Download:
pdf |
pdf§,q!3¤
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.
C
iti
ze
ns
hi
p
FOR
OFFICIAL
USE ONLY
OR go online at XXXX.XXXX.gov to complete your 2020 Census questionnaire.
:N
Use a blue or black pen.
o
Start here
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
AF
T
• 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:
3.
Is this house, apartment, or mobile home — Mark K
J ONE box.
I
R
• If someone who does not have a permanent place to live is
staying here on April 1, 2020, count that person.
No additional people
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)?
D
• 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-Q1 (02-05-2019) Draft 1
11800018
–
§,q!;¤
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.
MI
hi
p
First Name
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
ze
What is Person 1’s sex? Mark K
J ONE box.
I
Male
Female
Chinese
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.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
o
years
Vietnamese
iti
7.
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
C
6.
ns
Last Name(s)
Some other race – Print race or origin. C
Is Person 1 of Hispanic, Latino, or Spanish origin?
AF
T
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
R
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
D
8.
:N
➜ NOTE: Please answer BOTH Question 8 about Hispanic
origin and Question 9 about race. For this census, Hispanic
origins are not races.
➜ If more people were counted in Question 1 on
the front page, continue with Person 2 on the
next page.
2
11800026
§,q!C¤
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
4.
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
ze
How is this person related to Person 1? Mark K
J ONE box.
I
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
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
o
C
iti
Opposite-sex husband/wife/spouse
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
AF
T
5.
ns
Yes, for a military assignment
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
:N
3.
Yes, for college
Yes, with a parent or
other relative
hi
p
No
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
years
Is this person of Hispanic, Latino, or Spanish origin?
D
6.
R
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
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
11800034
§,q!K¤
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
4.
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
Chinese
How is this person related to Person 1? Mark K
J ONE box.
I
Vietnamese
Native Hawaiian
Korean
Samoan
Japanese
Chamorro
ze
Filipino
ns
Yes, for college
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
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Asian Indian
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
C
iti
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
o
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
AF
T
5.
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
Yes, with a parent or
other relative
:N
3.
hi
p
No
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
years
Is this person of Hispanic, Latino, or Spanish origin?
D
6.
R
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
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
11800042
§,q!\¤
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
4.
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
ze
How is this person related to Person 1? Mark K
J ONE box.
I
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
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
o
C
iti
Opposite-sex husband/wife/spouse
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
AF
T
5.
ns
Yes, for a military assignment
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
:N
3.
Yes, for college
Yes, with a parent or
other relative
hi
p
No
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
years
Is this person of Hispanic, Latino, or Spanish origin?
D
6.
R
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
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
11800059
§,q!d¤
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
4.
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
Chinese
How is this person related to Person 1? Mark K
J ONE box.
I
Vietnamese
Native Hawaiian
Korean
Samoan
Japanese
Chamorro
ze
Filipino
ns
Yes, for college
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
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Asian Indian
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
C
iti
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
o
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
AF
T
5.
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
Yes, with a parent or
other relative
:N
3.
hi
p
No
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
years
Is this person of Hispanic, Latino, or Spanish origin?
D
6.
R
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
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
11800067
§,q!l¤
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
4.
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
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
ze
How is this person related to Person 1? Mark K
J ONE box.
I
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
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
o
C
iti
Opposite-sex husband/wife/spouse
What is this person’s sex? Mark K
J ONE box.
I
Male
Female
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.
AF
T
5.
ns
Yes, for a military assignment
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
:N
3.
Yes, for college
Yes, with a parent or
other relative
hi
p
No
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
years
Is this person of Hispanic, Latino, or Spanish origin?
D
6.
R
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.
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
11800075
§,q!t¤
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
Age on April 1, 2020
Male
Female
Month
Day
Year of birth
Yes
years
Person 8
MI
Last Name(s)
Date of Birth
Age on April 1, 2020
Female
Day
Year of birth
Related to Person 1?
ze
Male
Month
years
MI
No
Last Name(s)
C
First Name
Yes
iti
Person 9
No
ns
First Name
Sex
Related to Person 1?
hi
p
Sex
Date of Birth
Age on April 1, 2020
Male
Female
MI
AF
T
First Name
Sex
Age on April 1, 2020
Male
Day
Year of birth
Related to Person 1?
Yes
No
:N
Person 10
years
Month
o
Sex
Female
Last Name(s)
Date of Birth
Month
Day
Year of birth
years
Yes
R
D
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:
Related to Person 1?
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
11800083
File Type | application/pdf |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |