1201 East 10th Street
First Name
First Name
Month
Month
First Name
Year
Day
Last Name
Last Name
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C
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PY
IN
FO
RM
AT
IO
N
AL
C
O
PY
Person 7
Person 8
Person 9
Person 10
Person 11
Person 12
Form D-61 (1-15-2009)
U S C E N S U S B U R E A U
D-61- Base prints in BLACK
D-61- Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
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U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
This is the official form for all the people at this address.
It is quick and easy, and your answers are protected by law.
Use a blue or black pen.
The Census must count every person living in the United
States on April 1, 2010.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.
• Count all people, including babies, who live and sleep here
most of the time.
The Census Bureau also conducts counts in institutions
and other places, so:
• Do not count anyone living away either at college or in the
Armed Forces.
• Do not count anyone in a nursing home, jail, prison,
detention facility, etc., on April 1, 2010.
• Leave these people off your form, 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.
The Census must also include people without a permanent
place to stay, so:
• If someone who has no permanent place to stay is staying
here on April 1, 2010, count that person. Otherwise, he or
she may be missed in the census.
1. How many people were living or staying in this house,
apartment, or mobile home on April 1, 2010?
Number of people =
IJ
Mark K all that apply.
No additional people
IJ
Mark K ONE box.
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
4. What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–
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5. Please provide information for each person livi