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Home My WebLink About20180072.tiffBOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW/ WORK SESSION REQUEST RE: UPDATE ON CENSUS 2020 PROCESS AND REQUEST FOR THE CHAIR'S SIGNATURE: DEPARTMENT: Weld County Information Technology DATE: 12-04-2017 PERSON REQUESTING: Ryan Rose / Jack Statler Brief description of the problem/issue: On November 17`h, the Census documents were sent to all Weld agencies. We have received information from nine agencies; 3 declined our offer of help and six have accepted. At this point Weld County needs to file our intent to participate in the Census 2020 process. There are two forms attached. One form (D-2002) requires the signature of the Chair of the BOCC. The second form (D- 2005) will also be submitted and indicates Weld County's authorized data reviewers. What options exist for the Board? (Include consequences, impacts, costs, etc. of options) There is no negative impact. • Approve Request • Provide Alternative Direction Recommendation: Approve the request Approve Recommendation Sean P. Conway Julie A. Cozad, Chair Mike Freeman Barbara Kirkmeyer Steve Moreno, Pro-Tem eent,„41- ()put.. I —3-2oIB 11 Schedule Work Session Other/Comments: awe- a ISO otr 2018-0072 Z 7-0 OO1 Esther Gesick From: Sent: To: Cc: Subject: Attachments: Jack Statler Thursday, December 28, 2017 4:56 PM Esther Gesick Ryan Rose CENSUS 2020 DOCUMENTS FOR SIGNATURE OF THE BOCC CHAIR CENSUS DOCUMENTS SUBMITTED.pdf; CENSUS PASS A ROUND.pdf Esther We have had a couple of board work sessions prior to the pass a round attached. Ryan would like it attached to a BOCC meeting under the consent agenda. Julie only needs to sign the first page. I'll have the original documents dropped off to you tomorrow. I'm going to be out of the office for a couple of weeks. If you have questions please let Ryan know. Jack Statler Operations Manager WC Public Safety Information Technology 1551 N. 17th Avenue, Suite 2 Greeley, CO 80631 970 400 2541 Public Safety IT Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 FORM D-2005 (4S-2017) OMB No. 0607-0994: Approval Expires 12/31/2019 Census 2020 CONFIDENTIALITY AGREEMENT FORM 2020 CENSUS LOCAL UPDATE OF cENSUS ADDRESSES OPERATIQN (LUCA) U.S. DEPARTMENT OF COMMERCE Economics -and Statistics Administration U.S. CENSUS BUREAU Entity ID Government Name A, TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION All LUCA liaisons, reviewers, and anyone wdti access to Title 13, United States Code (U.S.C.)-LUCA.mater als must agree to keep confidential the 3iiie. � 3 materials K` to which they have access, including any maps that contain structure points showing the location of living quarters. They may use this information'sd&ly for suggesting irnprovements.to the Census Bureau's -address list and maps. All individuals who will review or have access to Census Bureau Title 13 materials must sign below to indicate they have read and understand the Census Bureau's .Confidentiality and Security Guidelines for LUCA: In addition, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality of Cer t s Bureau . Materials protected under Title 13. Further, a signature indicates recognition that the penalty for wrongful disclosure is a fine of not more than .$250,000 orimprisofinent for not more than 5 years, or both. Atthough access to the data is temporary, this commitment is permanent. You must be at.least 18 years of age to i gn this 'agreement. By signing this agreement, your govemment�°:agrees to destroy all Census Bureau Title 13 materials or return them tote Census Bureau at thie Cotppletion of LUCA, Liaison's Printed Name AC �remie��1=•Z Liaison's Signature B. LIAISON INFORMATION Area code Telephone number t J Date Month Day Iii • -11-11111. Year 1zc1j17. Name of LUQ Liaison's Office, Department, or Agency -- (Assessor's Office, Planning Department, Regional Planning Agency, etc.) - Please print A/c/ 'd G 11.)7 zo 1 it C 44 l art 10 -Ace/Aid/0a Y Address of LUCA Liaison's Office, Department, or Agency - (House number and street