FORM D-2012 U.S. DEPARTMENT OF COMMERCE
(XX-XX-XXXX) ECONOMICS AND STATISTICS ADMINISTRATION
OMB Control No. XXXX-XXXX U.S. CENSUS BUREAU
DESTRUCTION OR RETURN OF TITLE 13, UNITED STATES CODE MATERIALS FORM 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA)
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Government Name
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Please complete this form and return it via email to GEO.2020.LUCA@census.gov or in the enclosed postage paid, preaddressed envelope. Keep the original completed, signed form for your records.
All LUCA Operation liaisons, reviewers, and anyone with access to Title 13, United States Code LUCA materials must sign and date this form at the conclusion of your government’s participation in LUCA. Should any liaison, reviewer, or anyone with access to Title 13 LUCA materials leave before the completion of LUCA, they must sign and date this form. If any liaison, reviewer, or anyone with access to Title 13 LUCA materials are unable to sign and date this form, the current liaison must sign and date on their behalf.
LUCA liaison destruction or return of Title 13, materials
I certify by my signature that I have properly destroyed or returned to the U.S. Census Bureau, the original LUCA Title 13 materials, and any copies, using the security requirements provided to my government by the Census Bureau.
Check one: Destroyed Title 13 LUCA materials (Preferred method)
Returned Title 13 LUCA materials
Printed Name of LUCA Liaison
Signature of LUCA Liaison Date - mm/dd/yyyy
LUCA reviewers and anyone With Access to Title 13 materials
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Section B continued on the back
Continued - LUCA reviewers and anyone with access to Title 13 materials
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
Printed Name
Signature Date - mm/dd/yyyy
If you require more signatures, you may duplicate this form.
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |