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PLEASE DO NOT FILL OUT THIS FORM.
                    This is not an official census form. It is for informational purposes only.

                                                                                        U.S. Department of Commerce • Bureau of the Census
                                                                                                                                                 DC
                                    This is the official form for all the people at this address. It is quick and
                                    easy, and your answers are protected by law. Complete the Census and
                                    help your community get what it needs — today and in the future!



Start Here                                       Please use a
                                                 black or blue pen.
                                                                      4. What is Person 1’s telephone number? We may call
                                                                          this person if we don’t understand an answer.
1. How many people were living or staying in this                         Area Code + Number
    house, apartment, or mobile home on April 1, 2000?                                 –                 –

                     Number of people
                                                                      5. What is Person 1’s sex? Mark # ONE box.
    INCLUDE in this number:                                                  Male            Female
        • foster children, roomers, or housemates
        • people staying here on April 1, 2000 who have




                                                                                                             PY
                                                                      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
        • people living here most of the time while working,




                                                                                                   CO
          even if they have another place to live

    DO NOT INCLUDE in this number:
                                                                          Print numbers in boxes.
        • college students living away while attending college




                                                                                             L
                                                                          Month      Day           Year of birth
        • people in a correctional facility, nursing home, or
          mental hospital on April 1, 2000
                                                                                           A
        • Armed Forces personnel living somewhere else
                                                                                    N
        • people who live or stay at another place most
                                                                              O
          of the time                                                     NOTE: Please answer BOTH Questions 7 and 8.
                                                                          TI


2. Is this house, apartment, or mobile home —                         7. Is Person 1 Spanish/Hispanic/Latino? Mark # the "No"
                                                                      A


    Mark # ONE box.                                                       box if not Spanish /Hispanic /Latino.
                                                             RM




                                                                             No, not Spanish / Hispanic / Latino            Yes, Puerto Rican
        Owned by you or someone in this household with a
        mortgage or loan?                                                    Yes, Mexican, Mexican Am., Chicano             Yes, Cuban
        Owned by you or someone in this household free and                   Yes, other Spanish / Hispanic / Latino — Print group.
                                                      FO




        clear (without a mortgage or loan)?
        Rented for cash rent?
        Occupied without payment of cash rent?
                                                 IN




                                                                      8. What is Person 1’s race? Mark # one or more races to
                                                                          indicate what this person considers himself/herself to be.
3. Please answer the following questions for each
    person living in this house, apartment, or mobile                        White
    home. Start with the name of one of the people                           Black, African Am., or Negro
    living here who owns, is buying, or rents this                           American Indian or Alaska Native — Print name of enrolled or principal tribe.
    house, apartment, or mobile home. If there is no
    such person, start with any adult living or staying
    here. We will refer to this person as Person 1.
    What is this person’s name? Print name below.                            Asian Indian     Japanese              Native Hawaiian
                                                                             Chinese          Korean                Guamanian or Chamorro
    Last Name
                                                                             Filipino         Vietnamese            Samoan
                                                                             Other Asian — Print race.              Other Pacific Islander — Print race.
    First Name                                            MI


                                                                             Some other race — Print race.




OMB No. 0607-0856: Approval Expires 12/31/2000                            If more people live here, continue with Person 2.

             Form   D-61A
Your answers are important!                                                               Census information helps your
                                                  Every person in the Census counts.                                                                     community get financial

      Person 2                                                                               Person 3                                             assistance for roads, hospitals,
                                                                                                                                                              schools, and more.

1. What is Person 2’s name? Print name below.                                          1. What is Person 3’s name? Print name below.
    Last Name                                                                              Last Name



    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.
       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
       Adopted son/daughter                         Housemate, roommate                       Adopted son/daughter                         Housemate, roommate
       Stepson/stepdaughter                         Unmarried partner                         Stepson/stepdaughter                         Unmarried partner
       Brother/sister                               Foster child                              Brother/sister                               Foster child
       Father/mother                                Other nonrelative                         Father/mother                                Other nonrelative
       Grandchild                                                                             Grandchild
       Parent-in-law                                                                          Parent-in-law
       Son-in-law/daughter-in-law                                                             Son-in-law/daughter-in-law




                                                                                                                           PY
       Other relative — Print                                                                 Other relative — Print
       exact relationship.                                                                    exact relationship.




