{| class="wikitable"
! colspan="11" |City, County, State
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! colspan="5" |Date: D Mon YEAR
! colspan="3" |Enumeration District #
! colspan="3" |Page #
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! colspan="5" |Address:
! colspan="3" |Dwelling #
! colspan="3" |Family #
|-
| colspan="11" |
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! style="width: 15%" rowspan="2" |Name
! rowspan="2" |Relationship
! rowspan="2" |Sex
! rowspan="2" |Race
! rowspan="2" |Age
! rowspan="2" |Marital Status
! colspan="3" |Birthplace
! rowspan="2" |Occupation
! rowspan="2" |Notes
|-
!Birthplace
!Father
!Mother
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