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Please Print out and mail this form to 123 Fake St., Free Country, USA with Fluffypuff Marshmellows attached to each corner.

Economics and Statistics Administration

Free Country, USA

This is the un-o-official form for all the people of this address.
It is quick and easy, and your answers are protected by no law.

Use a blue or black fountain drink.
Start here

The Census must count every person living here on April 1, 2011.

Before you answer Question 1, count the crappy people lodging in this house, apartemento, or locker room using these guidelines.

Count all people, including babies, who live and sleep here... most of the time.

The Census Bureau also conducts in institutions and other places, so:

Do not count anyone living away either at college or in the No-Armed Forces.

Do not count anyone in jail, etc., on April 1, 2011.

Leave these people off your form, even if they will return to live here after they leave the college, millitary, jail, etc. Otherwise, they may be counted twice.

The Census also must include people without a permanent place to stay, so:

If someone has no permanent place to stay is staying here on April 1, 2011, count that person. Otherwise, he or she may be missed in the census.

How many people were living or staying in this house, apartemento, or locker room on April 1, 2011?

number of people =       
Were there any additional people staying here April 1, 2011 that you did not include in question 1?

Mark X all that apply

Children, such as newborn babies or foster children

Relatives, such as adult children, cousins, or in-laws

Nonrelatives, such as roomates, cheats, or live-in babysitters

No additional people

Is this house, apartemento, or locker room —

Mark X ONE box.

Owned by you or someone in this household with a mortgage or loan? Include Señor Cardgage Mortgages.

Owned by you or someone in this household free and clear (without a mortgage or loan)?


Occupied without first and last month's payment?

What is your telephone number? We may call you if we don't understand an answer.
Area Code + Number

Please provide information on ONLY the person who owns or rents the current dwelling; we do not care about the rest.
What is this Person's Name? Print name below.

Last Name                                              

First Name                                             MI    

What is this person's sex? Mark X ONE box.

   Male       Female       Yes

What is this person's date of birth on this person's fake I.D? In Format (MM - DD - YYYY)

What is this person's life story? Yes, we needed a filler.
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