name, RR or HC, and box number) •- Please print City Email address Aug-A./Lie_ _Cp.] _toe. AIP State ZIP Code 8d631 C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Prints 'name "7 Signature 1 'Area code Telephone numfer I9h10 I) Date Month Day J I Year 2- 8' 2 t 2-1Or r p> KY Address, if different from Li ison — (House number and street name, RR or HC, and box number) — Please print City 4'o O ct o ft' c ., '/t Pd&a . _/‘ Email address #71-7142-4,2442,0e /Xr/r≤' ✓J /lam Dom• Get 1 S Printed name /0..1 t - State ZIP Code gsdisr/ Area code Telephone number Ext. 0 Signature Date Month Day Year 2- r l Address, if different from Liai n - (House number and street name, RR or HC, and box number) - Please print O 6 71.i 6€1 City A2-77—c- tie‘ E-mail address ec I/1 //./ ‘,..1 • rlt/1 11-'e State ZIP Code I e9C9,6 Section C continued on the reverse a O IS-- oolp OMB No 0607-0994 Approval Expires 12/31/2019 --- - - _- __ /- -• r t -,. .. ,, US DEPARTMENT OF COMMERCE / i, y Eeonanvesand 5 sti A4minhskabon - U S 'CENSUS BUREAU U nsurted REGIS`r.RAATIQ. O FORM, . - -. census ` 2020 - 2020 CENSUS LOCAL-UP,�ATEOF CErl9SUS _ . -, ADDRESSES OOER4TION"(LI CAj; Entity II:1 p' , ; �1 - -, - Gtn/emment Name A. PARTICIPATION RESPONSE (Submission Deadline December 15, 2017) • .` � r44 s , )' A-'` �.Y t... 5- �?`/�tV -„-1', + 4p-0 < t r1*w 0� 1. DYES Our g04emment is:register :registering' LUCA--Con'ip/ate 2a, T NO-Qur government ii -not registering forVL1lCA —Complete a.` Another level of government-(state'or coUnty's f. that in udes our-junsdicti0lt is participating g. a b. II Insufficient staff h. , s f c. ❑ Lack offunds ' _ a d. 0 No tirnfe/too busy" Sections L � - ■ i� -'-', - .... _ B and C. „- , ;�' . „. Section B and mark an (Q for each reason that „applies "a yConcerns about Census ButeaU Title413 matenals `;- _ Restrictions on using Census BureauLTitle 13 materials' -for other, purposes _ Other reason - Specify (Please pant) e. 1:3 -No lord address',1iSt available ` z; - f,4 = L, ,Thank you, for your comrtients We ;Will, use, them to help improve future LUCA ,operations. _ w B. SIGNATURE OF TRIBAL CHAIR. OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION 1,, Printed .name `dit Tribal their or Highesii{Elected'Officialldppointed'Official =First; middle initial, last ' ,. ,_� 2. Signet of Tribal Chair or High t Elected Official/Appointed Official - ji.,� ,(e Date n Month Day Yearl, , 1 / I / l b. - 112t OI i 1'? 1 3: PosltionJ— g , Tribal air Governor,, Commissioner, Mayor, Supervisor; please do not abbreviate) — Please print _ Number and street name 4.1 Physical/ 4100 ,C.Ai Ai 4 ,4ev Vc Mailing City I State ,I ZIP Cede ' 'address , ', Pf 2J,z L-- i Z-Oi .S10E>.1-1 5;, Telephone . ,Q Area code Number ' Extension ' 6.. Email address C. LIAISON. INFORMATION - eAJ - •,- , / G IJ/as Ca , d-4.. Designate your LUCA Liaison. This is the person responsible ,for protecting the Title 13, .Coinplele,thisFsestrog doly�gt ,ofiare,perficlpahrR n LL1CA''r, i "� 1. Name- — (Please pn7iQ . / confidential Census Bureau materials covered by U.S. Code. y : x, 1,-� ;, _ = ; - -7'. „� r^, • -..�a _�- ., ` ,r one -" ��'~ ,---r-, J � Yom' �', i. - . „', 2. Department, Orgenization, or Agency name —(e g„ Planning and A21:4 4 lol_tiv7-- `I Zoning, Regional Planning Agency; please do not abbreviate) 3.,,Posibon — (e.g , Tribal President,' Director, Assessor, Planner; /44'77"\S J'-1-,l'a t`Z please do not abbreviate) 4. . Number and street name - / , „Physical?iCT�T—/ ..t/. />Th �1,Pvi�. - - - - - . .s c),� '...t address_`. City , - 66.ze..4./r- y ,I State ' i;Zyi' Code 'l Lv 1 8061/ 5. Telephone - - Area codeNumber Extension 6. Email address r - - , - = -S7&J//Z Lc%ri/4oV, Can't III y�d1F k v r —t2kt41 A -I I I I Complete this form and return it along with the completed, signed copies Of the Product Preference Form, Self -Asses Checklist; and Confidentiality Agreement Use the endo§ed postage -paid envelope addressed to ATM' Geography LUCA M atenals• 63E National Processing Center„1201 East 10tt),St. Jei(ersonyi'Ae IN 47,132. As