Informational Copy
PLEASE DO NOT FILL OUT THIS FORM.
This is not an official census form. It is for informational purposes only.
Persons 7 – 12
U.S. Department of Commerce • Bureau of the Census DC
The Census Bureau estimates that, for the
If you didn’t have room to list everyone who
average household, this form will take about
lives in this house or apartment, please list the
10 minutes to complete, including the time for
This is the official form for all the people at this address. It is quick and
others below. You may be contacted by the
reviewing the instructions and answers.
Census Bureau for the same information about
Comments about the estimate should be directed
easy, and your answers are protected by law. Complete the Census and
these people.
to the Associate Director for Finance and
help your community get what it needs — today and in the future!
Administration, Attn: Paperwork Reduction Project
Person 7 — Last Name
0607-0856, Room 3104, Federal Building 3,
Bureau of the Census, Washington, DC 20233.
Start Here
Respondents are not required to respond to any
Please use a
4. What is Person 1’s telephone number? We may call
First Name
MI
information collection unless it displays a valid
black or blue pen.
this person if we don’t understand an answer.
approval number from the Office of Management
Area Code + Number
and Budget.
1. How many people were living or staying in this
house, apartment, or mobile home on April 1, 2000?
–
–
Person 8 — Last Name
Number of people
5. What is Person 1’s sex? Mark # ONE box.
INCLUDE in this number:
Male
Female
First Name
MI
Thank you for
• foster children, roomers, or housemates
completing your official
• people staying here on April 1, 2000 who have
6. What is Person 1’s age and what is Person 1’s date of birth?
no other permanent place to stay
Age on April 1, 2000
U.S. Census 2000 form.
• people living here most of the time while working,
even if they have another place to live
Person 9 — Last Name
DO NOT INCLUDE in this number:
•
Print numbers in boxes.
college students living away while attending college
First Name
MI
Month
Day
Year of birth
• people in a correctional facility, nursing home, or
mental hospital on April 1, 2000
• Armed Forces personnel living somewhere else
The "Informational Copy" shows
• people who live or stay at another place most
the content of the United States
of the time
NOTE: Please answer BOTH Questions 7 and 8.
Census 2000 "short" form
#
Person 10
questionnaire. Each household will
7. Is Person 1 Spanish/Hispanic/Latino? Mark
the
"No"
— Last Name
2. Is this house, apartment, or mobile home —
box if not Spanish /Hispanic /Latino.
receive either a short form
Mark # ONE box.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
(100-percent questions) or a long
Owned by you or someone in this household with a
First Name
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
form (100-percent and sample
mortgage or loan?
Yes, other Spanish / Hispanic / Latino — Print group.
questions). The short form
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
questionnaire contains 6 population
Rented for cash rent?
questions and 1 housing question.
INFORMATIONAL COPY
On average, about 5 in every
Occupied without payment of cash rent?
Person 11 — Last Name
8. What is Person 1’s race? Mark # one or more races to
6 households will receive the short
INFORMATIONAL COPY
indicate what this person considers himself/herself to be.
form. The content of the forms
3. Please answer the following questions for each
If you need help completing this form, call 1-800-XXX-XXXX between
person living in this house, apartment, or mobile
White
resulted from reviewing the 1990
First Name
MI
home. Start with the name of one of the people
Black, African Am., or Negro
census data, consulting with federal
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
living here who owns, is buying, or rents this
American Indian or Alaska Native — Print name of enrolled or principal tribe.
and non-federal data users, and
house, apartment, or mobile home. If there is no
TDD — Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX
conducting tests.
such person, start with any adult living or staying
between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
here. We will refer to this person as Person 1.
Person 12 — Last Name
For additional information about
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario
What is this person’s name? Print name below.
Asian Indian
Japanese
Native Hawaiian
Census 2000, visit our website at
llame al 1-800-XXX-XXXX entre las 8:00 a.m. y las 9:00 p.m., 7 días a la semana.
Chinese
Korean
Guamanian or Chamorro
www.census.gov or write to the
Last Name
La llamada telefónica es gratis.
First Name
MI
Filipino
Vietnamese
Samoan
Director, Bureau of the Census,
Other Asian — Print race.
Other Pacific Islander — Print race.
Washington, DC 20233.
First Name
MI
FOR OFFICE USE ONLY
Some other race — Print race.
A. JIC1
B. JIC2
C. JIC3
D. JIC4
OMB No. 0607-0856: Approval Expires 12/31/2000
If more people live here, continue with Person 2.
1041
)
Form D-61A
Your answers are important!
Census information helps your
Knowing about age, race, and
Information about children helps
Your answers help
community get financial
sex helps your community
Person 2
Every person in the Census counts.
your community plan for child
your community plan
assistance for roads, hospitals,
better meet the needs of
care, education, and recreation.
for the future.
Person 3
Person 4
Person 5
Person 6
schools, and more.
everyone.
1. What is Person 2’s name? Print name below.
1. What is Person 3’s name? Print name below.
1. What is Person 4’s name? Print name below.
1. What is Person 5’s name? Print name below.
1. What is Person 6’s name? Print name below.
Last Name
Last Name
Last Name
Last Name
Last Name
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Natural-born son/daughter
Roomer, boarder
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Adopted son/daughter
Housemate, roommate
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Stepson/stepdaughter
Unmarried partner
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Brother/sister
Foster child
Brother/sister
Foster child
Brother/sister
Brother/sister
Foster child
Foster child
Brother/sister
Foster child
Father/mother
Other nonrelative
Father/mother
Other nonrelative
Father/mother
Father/mother
Other nonrelative
Other nonrelative
Father/mother
Other nonrelative
Grandchild
Grandchild
Grandchild
Grandchild
Grandchild
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
exact relationship.
exact relationship.
exact relationship.
exact relationship.
exact relationship.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
Please turn
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
to go to last
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
page.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
INFORMATIONAL COPY
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
INFORMATIONAL COPY
INFORMATIONAL COPY
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
White
White
White
White
White
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
If more people live here, continue with Person 3.
If more people live here, continue with Person 4.
If more people live here, continue with Person 5.
If more people live here, continue with Person 6.
If more people live here, list their names on the
back of this page in the spaces provided.
Form D-61A
1042
*
Your answers are important!
Census information helps your
Knowing about age, race, and
Information about children helps
Your answers help
community get financial
sex helps your community
Person 2
Every person in the Census counts.
your community plan for child
your community plan
assistance for roads, hospitals,
better meet the needs of
care, education, and recreation.
for the future.
Person 3
Person 4
Person 5
Person 6
schools, and more.
everyone.
1. What is Person 2’s name? Print name below.
1. What is Person 3’s name? Print name below.
1. What is Person 4’s name? Print name below.
1. What is Person 5’s name? Print name below.
1. What is Person 6’s name? Print name below.
Last Name
Last Name
Last Name
Last Name
Last Name
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Natural-born son/daughter
Roomer, boarder
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Adopted son/daughter
Housemate, roommate
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Stepson/stepdaughter
Unmarried partner
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Brother/sister
Foster child
Brother/sister
Foster child
Brother/sister
Brother/sister
Foster child
Foster child
Brother/sister
Foster child
Father/mother
Other nonrelative
Father/mother
Other nonrelative
Father/mother
Father/mother
Other nonrelative
Other nonrelative
Father/mother
Other nonrelative
Grandchild
Grandchild
Grandchild
Grandchild
Grandchild
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
exact relationship.
exact relationship.
exact relationship.
exact relationship.
exact relationship.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
Please turn
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
to go to last
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
page.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
INFORMATIONAL COPY
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
INFORMATIONAL COPY
INFORMATIONAL COPY
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
White
White
White
White
White
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
If more people live here, continue with Person 3.
If more people live here, continue with Person 4.
If more people live here, continue with Person 5.
If more people live here, continue with Person 6.
If more people live here, list their names on the
back of this page in the spaces provided.
