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[-OHM D-2002 (2-22-2017) OMB No. 0607-0994: Approval Expires 12/31/2019 <br /> U.S. DEPARTMENT OF COMMERCE Entity ID <br /> Economics and Statistics Administration <br /> U.S.CENSUS BUREAU <br /> United States- PL5322640 <br /> Census REGISTRATION FORM <br /> 2020 2020 CENSUS LOCAL UPDATE OF CENSUS Government Name <br /> ADDRESSES OPERATION (LUCA) Everett city <br /> A. PARTICIPATION RESPONSE (Submission Deadline December 15, 2017) <br /> 1.LYES Our government is registering for LUCA. - Complete Sections B and C. <br /> 2. NO Our government is not registering for LUCA. - Complete Section B and mark an (X) for each reason that applies: <br /> a. ❑ Another level of government (state or county) f. n Concerns about Census Bureau Title 13 materials <br /> that includes our jurisdiction is participating <br /> in LUCA g. ❑ Restrictions on using Census Bureau Title 13 materials for <br /> other purposes <br /> b. ❑ Insufficient staff <br /> h. ❑ Other reason- Specify(Please print) g <br /> c. ❑ Lack of funds <br /> d. ❑ No time/too busy <br /> e. ❑ No local address list available <br /> Thank you for your comments. We will use them to help improve future LUCA operations. <br /> B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION <br /> 1. Printed name of Tribal Chair or Highest Elected Official/Appointed Official - First, middle initial, last <br /> r�cm�l A\ -t.F-h�r)s• A .;$r e A,t-N <br /> 2. Signature Tribal Chair or Highest Elected Off i1f .•:i TOff / Date <br /> • M nth Day Year <br /> 3. Positio e.g., T al Chair, Governor, Commissioner, Mayoror, ur;;please do not abbreviate)-Please print <br /> Mayor- <br /> Number and street name <br /> 4. Physical/ R. 930 W-f'i-,, v-( v'r t(-1-10 A9 r/ <br /> addregs Mailin <br /> City I State I ZIP Code <br /> F f f-f 110/F I `E-0201 <br /> 5. Telephone 6. Email address <br /> Area code Number Extension <br /> -■■ -MIME -MIME <br /> C. LIAISON INFORMATION - Designate your LUCA Liaison. <br /> This is the person responsible for protecting the confidential Census Bureau materials covered by <br /> Title 13, U.S. Code. <br /> Complete this section only if you are participating in LUCA <br /> 1. Name- (Please print) <br /> 2. Department, Organization, or Agency name-fJ(e.g., Planning and Zoning, Regional Planning Agency;please do not abbreviate) <br /> AK : K 4 (©i+1 Mgt ;iy sP,Pay/o7lviY/t <br /> 3. Position - (e.g., Tal President, Director, Asessor, Planner;please do not abbreviate) <br /> Lv N FhPi H ,` .4y Mef Ka y."-- <br /> 4. umber and street name <br /> Physical/ 2.'3D B( )9-di. EA <br /> Mailing City I State I ZIP Code <br /> address <br /> �d-r•-.��-I' I WO- I 9gaD/ <br /> 5. Telephone 6. Email address <br /> Area code Number Extension <br /> `( a5 - a5- 7 - 736 - A4crikeW1/4 edYr Wo . 1G(/ <br /> Complete this form and return it along with the completed,signed copies of the Product Preference Form,Self-Assessment Checklist,and Confidentiality Agreement. Use <br /> the enclosed postage-paid envelope addressed to ATTN:Geography LUCA Materials 63-E,National Processing Center, 1201 East 10th St,Jeffersonville IN 47132.As an <br /> \alternative,you may scan your completed forms, including forms with signatures,and email them to GEO.2020.LUCA@census.gov. <br /> copy <br /> 11111111,111111111111 37701 <br /> III1111111I <br />