an / you -may scar- yobr completedd forms, including forms with signatures, and (rind them IoGE02020 LUCAt census we . - / `altemative, C. INFORMATION FOR REVIEWER(SJ. ,iid PERSON(S) V14tH ACCESS TO TITLE t3,`U.S. C-. MATERIALS - Co iti;nupd Area code Telephone number Ext. "7 name Erika Rasmussen 9 7 0- 5 3 5- 4 4 7 7_- Sture p ,A,.' I� CL -ti t,�.,c s.e ,-� Date Month f31 Year it tray u L ddress, if different hum -liaison - (House number and street name, RR or I. and box nuMbe4 — Reese Wee 441 Third Street / PO Box 626 City State ZIP Code Mead CO i 80542 Email addnsss sastratopiownefirteatkurg- �t'asynusSe/JO 40 ��ad o{ Printed name Area code Tele number Ext. I -fl I I 1 I I I I Signature Date Month Day Year I II I Address, If different from Liaison - (House number end street name, Mot HC, and box number) - Please pent State ZIP Code I 1 E-mail address Printed name Area code T number Ext. .. - - Signature Date Month Year Address, if different from Liaison- (House number and street name, RR or HC and box number) - Please pWe qty State ZIP Code I 1 Erman address Printed name Area code Tonp number Ext:____,___ — — Signature Date Month Day Year -nm Address. I ddfferent from Liaison — (House number and street name, RR Of HC, and box number)— Please Pant City State ZIP Code I I E-mail address Complete this fon and mum it along with The omrplessd, signed copies of the Reglebeton Preference Fenn. Use Ole enclosed postagepaid envelope addressed to ATI'N: Geography .aedltsonvllle IN 47192 Rather than mailing, you may seen your completed forms. inducting OEO.2020.WCAecen uatiov Form, Sen,Aseesement Checklist and the Pmduat 1Lt(4 d3E, National Accessing Can* 1201 East 10th St, fora with slgnehnast and email stem to us at FORM 8)4005 (4420$ X104005 (•440n) OMB No. 0807.0994 Approval Expree 1031/2019 u.s. DEPARTMENT OF COMMERCE MOW AGIMIKIIIINT Mill jN 2020 CRN$ LOCAL UPDATE OIN$LH 110011205815 OPERATION (UM) EndiY ID ant Government Government Name Mead Town A. TERMS, CONDITIONS. AND FHESPONSIDILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION a krep.adbtaad the 13 smelt Ail LOA lame. redsee s, and oyes WM saw to Tire 13, Wad Item Cads NIL'NILO LUCA mad* moat apt to shish they have OAK, Isidro my asps my cent* aUuorae porn. Matto h looMoi a lIw +w.roa.. Trny may we tae throaoe.daly for insgaeng L5lwawr.-ai leAr Cm. tfums widow la aid nap., Al halide* olio vM mss, or have b Census Bissau Tide 13 new.a rad tips blow b hidoaa they have reed aid alderttand the GM. BWMIU ftriNo‘d1Wand am* militias avl w umnl solvates r' a eaaacoplial .e � Os pan* kr �r. I,+dper�t b and d sot nito Om MAO Osallienkfri adC. �."S arm .II4ie no we Man b esm. or boa. Atdlteph soaves burs date id Isaparery. the aorraldrryol Is permirra w roust be at Mn 1e )wed ees a rasa lo ap.wnnd. Ily MMIWp tale a yea rack tor povelmela mess to doom d Ceram Bum 1ri.13 road* or alum Sam to the Coma aersau et the anew 4t1Cd . D. LIAISON INFORMATION Llalaonls Printed Name 119 Area code Telephone number Ext jack Stotler 17101-14 10101— 5 4 1 -1 1 1 1 1 tle�on's Signature Month ay Year IIZI10t(412.Iet119I Name of LUCA Daperbmnt, or Agency - filaseseors CAbss Planning Department, Avenel Pfanr>ig Aging ells) - Phase ON Weld County Public Safety and Information Technology Address of LUCA Lisbon's Office. Department. or Agency - (Houle number and sheet names RR or HO, and box number) - Phase prb►t 1551 N 17th Ave, Suite 2 City Siste ZIP Code Greeley CO 1 80631 Email address statlereeawel' <. v.com C. INFORMATION FOR REVIEWERS) ; d PERSONS) WITH ACCESS TO TITLE ...'