Form D-61A
1042
*
Your answers are important!
Census information helps your
Knowing about age, race, and
Information about children helps
Your answers help
community get financial
sex helps your community
Person 2
Every person in the Census counts.
your community plan for child
your community plan
assistance for roads, hospitals,
better meet the needs of
care, education, and recreation.
for the future.
Person 3
Person 4
Person 5
Person 6
schools, and more.
everyone.
1. What is Person 2’s name? Print name below.
1. What is Person 3’s name? Print name below.
1. What is Person 4’s name? Print name below.
1. What is Person 5’s name? Print name below.
1. What is Person 6’s name? Print name below.
Last Name
Last Name
Last Name
Last Name
Last Name
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
2. How is this person related to Person 1? Mark # ONE box.
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Husband/wife
If NOT RELATED to Person 1:
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Natural-born son/daughter
Natural-born son/daughter
Roomer, boarder
Roomer, boarder
Natural-born son/daughter
Roomer, boarder
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Adopted son/daughter
Adopted son/daughter
Housemate, roommate
Housemate, roommate
Adopted son/daughter
Housemate, roommate
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Stepson/stepdaughter
Stepson/stepdaughter
Unmarried partner
Unmarried partner
Stepson/stepdaughter
Unmarried partner
Brother/sister
Foster child
Brother/sister
Foster child
Brother/sister
Brother/sister
Foster child
Foster child
Brother/sister
Foster child
Father/mother
Other nonrelative
Father/mother
Other nonrelative
Father/mother
Father/mother
Other nonrelative
Other nonrelative
Father/mother
Other nonrelative
Grandchild
Grandchild
Grandchild
Grandchild
Grandchild
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Parent-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Son-in-law/daughter-in-law
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
Other relative — Print
exact relationship.
exact relationship.
exact relationship.
exact relationship.
exact relationship.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
3. What is this person’s sex? Mark # ONE box.
Please turn
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
4. What is this person’s age and what is this person’s date
to go to last
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
of birth?
Print numbers in boxes.
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
Age on April 1, 2000
Month
Day
Year of birth
page.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
5. Is this person Spanish/Hispanic/Latino? Mark
# the
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
"No"
box if not Spanish / Hispanic / Latino.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
INFORMATIONAL COPY
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
Yes, other Spanish / Hispanic / Latino — Print group.
INFORMATIONAL COPY
INFORMATIONAL COPY
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
6. What is this person’s race? Mark # one or more races to
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
indicate what this person considers himself/herself to be.
White
White
White
White
White
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Other Asian — Print race.
Other Pacific Islander — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
Some other race — Print race.
If more people live here, continue with Person 3.
If more people live here, continue with Person 4.
If more people live here, continue with Person 5.
If more people live here, continue with Person 6.
If more people live here, list their names on the
back of this page in the spaces provided.
Form D-61A
1042
*
PLEASE DO NOT FILL OUT THIS FORM.
This is not an official census form. It is for informational purposes only.
Persons 7 – 12
U.S. Department of Commerce • Bureau of the Census DC
The Census Bureau estimates that, for the
If you didn’t have room to list everyone who
average household, this form will take about
lives in this house or apartment, please list the
10 minutes to complete, including the time for
This is the official form for all the people at this address. It is quick and
others below. You may be contacted by the
reviewing the instructions and answers.
Census Bureau for the same information about
Comments about the estimate should be directed
easy, and your answers are protected by law. Complete the Census and
these people.
to the Associate Director for Finance and
help your community get what it needs — today and in the future!
Administration, Attn: Paperwork Reduction Project
Person 7 — Last Name
0607-0856, Room 3104, Federal Building 3,
Bureau of the Census, Washington, DC 20233.
Start Here
Respondents are not required to respond to any
Please use a
4. What is Person 1’s telephone number? We may call
First Name
MI
information collection unless it displays a valid
black or blue pen.
this person if we don’t understand an answer.
approval number from the Office of Management
Area Code + Number
and Budget.
