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<br /> 1. Print name of 7. What is this person's race?
<br /> First Name MI Mark n one or more boxes AND print origins.
<br /> - ❑ White—Print,for example, German,Irish,English, Italian,
<br /> -- -- Lebanese,Egyptian,etc.,;?,
<br /> Last a me(s)
<br /> Black or African Am.—Print,for example,African American,
<br /> 2. Does this person usually live or stay somewhere else? Jamaican,Haitian,Nigerian,Ethiopian,Somali,etc.
<br /> Mark jX all that apply. TTT�I I
<br /> r 1 No
<br /> American Indian or Alaska Native—Print name of enrolled or
<br /> Yes,for college ❑ Yes,with a parent or principal tribe(s),for example,Navajo Nation,Blackfeet Tribe,
<br /> other relative Mayan,Aztec,Native Village of Barrow Inupiat Traditional
<br /> U1 Yes,for a military assignment ❑ Yes, at a seasonal or Government,Nome Eskimo Community,etc.
<br /> second residence
<br /> ElYes,for a job or business ❑ Yes, in a jail or prison
<br /> ❑ Yes, in a nursing home Yes,for another reason
<br /> ❑ Chinese ❑ Viet O Native Hawaiian
<br /> 3. How is this person related to Person 1?Mark❑X ONE box. ❑ Filipino ❑ ern 1 Samoan
<br /> Opposite-sex husband/wife/spouse Father or mother ❑ Asian Indian J n e ❑ Chamorro
<br /> Opposite-sex unmarried partner Grandchild
<br /> ❑ Other,4 ian— ❑ Other Pacific Islander—
<br /> Print, r xam le, Print,for example,
<br /> Li Same-sex husband/wife/spouse LJ Parent-in-law to odian, Tongan,Fijian,
<br /> c Marshallese, etc.7
<br /> ❑ Same-sex unmarried partner ❑ Son-in-law or daughter-in-law
<br /> ❑ Biological son or daughter ❑ Other relative j
<br /> Cl Adopted son or daughter ❑ Roommate or house a
<br /> Some other race—Print race or origin.�
<br /> ❑ Stepson or stepdaughter ❑ Foster child
<br /> Brother or sister ❑ Other elativ - -- -- --- -—--
<br /> 4. What is this person's sex?Mark X
<br /> I Male Female
<br /> 5. What is this person' h s this person's date of
<br /> birth?Forbabies I s an 1 old,do not write the age in
<br /> months. Write 0 a
<br /> rint numbers in boxes.
<br /> Age on i Month Day Year of birth
<br /> ears
<br /> 4 NOTE: Please answer BOTH Question 6 about Hispanic
<br /> origin and Question 7 about race.For this census,Hispanic
<br /> origins are not races.
<br /> 6. Is this person of Hispanic,Latino,or Spanish origin?
<br /> l._j No,not of Hispanic,Latino,or Spanish origin
<br /> ❑ Yes,Mexican,Mexican Am.,Chicano
<br /> Cl Yes,Puerto Rican
<br /> El Yes,Cuban
<br /> ❑ Yes,another Hispanic,Latino,or Spanish origin—Print,for
<br /> example,Salvadoran,Dominican, Colombian, Guatemalan,
<br /> Spaniard, Ecuadorian,etc. -> If more people were counted in Question 1 on
<br /> the front page, continue with Person 4 on the
<br /> - _ next page.
<br /> 4
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