. U.S.C. MATERIALS -, , , nanie Area code Telephone number Mary Struts 917 0 — 513 5 — 4 417 7 — `ITI Signature Date Month Oa Year a 7z OF ETEM Address, II dlllererd US S — (House trumber and *beet neme, RR or HC, and box number) —Peeese print 441 1 Third Street / PO Box 626 C!State ZIP Code Mead CO i 80542 EmaU address mstrutt@townofinead org Printed name Area Dods Telephone number Ext. Cans Kennt dv 1 Signature 1I9I7I_l5I3I51_14I4[1I..7I_I Month Lary Year `._ 13E1fo`fa - - Address. H dMterent from liaison — (Name RR or HO. and box number) — Please print 441 Third Street / PO Box 626 City State ZIP Code I Mead CO i 80542 E-rnad address leablen C Gentimed en ckennedy@townofinead.org the rea"enee FORM Ian (2 22 2017) OMB No 0807-0994 Approval Expires 12/31/2019 U.S DEPARTMENT OF COMMERCE Uniteds FIEGIS°�ATION PORE! Entity ID P1.0849600 ... OE1�E LOCAL UPDATE OP CE ,AININIIESSES TON (L) „Q. PARTICIPATION `RESPONSE1FSubrnission Dea`dl'ine Decm eber 15 ' . •,._ Government Name Mead Town 20.1;7), - 9. �. VA ❑ TM Our government is registering for LUCA. —Complete NO Our government is not registering for LUCA —Complete ea. ❑ Another level of government (state or county) f. that Includes our junsditxion is parUapating t ®. 6 h. 13 Sections ■ • O 8 and C. Section B and mark en pc) for each reason that applies Concerns about Census Bureau Tale 13 materials Restrictions on using Census Bureau Title 13 materiels for other purposes Other reason - Specify (Please pnnt) 0' l:11taddress list available Thank you for your commence, Idle will Sae !B.,,SI,GNAT0R'E.OF t11113 CH41R'OR HIGHE§S,T EtECTEOA them to help Improve Mum LUCA P,_'P01NT.ED 0F'FICIAL 13ESp,ONUfN'G;tr13 THf,;L.(!NVI'tATI0N ti. Printed nartie of Tribal Chair or Highest Elected Oflrs"allAppointed Gary Official-Fiist, middle 'Oval, last R Shields Signature Tribal Ch o 'Elected OffidalAppointed Xr•C44. Official Date Month Day Year 1 J, 12.71;.0 _1 _7 3. Position — (9 g , Tnbel Chair, Governor, Commissioner, Mayor, Mayor Supervisor; please do not abbreviate) — Please print - Number and street name 4. Physical/ 441 Third Street / PO Box 626 ress ailing s City aadd Mead I i State ZiP Code t CO I 80542 8. Telephone Area code Number Extension S. Email address 9 7.0 — 5 3 5 — 4 4 7 7 — ' C'..LIA�ISON INFORMAT19 4D,esi9nate This 15 A'iie Aerson, responsible •lorr-••proteeting the TiVIle 14 "l/:5 •• 7-' , Is asctlorr only ' you are • : ;'. pat • in LI I. Name — (Please print) sack Statler mstrutt r . ownofinead„o • •._„ - „ _ your LUCA•'Liaison con/rden ril Census'•: Bureau n5.It'e'rials c:ovei'er1, by Codes. _ 2. Department, Organization, or Agency name — (e g, Planning and Zoning, Regional Planning Agency, please do not abbreviate) Weld County 3. Position — (eg, . Tribal President, Director, Assessor, Planner; please do not abbreviate) Operations Manager, WC Public Safety Information Technology Number and street name Physical/ 1551 N. 17th Avenue, Suite 2Melling f t ZP address Siete Code Greeley 1 CO i 80631 3. Telephone Area code Num r Extension S. Email address istatler@weldgov.com 9. 7 0- 4 0. 0— 4 1 —I IIII ate this-fomt and Mum it eking with the completed, signed copies el the Redid Refinance Form es ChochleL end idle dve, yeti mayour coneated forms, Including forms a signatureonset them foGEO.202ai simc Nth Use dm an 0a rb 24.201 OMB. Na 0607-0994 Approval &piles 12/31/2019 C� 2020 U S DEPARTMENT OF COMMERCE Economia and Mad= AdWnic atlon U.S CENSUS BUREAU S SELF -ASSESSMENT CHECKLIST 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID Government Name n l0al PROTECTING CENSUS BUREAU TITLE 13 MATERIALS Confidentiality & ecurity Guidelines Reference Circle Y, N or Na 1. Do you understand that the Census Bureau's Title 13 data, Including addresses and latitude/longitude coordinate data Otructure points), cannot be used- to create, update, nor modify a tribal, state,'or local jurisdiction address data base? 3 Y N 2.-WIll you store Title 13 materials Ina secure location? 41, 4.2 sii @N1 N 3. WM you secure Title 13 materials to prevent unauthorized staff from accessing these materials?This includes staff members other than those who signed the Confiderdlality Agreement, that have access to the offices, cabinetsor other areas whereTitle 13 materials are Stored. , . 