The personal information recorded on this form is strictly confidential and will be used only for statistical purposes.

Citizens are obliged to supply complete and correct information to the enumerator.

The enumerator is prohibited from asking for information other than that included in the census.

___ County
___ Town/City/Village
___ Locality/Village
___ Street
___ Number
___ Block house
___ Stairs (Entrances)
___ Floor
___ Flat
___ Sector

_ _ _ _ _ _ Number of the file
_ _ _ The order number of the building in the file
_ _ _ The order number of the dwelling within the building
___ _ _ _ The PL form's number within the file
_ The order number of the household