Each question helps to determine how more than $400 billion will be allocated to communities across the country.
1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2010?
Number of people = ___
2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1?
__ Children, such as newborn babies or foster children
__ Relatives, such as adult children, cousins, or in-laws
__ Nonrelatives, such as roommates or live-in baby sitters
__ People staying here temporarily
__ No additional people
3. Is this house, apartment, or mobile home —
Mark ONE box.
__ Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
__ 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.
5. Please provide information for each person living here. Start with a person living here who owns or rents this house, apartment, or mobile home. If the owner or renter lives somewhere else, start with any adult living here. This will be Person 1.
What is Person 1’s name? Print name below.
6. What is Person 1’s sex?
__ Male
__ Female
7. What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
8. Is Person 1 of Hispanic, Latino, or Spanish origin?
__ 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 origin,
for example,
__ Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran,
Spaniard, and so on.
9. What is Person 1’s race?
__ White
__ Black, African Am., or Negro
__ American Indian or Alaska Native — Print name of enrolled or
principal tribe.
__ Asian Indian
__ Chinese
__ Filipino
__ Japanese
__ Korean
__ Vietnamese
__ Other Asian — Print race, for example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on.
__ Native Hawaiian
__ Guamanian or Chamorro
__ Samoan
__ Other Pacific Islander — Print race, for example, Fijian, Tongan,
and so on.
10. Does Person 1 sometimes live or stay somewhere else?
__ No
__ Yes - Mark all that apply:
__ In college housing
__ In the military
__ At a seasonal or second residence
__ For child custody
__ In jail or prison
__ In a nursing home
__ For another reason