41, 4 2 4. Will you construct electronic security profiles to allow on those who signed the Confldentiabty Agreement to access the Census Bureau's Title 13 materials, if the Title 13 Infomiatfon le placed on a shared computer system? Required If you are selecting GIPS, the ' -digital address Iist, or the Paper/PDF maps. 41 Y O NA 5.'W111 you ensure that your IT system restricts the read, wnte,,delete, and execute functions applicable to the Census Bureau's Title 13 materials to only those individuals that signed the Confidentiality Agreement? Required If you are selecting GUPS, the digital address list; or the Paper/PDr maps. 4 1 Y N NA 6: WIII you assign_an encrypted, unique utter -ID and password for each LUCA Liaison, reviewer, and anyone With access to Title 13 materials' Required If you,are selecting GUPS, the digital address,fat, or,the PaperIPDF maps. 41 Y N NA you ke le 13 data ep_TitSeparate from your other data? Title 13 data cannot be T. backed -up; backed•up; mixed with, nor stored with other data? Required K you are selecting GUPS, i , the digital address list, or the Paper/PDF maps 41 Y N e\IA, Circle or N - - REPORTING AN INCIDENT Confidentiality &- Securlty ' Guidelines Reference 'Y 6. -Will you report to the Census Bureau all violations of unauthorized viewing or loss of Title,13 materials within 24 hours of discovery? 4 3 (;) . N , OWSITE-VISITS Confidentiality & Security - Guidelines Reference Circle YON 9. Do you understand that the Census Bureau may conduct on -site visits toyoUr office to Inspect your security Measures regarding the Census Bureau's Title materials? 4 4 (ND N , - DESTRUCTION OR -RETURN OF CONFIDENTIAL MATERIALS Confidentiality & ice' Reference Circle Y pr N 10. Will you-destroy'(the preferred method) or return -the Title 13 materials according to the approved destruction or return methods outlined in the Confidentiality and Secty Guidelines? " 4.5, 4.6 / Y J N LUCA Liaison Sig tore /---- LUC at Name (Prra?t Date C Product Preference Processing forms with form and return it along with INeted, Signed copies of_the Regishatiorl Form, .Form. Use the enclosed postage -paid envelope addressed to TTN: Geography Center, 1201 East 10th St, Jelle►sonvlle IN 47132 Ratherthan mailing, you may scan signatures, and email them to us at GE0.2020.LUCA ®census oov Confidentiaffty Agreement, and the LUCA Materials 63-E, National your completed forms, including - l E»mail addi name Signature Area code Teiepf►oine number I I L 1-I I l I-1 I I I 1-I l I I Date Month Day Year IIIIIIIIII Address, it different from Liaison — (House number and street name, RR or NC, and box numbed— Please print City:'. State ZIP Code Email address '. Printed name Signature Area -code . _T H 1 1 ne number _ICI I I - Date Month Day Year I11.1.11[.III Address, it different from Liaison - (House number and street name, AR or NG, and box number) -Phase prat State } ZIP C I J I I Prirs€ad name'; bignature Address; ff different from Liaison - (House number and*E eet'name RR or FIG, and Area code IIlI4 Month . Day Year State I p 1 ZIP. -mail a name Signature City different from liaison — (House number and stmef Milner RR ar Araa code IH Telephone number Date Month Day Year I .1-TlFTTEI and bvrtriU nber) —.Please Flint State. ZIP Cede E-mail address c omplete this torgt and ram; it along with .the completed, signed copies of the Registration FORM Sell-Assessment,Ghe( st and the ahtct' Prate Font. Use the enclosed postage -paid envelope addressed b A77ttt: Gemmel* WCA 63-E, National Processing Centex ?2Q1 East 10th St, Jetlersonvi le IN 47132. Rather than mailing, you may scan your completed loans,, including forms with signatures, and *mad them to us at GE 2o2o.11Jc census aa/ FORµ D•20O5 (a-5-2017) FORM D-2005 4-5-2017) OMB No. 0607-0994: Approval Expires 12/31/2019 United States Census 2020 U.S. DEPARTMENT OF COMMERCE CONFIDENTIALITY Economics and Statistics Administration AGREEMENT FORM U.S. CENSUS BUREAU 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID Oct' z3 Government Name vJetc) Coc"lFy A. TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION All LUCA liaisons, reviewers, and anyone with access to Title 13, United States Code (U.S.C.) LUCA materials must agree to keep confidential the Title 13 materials to which they have access, including any maps that contain structure