                                                                                                                  CO
3. What is this person’s sex? Mark # ONE box.                                          3. What is this person’s sex? Mark # ONE box.
       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




                                                                                                           L
    of birth?                       Print numbers in boxes.                                of birth?                       Print numbers in boxes.




                                                                                                        A
    Age on April 1, 2000            Month       Day          Year of birth                 Age on April 1, 2000            Month       Day           Year of birth



                                                                                                 N
                                                                                            O
                                                                                       TI
    NOTE: Please answer BOTH Questions 5 and 6.                                            NOTE: Please answer BOTH Questions 5 and 6.                                                
                                                                                       A

5. Is this person Spanish /Hispanic /Latino? Mark # the                                5. Is this person Spanish /Hispanic /Latino? Mark # the
                                                                             RM



    "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
       Yes, Mexican, Mexican Am., Chicano             Yes, Cuban                              Yes, Mexican, Mexican Am., Chicano             Yes, Cuban
                                                                  FO




       Yes, other Spanish / Hispanic / Latino — Print group.                                  Yes, other Spanish / Hispanic / Latino — Print group.
                                                          IN




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.
       White                                                                                  White
       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.



       Asian Indian     Japanese              Native Hawaiian                                 Asian Indian     Japanese              Native Hawaiian
       Chinese          Korean                Guamanian or Chamorro                           Chinese          Korean                Guamanian or Chamorro
       Filipino         Vietnamese            Samoan                                          Filipino         Vietnamese            Samoan
       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.




    If more people live here, continue with Person 3.                                      If more people live here, continue with Person 4.                                          
Knowing about age, race, and
                                                         Information about children helps                                                                    sex helps your community
                                                            your community plan for child
     Person 4                                             care, education, and recreation.         Person 5                                                    better meet the needs of
                                                                                                                                                                             everyone.

1. What is Person 4’s name? Print name below.                                                1. What is Person 5’s name? Print name below.
    Last Name                                                                                    Last Name



    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.
       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
       Adopted son/daughter                         Housemate, roommate                             Adopted son/daughter                         Housemate, roommate
       Stepson/stepdaughter                         Unmarried partner                               Stepson/stepdaughter                         Unmarried partner
       Brother/sister                               Foster child                                    Brother/sister                               Foster child
       Father/mother                                Other nonrelative                               Father/mother                                Other nonrelative
       Grandchild                                                                                   Grandchild
       Parent-in-law                                                                                Parent-in-law




                                                                                                                            PY
       Son-in-law/daughter-in-law                                                                   Son-in-law/daughter-in-law
       Other relative — Print                                                                       Other relative — Print
       exact relationship.                                                                          exact relationship.




                                                                                                                  CO
3. What is this person’s sex? Mark # ONE box.                                                3. What is this person’s sex? Mark # ONE box.
       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




                                                                                                              L
    of birth?                       Print numbers in boxes.                                      of birth?                       Print numbers in boxes.




                                                                                                        A
    Age on April 1, 2000            Month       Day          Year of birth                       Age on April 1, 2000            Month       Day           Year of birth


                                                                                                   N
                                                                                              O
                                                                                             TI
    NOTE: Please answer BOTH Questions 5 and 6.                                                  NOTE: Please answer BOTH Questions 5 and 6.                                               
                                                                                         A

5. Is this person Spanish /Hispanic /Latino? Mark # the                                      5. Is this person Spanish /Hispanic /Latino? Mark # the
                                                                             RM



   "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
       Yes, Mexican, Mexican Am., Chicano             Yes, Cuban                                    Yes, Mexican, Mexican Am., Chicano             Yes, Cuban
                                                                  FO




       Yes, other Spanish / Hispanic / Latino — Print group.                                        Yes, other Spanish / Hispanic / Latino — Print group.
                                                          IN




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.
       White                                                                                        White
       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.



       Asian Indian     Japanese              Native Hawaiian                                       Asian Indian     Japanese              Native Hawaiian
       Chinese          Korean                Guamanian or Chamorro                                 Chinese          Korean                Guamanian or Chamorro
       Filipino         Vietnamese            Samoan                                                Filipino         Vietnamese            Samoan
       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.




