SC-921(GQ) Group Quarters Add Page

Attachment K
FORM

SC-921(GQ)

(5-9-2012)

This report contains information, including Title 13 and Personally Identifiable Information (PII), the release of which is protected by the Privacy Act of 1974.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

GROUP QUARTERS ADD PAGE

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

A. SC ID
Sheet

B. AA

Special Census

of

sheets

C. SCO

Line
No.

Block
number

Map
spot

Group quarters name

House number

Street name, rural route
and box, or PO box

Location description

ZIP
code

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

GQ contact name – Last name, First name

(10)

Area code and telephone number

(

(9)

GQ contact name – Last name, First name

(10)

(9)

GQ contact name – Last name, First name

(10)

(9)

GQ contact name – Last name, First name

(10)

DRAFT #5 (05/09/2012)

(11)

Supervisor/Crew Leader

(12) Notes

(11)

Supervisor/Crew Leader

(12) Notes

(11)

Supervisor/Crew Leader

(12) Notes

)

Area code and telephone number

(

(12) Notes

)

Area code and telephone number

(

Supervisor/Crew Leader

)

Area code and telephone number

(

(11)

)