points showing the location of living quarters. They may use this information solely for suggesting improvements to the Census Bureau's address list and maps. All individuals who will review or have access to Census Bureau Title 13 materials must sign below to indicate they have read and understand the Census Bureau's Confidentiality and Security Guidelines for LUCA. In addition, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality of Census Bureau materials protected under Title 13. Further, a signature indicates recognition that the penalty for wrongful disclosure is a fine of not more than S250,000 or imprisonment for not more than 5 years. or both. Although access to the data is temporary, this commitment is permanent. You must be at least 18 years of age to sign this agreement. By signing this agreement, your government agrees to destroy all Census Bureau Title 13 materials or return them to the Census Bureau at the completion of LUCA. B. LIAISON INFORMATION Liaison's Printed Name i1 Liaison's Signature .1 4 I., / v r ;I Area code Telephone number 7 J 4f G, Date Month Day Year Ext a a� L 2 Name of LUCA Liaison's Office, Department, or Agency - (Assessor's Office, Planning Department, Regional Planning Agency, etc.) - Please orint w eLA (co 'Akin- noire J-, r.; Address of LUCA Liaison's Office. Department. or Agency - (House number and street name, RR or HC, and box number) - Please print City Email address State ZIP Code LL' tt^ ;,I C(c1Jc.J. ( c'.' C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Printed name Signature Area code Telephone number Ext. Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please print City Email address State ZIP Code Printed name Signature Area code Telephone number Ext. OMIMMI Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please print City State ZIP Code E-mail address Section C continued on the reverse FORM D-2005 (4.5.2017) IIGI EEMli1ENT FORIA 2020 CENSUS LO AL. UPDATE OF CENSUS ADDRESSESTlON.(LUCA OMB No. 0607-0994: Approval Expires 12/31/2019 COMMERCE CONF#4ENTIALITY U.S.E scats, aa, U.S. CENSUS BUREAU Entity ID Government Name A. TERMS, CONDITIONS. AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION Ad t.DCA. tip reviewers, and anyone with west to The 18, United States CD del 0j LUCA materials must agree Mimi) confidential the TIUe 13 mMefglls . So ttrey trove spores, hnud arsmaps that onto shi repo is the Wilton of Piing quarters. They may use this information solely for suggesting, the Qensus Sumac's address No and maps. [ Heusi or have arms to Census Bureau Tile 13 niatetlats must stgn below to iri�Cate tlhey have read and understand Gil de6rlee"h# Lt1CA In addlttorh, tthctra v1w sigh the trees intder of peryuty to mait�fa`ri the cmrhft�r of r ; :13: Puitrer, a s ignstw ndic s gn�an illhat the' penalty for wren is aline of no* mote glen $250 }'cur (tripe • or both. Although access to the data Is teitiporary, this co ninenhent Is pernienett.,You must be at least 18 years sage to shah the tgrrametyf . tu3 deatm ra Census 8ur� 3 Materials Of r n them to the Census Bureau,at the oghn� ted`Name 's Signature Area code Telephone number _ I £ 9 Date Month Day Year 11 1 11 I , DiPattment, or Agency+'- (Assessor's Office, Planning Department Regional tanning Agency,etc.) --PI Weld County Public Safety IT. Address of LUCAliaison's Office, Department, or Agency — (Norse number and street name, RR or HC, and box number) - 1401 N. 17th Ave C. Greeley Email address srenature/ State CO ZIP Code I 80631 C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS from Liaison City Email address Yin r "t..c lei 0 ate.-.