SC-921(HU) Housing Unit Add Page

FORM

SC-921(HU)

(5-31-2012)

Attachment J

THIS FORM CONTAINS CONFIDENTIAL INFORMATION, INCLUDING TITLE 13 AND PERSONALLY IDENTIFIABLE
INFORMATION (PII), THE RELEASE OF WHICH IS PROTECTED BY THE PRIVACY ACT OF 1974.

OMB No. 0607-0368: Approval Expires XX/XX/XXXX

U.S. DEPARTMENT OF COMMERCE

B. SCO

A. SCID

Economics and Statistics Administration

U.S. CENSUS BUREAU

HOUSING UNIT ADD PAGE
Special Census

C. AA
Sheet

SC-1
Line completion
date
No.

Barcode ID

Block
No.

Map
spot

House No.

Street Name, Rural Route and
Box or PO Box

Apt. No.
or unit
designation

Location Description

Notes
(Ex. Resp. Name/Tel.)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(2)
(1) Month Day

of

sheets

FOR OFFICE USE ONLY
Was this address
Crew coded A5 in another
Leader
Reviewer
SCA Block?
initials If "Yes" – Specify
initials
below from Address
Listing Page
(12)

(11)
Yes

(13)
No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes

No

AA
Line No.
Yes
AA
Line No.

No