Form 1 2020 Census Draft w/ citizenship

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OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

TM

This is the official questionnaire for this address.
It is quick and easy to respond, and your answers are protected by law.

Start here

R
AF

T

FOR
OFFICIAL
USE ONLY

OR go online at XXXX.XXXX.gov to complete your 2020 Census questionnaire.

Use a blue or black pen.

2.

Before you answer Question 1, count the people living in this
house, apartment, or mobile home using our guidelines.

Were there any additional people staying here on April 1, 2020
that you did not include in Question 1?
Mark I
K all that apply.
J
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

D

• Count all people, including babies, who live and sleep here
most of the time.
• If no one lives and sleeps at this address most of the time, go
online at XXXX.XXXX.gov or call the number on page 8.

Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily

The census must also include people without a permanent
place to live, so:
• If someone who does not have a permanent place to live is
staying here on April 1, 2020, count that person.

No additional people

3.

Is this house, apartment, or mobile home — Mark K
J ONE box.
I
Owned by you or someone in this household with a mortgage
or loan? Include home equity loans.

The Census Bureau also conducts counts in institutions and
other places, so:

Owned by you or someone in this household free and clear
(without a mortgage or loan)?

• Do not count anyone living away from here, either at college
or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention
facility, etc., on April 1, 2020.
• Leave these people off your questionnaire, even if they will
return to live here after they leave college, the nursing home,
the military, jail, etc. Otherwise, they may be counted twice.

1.

How many people were living or staying in this house,
apartment, or mobile home on April 1, 2020?

Rented?
Occupied without payment of rent?

4.

What is your telephone number?
We will only contact you if needed for official Census Bureau
business.
Telephone Number
–

Number of people =
FORM

D-Q (01-22-2019) Draft 21

11650017

–

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Person 1

5.

9.

Please provide information for each person living here. If
there is someone living here who pays the rent or owns this
residence, start by listing him or her as Person 1. If the
owner or the person who pays the rent does not live here,
start by listing any adult living here as Person 1.

What is Person 1’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

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

MI
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Last Name(s)

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

7.

Female

T

Male

What is Person 1’s age and what is Person 1’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes.
Month
Day

Age on April 1, 2020
years

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

➜ NOTE: Please answer BOTH Question 8 about Hispanic
origin and Question 9 about race. For this census, Hispanic
origins are not races.

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Is Person 1 of Hispanic, Latino, or Spanish origin?

D

8.

Chinese

R
AF

6.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

No, not of Hispanic, Latino, or Spanish origin

10.

Yes, Mexican, Mexican Am., Chicano

Is Person 1 a citizen of the United States?

Yes, Puerto Rican

Yes, born in the United States

Yes, Cuban

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

No, not a U.S. citizen

➜ If more people were counted in Question 1 on
the front page, continue with Person 2 on the
next page.

2

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1.

Person 2

Print name of

7.

First Name

MI

What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Last Name(s)

2.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Brother or sister

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

T

How is this person related to Person 1? Mark K
J ONE box.
I

Stepson or stepdaughter

4.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

R
AF

3.

Yes, for college

Yes, with a parent or
other relative

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Foster child

Other nonrelative

8.

What is this person’s sex? Mark K
J ONE box.
I

Is this person a citizen of the United States?
Yes, born in the United States

Male

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.

D

5.

Female

Age on April 1, 2020

Print numbers in boxes.
Month
Day

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

Year of birth

years
No, not a U.S. citizen

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

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, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question 1 on
the front page, continue with Person 3 on the
next page.

3

11650033

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1.

Person 3

Print name of

7.

First Name

MI

What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Last Name(s)

2.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

T

How is this person related to Person 1? Mark K
J ONE box.
I

Same-sex unmarried partner

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Son-in-law or daughter-in-law

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Other relative

Roommate or housemate

Some other race – Print race or origin. C

Foster child

Other nonrelative

Brother or sister

4.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

R
AF

3.

Yes, for college

Yes, with a parent or
other relative

8.

What is this person’s sex? Mark K
J ONE box.
I

Is this person a citizen of the United States?
Yes, born in the United States

Male

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on April 1, 2020

D

5.

Female

Print numbers in boxes.
Month
Day

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

Year of birth

years
No, not a U.S. citizen

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

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, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question 1 on
the front page, continue with Person 4 on the
next page.

