on or before October 1.
Go to www.census.gov to find out how to respond online.
How many people were living or staying at this address on October 1, 2012?
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Yes No Babies? Yes No Foster children? Yes No Any other relatives? Yes No Roommates or people not related to you? Yes No People staying here temporarily? Yes No Anyone staying here who had no permanent place to live?
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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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On the inside of this form, list all the people that you identified in Questions 1 and 2.
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Person 1 |
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What is Person 1’s name? Print name below
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Male Female |
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Print Numbers in Boxes Age on October 1, 2012 Month Day Year
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No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
Some other race—Print race
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Continue to Question 10 |
Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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Yes—what date? ___________________ No
Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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The address printed on the back of this questionnaire The address or location listed in Question 13 Both places equally
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The address printed on the back of this questionnaire The address or location you listed in Question 13 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 2 |
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1. What is Person 2’s name? Print name below
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2. How is Person 2 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 2’s sex? Mark ONE box. Male Female |
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4. What is Person 2’s age and what is Person 2’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 October 1, 2012 Month Day Year
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5. Is Person 2 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 2’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 2 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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8. On October 1, 2012, did Person 2 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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9. Did Person 2 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 2 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 2 was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 2 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 2 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 3 |
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1. What is Person 3’s name? Print name below
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2. How is Person 3 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 3’s sex? Mark ONE box. Male Female |
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4. What is Person 3’s age and what is Person 2’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 October 1, 2012 Month Day Year
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5. Is Person 3 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 3’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 3 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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8. On October 1, 2012, did Person 3 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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9. Did Person 3 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 3 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 3 was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 3 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 3 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 4 |
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1. What is Person 4’s name? Print name below
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2. How is Person 4 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 4’s sex? Mark ONE box. Male Female |
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4. What is Person 4’s age and what is Person 4’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 October 1, 2012 Month Day Year
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5. Is Person 4 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 4’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 4 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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8. On October 1, 2012, did Person 4 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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9. Did Person 4 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 4 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 4 was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 4 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 4 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 5 |
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1. What is Person 5’s name? Print name below
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2. How is Person 5 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 5’s sex? Mark ONE box. Male Female |
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4. What is Person 5’s age and what is Person 5’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 October 1, 2012 Month Day Year
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5. Is Person 5 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 5’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 5 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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8. On October 1, 2012, did Person 5 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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9. Did Person 5 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 5 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 5 was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 5 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 5 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 6 |
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1. What is Person 6’s name? Print name below
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2. How is Person 6 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 6’s sex? Mark ONE box. Male Female |
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4. What is Person 6’s age and what is Person 6’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 October 1, 2012 Month Day Year
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5. Is Person 6 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 6’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 6 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No, does not live or stay somewhere else |
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8. On October 1, 2012, did Person 6 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No, did not stay in a facility on October 1 |
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9. Did Person 6 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 6 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 6 was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 6 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 6 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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If more people were counted in Question 1 or 2, continue. |
Person 7 |
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1. What is Person 7’s name? Print name below
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2. How is Person 7 related to Person 1? Mark ONE box. Husband or wife Parent-in-law Biological son or daughter Son-in-law or daughter-in-law Adopted son or daughter Other relative Stepson or stepdaughter Roomer or boarder Brother or sister Housemate or roommate Father or mother Unmarried partner Grandchild Other nonrelative |
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3. What is Person 7’s sex? Mark ONE box. Male Female |
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4. What is Person 7’s age and what is Person 7’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 October 1, 2012 Month Day Year
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5. Is Person 7 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin—Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on
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6. What is Person 7’s race? Mark one or more boxes. White Black, African American, or Negro American Indian or Alaska Native—Print name of enrolled or principal tribe Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan
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Some other race—Print race
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Continue to Question 7 |
7. Does Person 7 sometimes live or stay somewhere else? Mark all that apply Yes, for college (on or off campus) Yes, in the military Yes, for a job or business Yes, with a parent or grandparent Yes, with a friend Yes, at another home, like a second or seasonal residence Yes, at another place No - does not live or stay somewhere else |
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8. On October 1, 2012, did Person 7 stay in a facility, like those listed below? Yes, in jail or prison Yes, in a nursing home or group home Yes, in a shelter Yes, in another type of facility No – did not stay in a facility on October 1 |
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9. Did Person 7 move into this address after September 1, 2012? Yes—what date? ___________________ No |
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10. If you marked yes above indicating that Person 1 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where person was most of the time. Street Address (House Number and Street Name)
Apartment Number City State ZIP Code County/Township/Parish
Facility name (if necessary): Other location information (if necessary):
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11. Where does Person 7 live or stay most of the time? The address printed on the back of this questionnaire The address or location listed in Question 10 Both places equally |
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12. On October 1, 2012, where was Person 7 staying? The address printed on the back of this questionnaire The address or location you listed in Question 10 Some other place |
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RESIDENT AT:
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | smirn001 |
File Modified | 0000-00-00 |
File Created | 2021-02-02 |