- Printed fame t4' C,ti O Signature red code Telephone number Ext.... Date 'Month Day ' Year 1-517-6-n-1 RR or 1'C', and r tuatbef = Please plait' State City ZIP 4•VB1063 Telephone numbs Date Month �''` Day Year ` 1 I t Hill ess, if different from Liaison - (mouse number and street name, RR or NC, and box number) -'Please print State ZIP Code E-mail address Section C continued on the reverse aoI$-oo'i' , OMB No 0607-0994 Approval Expires 12/31/2019 U S DEPARTMENT OF COMMERCE Economics end Statist Mnunistralion tail CENSUS BUREAU UmtedStalze FORM Entity ID 1 202®� T I. . % 7ES 2 , ' NO a. b. c. d. Our *nether ❑ ❑ N REGISTRATION 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) A. PARTICIPATION RESPONSE (Submission Deadline December 15, Our government is registenng for LUCA — Complete Sections B and C government is not registering for LUCA — Complete Section B and mark an (X) for each level of government (state or county) t. ❑ Concerns about Census Bureau Title that includes our jurisdiction is participating g. O Restrictions on using Census Bureau in LUCA other purposes Insufficient staff h. ❑ Other reason — Specify (Please pnnt) Lack of funds No time/too busy Government Name Twn ; toy _ 2017) reason that applies 13 materials Title 13 matenais for 7 e. ❑ No local address list available Thank you for your comments. We will use them to help Improve future LUCA operations. B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE. LUCA INVITATION I. Printed name of Tribal Chair or Highest Elected Official/Appointed Official — First, middle initial, last c --1611t. ye_ _ 0/2 fit, 2. Signature of Tribal Clair or t hest Elected OfficiaVAppointed Official I ,/ � ate Month Day Year I! 1111012;1121 III -7l 3. Po ion — (e g , Tribal Chair, mor, Commissioner, Mayor, Supervisor; please do not abbreviate) — Please print /0 in rvtiViiS ftJ Number and street name 4. Physeal/ 70.3( t' Xr1 12000 7 Mailing City // I State ^� TT I ZIP Code address L -1›L h b L{ / 1 W I &31400 5. Telephone 6. Email address Area code Number Extension (_oL / LC t C C. LIAISON INFORMATION - Designate your LUCA Liaison. This is the person responsible for protecting the confidential Census Bureau materials covered by Title 13, U.S. Code. Complete this section only if you are participating in LUCA 1. Name - (Please pant) 2. Departm aril on, or Agency name - (e g, Pia and Zoning, Regional Planning Agency, please do not abbreviate) I L ' to -C-- LAO C -- 3. Position - (e g , Tribal President, Director, Assessor, Planner, please do not abbreviate) ---i-c";LL) V\ (J _ v [C_ f P l0 4. Number and street nam PhysicaV 763 �0 LCy1 -(-'*/-` / 12._42(1 S-1 Mailing City I L.J address 2 O L J„ r V L _ I State I ZIP Code /W e_ I - l u 5. Telephone Area code Number Extension 6. Email address s, Y111 ICY .az/dzw— G 10 cA9tAke- ffrirgl— U [3 —fig �rI� — I I i Cartplete this fom and return k along iwtt the completed signed copies of the Product Preference Fom►, Se -Assessment Cheer and the enclosed postage -paid envelope addressed to ATM Geography LUCA Materials 6b National Processing Center, 1201 East 10th SL 47132 may scan your completed lams, kichidhlg forms tti4fh signatures and email them to GE0.202a.LUCAecensuseov `alfernatit% you C. INFORMATION FOR FtEVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS - Continued Printed name Wendy Heywood Area code Telephone number 9 7 0 2 8 4 6 9 3 1 Signature Date Month Day Year 1 1 2 1 1 2 0 Address, if different a Li: son -1ase number and street name, RR or HC, and box number) - Please pnnt 128 North 2n S eet City LaSalle State Colorado 1 7 ZIP Code 180645 Email address wheywood@lasalletown corn Pnnted name Signature Area code Telephone number ' III — I I I I — I-T- Date Month Day Year m Address, if different from Liaison — (House number and street name, RR or HC, and box number) — Please print City State Ext ZIP Code E-mail address Printed name Signature Area code Telephone number -IIII— Date Month Day Year I -I -I Address, if different from Liaison — (House number and street name, RR or HC, and box number) — Please print City State Ext. ZIP Code E-mail address Printed name Signature Area code Telephone number -IIII— Date Month Day Year Ext Address, if different from Liaison — (House number and street name, RR or HC, and box number) — Please print City State ZIP Code E-mail address Complete This form and return it along wNh the completed, signed copies of the Registration Form, Self -Assessment Checklist and the Product Preference