4

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1.

Person 4

Print name of

7.

First Name

MI

What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Last Name(s)

2.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Brother or sister

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

T

How is this person related to Person 1? Mark K
J ONE box.
I

Stepson or stepdaughter

4.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

R
AF

3.

Yes, for college

Yes, with a parent or
other relative

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Foster child

Other nonrelative

8.

What is this person’s sex? Mark K
J ONE box.
I

Is this person a citizen of the United States?
Yes, born in the United States

Male

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.

D

5.

Female

Age on April 1, 2020

Print numbers in boxes.
Month
Day

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

Year of birth

years
No, not a U.S. citizen

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

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, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question 1 on
the front page, continue with Person 5 on the
next page.

5

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1.

Person 5

Print name of

7.

First Name

MI

What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Last Name(s)

2.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

T

How is this person related to Person 1? Mark K
J ONE box.
I

Same-sex unmarried partner

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Son-in-law or daughter-in-law

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Other relative

Roommate or housemate

Some other race – Print race or origin. C

Foster child

Other nonrelative

Brother or sister

4.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

R
AF

3.

Yes, for college

Yes, with a parent or
other relative

8.

What is this person’s sex? Mark K
J ONE box.
I

Is this person a citizen of the United States?
Yes, born in the United States

Male

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on April 1, 2020

D

5.

Female

Print numbers in boxes.
Month
Day

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

Year of birth

years
No, not a U.S. citizen

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

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, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question 1 on
the front page, continue with Person 6 on the
next page.

6

11650066

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1.

Person 6

Print name of

7.

First Name

MI

What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Last Name(s)

2.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in a jail or prison

Yes, in a nursing home

Yes, for another reason

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Brother or sister

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

T

How is this person related to Person 1? Mark K
J ONE box.
I

Stepson or stepdaughter

4.

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

R
AF

3.

Yes, for college

Yes, with a parent or
other relative

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Foster child

Other nonrelative

8.

What is this person’s sex? Mark K
J ONE box.
I

Is this person a citizen of the United States?
Yes, born in the United States

Male

Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas

What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.

D

5.

Female

Age on April 1, 2020

Print numbers in boxes.
Month
Day

Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C

Year of birth

years
No, not a U.S. citizen

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

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, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question 1 on
the front page, continue with Person 7 on the
next page.

7

11650074

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Use this section to complete information for the rest of the people you counted in Question 1 on the front page.
We may call for additional information about them.

Person 7
First Name

MI

Last Name(s)

Date of Birth
Sex

Age on April 1, 2020
Male

Female

Month

Day

Year of birth

Related to Person 1?
Yes

years

No

Person 8
First Name

MI

Last Name(s)

Date of Birth
Age on April 1, 2020
Male

Female

Month

years

Person 9
MI

Year of birth

Related to Person 1?
Yes

No

Last Name(s)

R
AF

First Name

Day

T

Sex

Date of Birth

Sex

Age on April 1, 2020
Male

Female

Person 10

Sex

MI

Age on April 1, 2020

Male

Day

Year of birth

years

D

First Name

Month

Female

Related to Person 1?
Yes

No

Last Name(s)

Date of Birth
Month

Day

Year of birth

years

Related to Person 1?
Yes

No

FOR OFFICIAL USE ONLY

Thank you for completing your 2020 Census questionnaire.
If your enclosed postage-paid envelope is missing,
please mail your completed questionnaire to:

JIC1

JIC2

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

If you need help completing this questionnaire, call toll-free 1-844-330-2020, Sunday through Saturday from 7:00 a.m. to 2:00 a.m. ET.
TDD — Telephone display device for the hearing impaired. Call toll-free 1-844-467-2020, Sunday through Saturday from 7:00 a.m. to 2:00 a.m. ET.
The U.S. Census Bureau estimates that completing the questionnaire will take 10 minutes on average. Send comments regarding this burden estimate or any other aspect
of this burden to: Paperwork Reduction Project xxxx-xxxx, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments
to <2020.census.paperwork@census.gov>. Use “Paperwork Reduction Project xxxx-xxxx” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number XXXX-XXXX confirms this
approval. If this number were not displayed, we could not conduct the census.

8

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