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Form Bc-600 - Application For Search Of Census Records - U.s. Department Of Commerce Page 3

OMB No. 0607-0117

BC-600

U.S. DEPARTMENT OF COMMERCE

FORM

DO NOT USE THIS SPACE – OFFICIAL USE ONLY

Economics and Statistics Administration

(9-14-2011)

U.S. CENSUS BUREAU

Case number

APPLICATION FOR SEARCH OF CENSUS RECORDS

$ ________ (Fee)

RETURN TO: U.S. Census Bureau, P.O. Box 1545, Jeffersonville, IN 47131

Money Order

NAME OF

APPLICANT

Check

Purpose for which record is to be used (See Instruction 1)

Other

Passport

Proof of age

(date required)

Papers received (itemize)

Returned

Other – Please specify

Genealogy

I certify that information furnished about anyone other than the applicant will

not be used to the detriment of such person or persons by me or by anyone

else with my permission.

Signature – Do not print (Read instruction 2 carefully before signing)

Received by

Date

Returned by

Date

Number and street

PRESENT

If the census information is to be sent

FEE REQUIRED: (See instructions 4 and 5)

MAILING

to someone other than the person

A check or money order (DO NOT SEND

City

State

ZIP Code

ADDRESS

whose record is requested, give the

CASH) payable to "Commerce – Census"

name and address, including ZIP Code,

must be sent with the application. This

of the other person or agency.

fee covers the cost of a search of no

more than one census year for one

Telephone number (Include area code)

This authorizes the U.S. Census Bureau

person only.

to send the record to: (See instruction 3)

IF SIGNED BY MARK (X), TWO WITNESSES MUST SIGN HERE

65.00

Fee required . . . . . . . . . . . . . .

Signature

____

extra copies @

$2.00

____

full schedules @

$10.00

NOTICE – Intentionally falsifying this application may result in a fine of

____

expedited fee @

$20.00

$10,000 or 5 years of imprisonment, or both (title 18, U.S. Code,

section 1001).

TOTAL amount enclosed

First name

Present last name

Nicknames

Middle name

Maiden name (If any)

FULL NAME OF

PERSON WHOSE

CENSUS RECORD

Date of birth (If unknown, estimate)

Place of birth (City, county, State)

Race

Sex

IS REQUESTED

Full name of father (Stepfather, guardian, etc.)

Nicknames

Full maiden name of mother (Stepmother, etc.)

Nicknames

First marriage (Name of husband or wife of applicant)

Year married (Approximate) Second marriage (Name of husband or wife of applicant)

Year married (Approximate)

Names of brothers and sisters

Name and relationship of all other persons living in household (Aunts, uncles, grandparents, lodgers, etc.)

PLEASE COMPLETE REVERSE SIDE

Form Bc-600 - Application For Search Of Census Records - U.s. Department Of Commerce Page 3

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