1. How many people were living or staying in this
house, apartment, or mobile home on April 1, 2000?
–
–
Person 8 — Last Name
Number of people
5. What is Person 1’s sex? Mark # ONE box.
INCLUDE in this number:
Male
Female
First Name
MI
Thank you for
• foster children, roomers, or housemates
completing your official
• people staying here on April 1, 2000 who have
6. What is Person 1’s age and what is Person 1’s date of birth?
no other permanent place to stay
Age on April 1, 2000
U.S. Census 2000 form.
• people living here most of the time while working,
even if they have another place to live
Person 9 — Last Name
DO NOT INCLUDE in this number:
•
Print numbers in boxes.
college students living away while attending college
First Name
MI
Month
Day
Year of birth
• people in a correctional facility, nursing home, or
mental hospital on April 1, 2000
• Armed Forces personnel living somewhere else
The "Informational Copy" shows
• people who live or stay at another place most
the content of the United States
of the time
NOTE: Please answer BOTH Questions 7 and 8.
Census 2000 "short" form
#
Person 10
questionnaire. Each household will
7. Is Person 1 Spanish/Hispanic/Latino? Mark
the
"No"
— Last Name
2. Is this house, apartment, or mobile home —
box if not Spanish /Hispanic /Latino.
receive either a short form
Mark # ONE box.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
(100-percent questions) or a long
Owned by you or someone in this household with a
First Name
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
form (100-percent and sample
mortgage or loan?
Yes, other Spanish / Hispanic / Latino — Print group.
questions). The short form
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
questionnaire contains 6 population
Rented for cash rent?
questions and 1 housing question.
INFORMATIONAL COPY
On average, about 5 in every
Occupied without payment of cash rent?
Person 11 — Last Name
8. What is Person 1’s race? Mark # one or more races to
6 households will receive the short
INFORMATIONAL COPY
indicate what this person considers himself/herself to be.
form. The content of the forms
3. Please answer the following questions for each
If you need help completing this form, call 1-800-XXX-XXXX between
person living in this house, apartment, or mobile
White
resulted from reviewing the 1990
First Name
MI
home. Start with the name of one of the people
Black, African Am., or Negro
census data, consulting with federal
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
living here who owns, is buying, or rents this
American Indian or Alaska Native — Print name of enrolled or principal tribe.
and non-federal data users, and
house, apartment, or mobile home. If there is no
TDD — Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX
conducting tests.
such person, start with any adult living or staying
between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
here. We will refer to this person as Person 1.
Person 12 — Last Name
For additional information about
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario
What is this person’s name? Print name below.
Asian Indian
Japanese
Native Hawaiian
Census 2000, visit our website at
llame al 1-800-XXX-XXXX entre las 8:00 a.m. y las 9:00 p.m., 7 días a la semana.
Chinese
Korean
Guamanian or Chamorro
www.census.gov or write to the
Last Name
La llamada telefónica es gratis.
First Name
MI
Filipino
Vietnamese
Samoan
Director, Bureau of the Census,
Other Asian — Print race.
Other Pacific Islander — Print race.
Washington, DC 20233.
First Name
MI
FOR OFFICE USE ONLY
Some other race — Print race.
A. JIC1
B. JIC2
C. JIC3
D. JIC4
OMB No. 0607-0856: Approval Expires 12/31/2000
If more people live here, continue with Person 2.
1041
)
Form D-61A
PLEASE DO NOT FILL OUT THIS FORM.
This is not an official census form. It is for informational purposes only.
Persons 7 – 12
U.S. Department of Commerce • Bureau of the Census DC
The Census Bureau estimates that, for the
If you didn’t have room to list everyone who
average household, this form will take about
lives in this house or apartment, please list the
10 minutes to complete, including the time for
This is the official form for all the people at this address. It is quick and
others below. You may be contacted by the
reviewing the instructions and answers.
Census Bureau for the same information about
Comments about the estimate should be directed
easy, and your answers are protected by law. Complete the Census and
these people.
to the Associate Director for Finance and
help your community get what it needs — today and in the future!
