Household Census Intake Form

Household Census Intake Form
Please provide accurate information about your household and its members for census purposes.
Household Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Head of Household Full Name*
First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Contact Email Address
example@example.com
Type of Dwelling*
OwnedRentedOther
Number of People Living in Household*
Household Members Information*
ElectricityWaterGasInternetSewerOther
YesNo
Should be Empty: