D-2012 Destruction or Return Form

2020 Census Local Update of Census Addresses Operation (LUCA)

D-2012 2020 LUCA Destruction or Return Form DRAFT_10_28_2016

2020 Census LUCA

OMB: 0607-0994

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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)


Entity ID


Government Name



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.

  1. 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



  1. 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 Typeapplication/msword
File Title2010 Census Dress Rehearsal LUCA Program
AuthorGeography Division
Last Modified ByCarrie A Hritz (CENSUS/GEO FED)
File Modified2016-09-30
File Created2016-09-23

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