Administration, Attn: Paperwork Reduction Project
Person 7 — Last Name
0607-0856, Room 3104, Federal Building 3,
Bureau of the Census, Washington, DC 20233.
Start Here
Respondents are not required to respond to any
Please use a
4. What is Person 1’s telephone number? We may call
First Name
MI
information collection unless it displays a valid
black or blue pen.
this person if we don’t understand an answer.
approval number from the Office of Management
Area Code + Number
and Budget.
1. How many people were living or staying in this
house, apartment, or mobile home on April 1, 2000?
–
–
Person 8 — Last Name
Number of people
5. What is Person 1’s sex? Mark # ONE box.
INCLUDE in this number:
Male
Female
First Name
MI
Thank you for
• foster children, roomers, or housemates
completing your official
• people staying here on April 1, 2000 who have
6. What is Person 1’s age and what is Person 1’s date of birth?
no other permanent place to stay
Age on April 1, 2000
U.S. Census 2000 form.
• people living here most of the time while working,
even if they have another place to live
Person 9 — Last Name
DO NOT INCLUDE in this number:
•
Print numbers in boxes.
college students living away while attending college
First Name
MI
Month
Day
Year of birth
• people in a correctional facility, nursing home, or
mental hospital on April 1, 2000
• Armed Forces personnel living somewhere else
The "Informational Copy" shows
• people who live or stay at another place most
the content of the United States
of the time
NOTE: Please answer BOTH Questions 7 and 8.
Census 2000 "short" form
#
Person 10
questionnaire. Each household will
7. Is Person 1 Spanish/Hispanic/Latino? Mark
the
"No"
— Last Name
2. Is this house, apartment, or mobile home —
box if not Spanish /Hispanic /Latino.
receive either a short form
Mark # ONE box.
No, not Spanish / Hispanic / Latino
Yes, Puerto Rican
(100-percent questions) or a long
Owned by you or someone in this household with a
First Name
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Cuban
form (100-percent and sample
mortgage or loan?
Yes, other Spanish / Hispanic / Latino — Print group.
questions). The short form
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
questionnaire contains 6 population
Rented for cash rent?
questions and 1 housing question.
INFORMATIONAL COPY
On average, about 5 in every
Occupied without payment of cash rent?
Person 11 — Last Name
8. What is Person 1’s race? Mark # one or more races to
6 households will receive the short
INFORMATIONAL COPY
indicate what this person considers himself/herself to be.
form. The content of the forms
3. Please answer the following questions for each
If you need help completing this form, call 1-800-XXX-XXXX between
person living in this house, apartment, or mobile
White
resulted from reviewing the 1990
First Name
MI
home. Start with the name of one of the people
Black, African Am., or Negro
census data, consulting with federal
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
living here who owns, is buying, or rents this
American Indian or Alaska Native — Print name of enrolled or principal tribe.
and non-federal data users, and
house, apartment, or mobile home. If there is no
TDD — Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX
conducting tests.
such person, start with any adult living or staying
between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
here. We will refer to this person as Person 1.
Person 12 — Last Name
For additional information about
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario
What is this person’s name? Print name below.
Asian Indian
Japanese
Native Hawaiian
Census 2000, visit our website at
llame al 1-800-XXX-XXXX entre las 8:00 a.m. y las 9:00 p.m., 7 días a la semana.
Chinese
Korean
Guamanian or Chamorro
www.census.gov or write to the
Last Name
La llamada telefónica es gratis.
First Name
MI
Filipino
Vietnamese
Samoan
Director, Bureau of the Census,
Other Asian — Print race.
Other Pacific Islander — Print race.
Washington, DC 20233.
First Name
MI
FOR OFFICE USE ONLY
Some other race — Print race.
A. JIC1
B. JIC2
C. JIC3
D. JIC4
OMB No. 0607-0856: Approval Expires 12/31/2000
If more people live here, continue with Person 2.
1041
)
Form D-61A
