2010 U.S. Census Sample Form

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Below you can read the information found on the 2010 United States Census form. We have removed checkboxes and input fields as this is not an official copy of the census form which will be distributed in the coming months.

View census form in PDF format

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 = _
  2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1? Mark all that apply.
    • 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.
    Area Code + Number
  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.
    Last Name
    First Name MI
  6. What is Person 1's sex? Mark ONE box.
    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 childe is less than 1 year old. Print numbers in boxes.
    Age on April 1, 2010 Month Day Year of birth
    NOTE: Please answer BOTH Question 8 about Hispanic origin and Question 9 about race. For this census, Hispanis origins are not races.
  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? Mark one or more boxes.
    • 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
    • Native Hawaiian
    • Guamanian or Chamorro
    • Samoan
    • Other Pacific Islander - Print race, for example, Fijian, Tongan, and so on.
    • Other Asian - Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
    • Some other race - Print race.
  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

If more people were counted in Question 1, continue with Person 2.

  1. Print name of Person 2
    Last Name
    First Name MI
  2. How is this person related to Person 1? Mark ONE box.
    • Husband or wife
    • Biological son or daughter
    • Adopted son or daughter
    • Stepson or stepdaughter
    • Brother or sister
    • Father or mother
    • Grandchild
    • Parent-in-law
    • Son-in-law or daughter-in-law
    • Other relative
    • Roomer or boarder
    • Housemate or roommate
    • Unmarried partner
    • Other nonrelative
  3. What is this person's sex? Mark ONE box.
    Male Female
  4. What is this person's age and what is this person's date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes.
    Age on April 1, 2010 Month Day Year of birth
    NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this census, Hispanic origins are not races.
  5. Is this person 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.
  6. What is this person's race? Mark one or more boxes.
    • 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
    • Native Hawaiian
    • Guamanian or Chamorro
    • Samoan
    • Other Pacific Islander - Print race, for example, Fijian, Tongan, and so on.
    • Other Asian - Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
    • Some other race - Print race.
  7. Does this person 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

Note: There is room for up to 6 people on the census form. If there are more people living in your household there is extra room for 6 additional persons as follows:

If more people live here, turn the page and continue.

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 Last Name First Name MI
Sex

  • Male
  • Female

Age on April 1, 2010
Date of Birth (Month Day Year)
Related to Person 1? (Yes No)

Person 8 Last Name First Name MI
Sex

  • Male
  • Female

Age on April 1, 2010
Date of Birth (Month Day Year)
Related to Person 1? (Yes No)

Note: Persons 9-12 follow in this same fashion.

Thank you for completing your official 2010 Census form.

If your enclosed postage-paid envelope is missing, please mail your completed form to: U.S. Census Bureau National Processing Center Jeffersonville, IN 47132

If you need help completing this form, call 1-866-872-6868 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 1-866-783-2010 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 1-866-928-2010 entre las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La llamada telefónica es gratis.

The U.S. Census Bureau estimates that, for the average household, this form will take about 10 minutes to complete, including the time for reviewing the instructions and answers. Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project 0607-0919-C, U.S. Census Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to Paperwork@census.gov use "Paperwork Project 0607-0919-C" as the subject.

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

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