    If more people live here, continue with Person 5.                                            If more people live here, continue with Person 6.                                         

                                                                                                                                                   1042
Your answers help
                                                                     your community plan
      Person 6                                                              for the future.


1. What is Person 6’s name? Print name below.
    Last Name



    First Name                                                  MI



2. How is this person related to Person 1? Mark # ONE box.
       Husband/wife                            If NOT RELATED to Person 1:
       Natural-born son/daughter                    Roomer, boarder
       Adopted son/daughter                         Housemate, roommate
       Stepson/stepdaughter                         Unmarried partner
       Brother/sister                               Foster child
       Father/mother                                Other nonrelative
       Grandchild
       Parent-in-law                                 PY
       Son-in-law/daughter-in-law
                                                   CO

       Other relative — Print
       exact relationship.
3. What is this person’s sex? Mark # ONE box.
                                                                                               Please turn
                                              L
                                          A



       Male                Female
4. What is this person’s age and what is this person’s date                                   to go to last
                                      N




    of birth?                       Print numbers in boxes.
                                    O




    Age on April 1, 2000            Month       Day          Year of birth
                                                                                                  page.
                             TI
                         A
                 RM




    NOTE: Please answer BOTH Questions 5 and 6.
         FO




5. Is this person Spanish /Hispanic /Latino? Mark # the
    "No" box if not Spanish /Hispanic /Latino.
    IN




       No, not Spanish / Hispanic / Latino            Yes, Puerto Rican
       Yes, Mexican, Mexican Am., Chicano             Yes, Cuban
       Yes, other Spanish / Hispanic / Latino — Print group.




6. What is this person’s race? Mark # one or more races to
    indicate what this person considers himself/herself to be.
       White
       Black, African Am., or Negro
       American Indian or Alaska Native — Print name of enrolled or principal tribe.



       Asian Indian     Japanese              Native Hawaiian
       Chinese          Korean                Guamanian or Chamorro
       Filipino         Vietnamese            Samoan
       Other Asian — Print race.              Other Pacific Islander — Print race.



       Some other race — Print race.




    If more people live here, list their names on the
    back of this page in the spaces provided.

                                                                                                        Form D-61A
Persons 7 – 12
                                                    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
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
these people.                                       to the Associate Director for Finance and
                                                    Administration, Attn: Paperwork Reduction Project
Person 7 — Last Name                                0607-0856, Room 3104, Federal Building 3,
                                                    Bureau of the Census, Washington, DC 20233.

                                                    Respondents are not required to respond to any
First Name                                    MI
                                                    information collection unless it displays a valid
                                                    approval number from the Office of Management
                                                    and Budget.


Person 8 — Last Name




                                                              PY
First Name                                    MI             Thank you for


                                                        CO
                                                        completing your official
Person 9 — Last Name
                                                    L   U.S. Census 2000 form.
                                                    A
                                             N

First Name                                    MI
                                         O
                                     TI



                                                        The "Informational Copy" shows
                                                        the content of the United States
                                 A




                                                        Census 2000 "short" form
                         RM




Person 10 — Last Name                                   questionnaire. Each household will
                                                        receive either a short form
                                                        (100-percent questions) or a long
                  FO




First Name                                    MI        form (100-percent and sample
                                                        questions). The short form
             IN




                                                        questionnaire contains 6 population
                                                        questions and 1 housing question.
                                                        On average, about 5 in every
Person 11 — Last Name
                                                        6 households will receive the short
                                                        form. The content of the forms
                                                        resulted from reviewing the 1990
First Name                                    MI
                                                        census data, consulting with federal
                                                        and non-federal data users, and
                                                        conducting tests.

Person 12 — Last Name                                   For additional information about
                                                        Census 2000, visit our website at
                                                        www.census.gov or write to the
First Name                                    MI        Director, Bureau of the Census,
                                                        Washington, DC 20233.



                                                                   FOR OFFICE USE ONLY

                                                         A. JIC1     B. JIC2    C. JIC3     D. JIC4
If you need help completing this form, call 1-800-XXX-XXXX between
       8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
       TDD — Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX
       between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.
       ¿ NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario
       llame al 1-800-XXX-XXXX entre las 8:00 a.m. y las 9:00 p.m., 7 días a la semana.
       La llamada telefónica es gratis.





)
1041

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2000 Census Form

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