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<br />0206 <br /> <br />FORM 1).1668 <br />(6- 12-201}7) <br /> <br />OMS No. 0607-0795 <br />U.S. DEPARTMENT OF COMMERCE ENTITY 10 <br />Economics and Statistics Administration <br />U.S. CENSUS BUREAU <br /> <br />A. PARTICIPATION INFORMATION <br /> <br />REGISTRATION FORM <br />LOCAL UPDATE OF CENSUS ADDRESSES (LUCA) PROGRAM <br />2010 Decennial Census C038017 <br /> <br />Please complete this form and retum it to your u.s. Census Bureau Regional Office. <br /> <br />1.~ YES! Our government would like to participate in the 2010 Decennial Census LUCA Program. <br /> <br />2. 1ST NO, we are not able to participate. Please mark (X) all that apply below. <br /> <br />a. D Insufficient staff f. D Restrictions on the use of the Census Bureau's <br />b. D Lack of funds address list for other purposes <br /> <br />c. D No timelToo busy g. D Other reason - Specify (Please print) il <br /> <br />d. D No local address list available <br /> <br />e. D Concerns about the security and <br />confidentiality of the Census Bureau's <br />address list <br /> <br />We rely on your comments to help us improve future LUCA programs. <br /> <br />B. HIGHEST ELECTED/APPOINTED OFFICIAL MAKING THIS COMMITMENT - <br />Please print <br /> <br />1. NaJ{.le of participating ~overnment <br />LOSJ1 Col1rtt boVtYT) YYJtnt <br />2. Printed name of Highest Elected/Appointed Official- First, middle initial, last <br />SCD+t {to W <br />3. Signature - First, mid 1e initial, last <br /> <br /> <br /> <br />4. Position - Governor, Commissioner, Mayor, Supervisor, etc. <br />CnairmaY' Q1tS Cou Comm;O\on <br />5. Telephone 6. E*mail address <br />Area code <br /> <br />1. Name - First, middle initial, last <br />7"""o~ P JO ibe.r!j <br />2. Position - Director, Assessor, Planner, etc. <br />P/q"f\el' <br />3. Department, Organization, or Agency name <br />H ,~~W"" Ve?ClI'+-,..,t",+- Ca:>3 COv^-+ <br />Number and street name <br />4. Mailing /20/ ,.vi",:", A.vtef'\ve. WeST" <br />address City <br />W e....~ +- F'ct ,. j c <br />Number and street name <br />12c \ M<l.:", Ave""...;," We:,>-r <br />5. Delivery <br />address. City <br />v.J<t..$T Fc.,. 0 <br /> <br />I State <br />I ,NO <br /> <br />I ZIP Code <br />1580,8-1'30\ <br /> <br />I State <br />I ND <br /> <br />I ZIP Code <br />I 51507'5-/301 <br /> <br />'The Census Bureau will ship all materia's via FedEx. <br />FedEx will not deliver to PO Box numbers or PO ZIP Codes. <br /> <br />USCENSUSBUREAU <br />