Form. Use the enclosed postage -paid envelope addressed to ATTN Geography WCA 63-E, National Processing Caentec 1201 East 10th St, Jeffersonville IN 47132 Rather than mailing, you may scan your completed forams, Including forms with signatures, and email them to us at GEO2020 WC4 Ooensusoov FORM D.2005 (4 5-2017) FORM D.2006 (4-5.2017) OMB No 0607.0994 Approval Expires 12/31/2019 AftUnitedStatea - CONFIDENTIALITY u S DEPARTMENT OF,COMMERCE Fmnonuce and samrots aemnmesratlan CensusAGREEMENT FORM U S CENSUS euaeAu 2020 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID 1 Government Name 'R. TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION All LUCA liaisons, reviewers, and anyone wah access to Title 13, United States Code (USG) LUCA materials must agree to keep confidential the Title 13 materials to which they have access, inducing any maps that contain stricture points showing the location of living quarters They may use this information solely for suggesting improvements to the Census Bureau's address list and maps All individuals who will review or have access to Census Bureau Title 13 materials must sign below to Indicate they have read and understand the Census Bureau's Confidentiality and Security Guidelines tor LUCA. In addtion, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality of Census Bureau materials protected under Title 13 Further, a signature indicates recognition that the penalty for wrongful disclosure Is a tine of not more than $250,000 or Imprisonment for not more than 5 years, or both Although access to the data is temporary, this commitment Is permanent You must be at least 18 years of age to sign this agreement By signing this agreement, your government agrees to destroy all Census Bureau Title 13 matenals or return them to the Census Bureau at the completion of LUCA B. LIAISON INFORMATION Liaison's Printed Name Area code Telephone number Ext Jack Statler 19 1 71 01-14 I O I O L-121514 11 I— I III I Liaison's Signatu a Date Month Day Year 11* -11/ IcII -IaItI7I Name of L A Liaison's Office, apartment, or Agency - (Assessor's Office, Planning Department, Regional Planning Agency, Wei 4( G0kdit,>1-0'el idgPrt .� etc) - Please pnnt Address of LUCA Liaison's 0th , Department, or Agency - (House number and street name, RR or HC, and box number) - Please 1551 North 17th Avenue, Suite 2 pnnt City State Greeley Colorado ZIP i 80631 Code Email address statler n weld • ov corn C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH.ACCESS Printed name TO TITLE 13. U.S.C. MATERIALS Area code Telephone number Ext Carl Harvey 7 0- 2 8 - 6 9 3 1- Signature P9 Date Month Day Year 1 1 2 1 2 0 1 7 Addre , Liaison - (House number a et name, RR or HC, and box number) - Please pnnt 128 North 2nd Street City State Town of LaSalle Colorado ZIP Code i 80645 Email address charvey@lasalletown corn Printed name Area code Tele hone number ExL Jessicca McKeown 9 7 0- 2 8 4= 6 9 3 1 — Srgnatu Date Month Day Year 1 1 2 1 2 0 1 7 Address, if 128 No City LaSalle fferent nom Liaison — (House number and street name, RR or HC, and box number) — Please print h 2nd Street - State ZIP Code 1 Colorado 180645 E-mail address Section C continued on jmckeown@lasalletown corn the reverse FORM D.2OO2 (222-2017) OMB No 0607-0994 Approval Expires 12131/2019 r U S UtF'AK I MtN I Ut UUMMtKGto Econom ca end8CSU FORM2020 U 3 Urn wilily ILI Censsus REGISTRATION uu 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) A. PARTICIPATION RESPONSE (Submission Deadline December 15, Government Name a10t1 • , a 2O17) 1. 2. ❑ Pl YES NO a. b. c. d. Our I4 (7 al F'l Our government is registenng for LUCA —Complete Sections B and C government is not reglstenng for LUCA —Complete Section B and mark an (X) for each reason that applies Another level of government (state or county) f. ❑ Concerns about Census Bureau Title 13 materials that includes our lunsdiction is participating in LUCA g. ❑ Restrictions on using Census Bureau Title 13 materials for other purposes Insufficient staff h. ❑ Other reason — Specify (Please print) Y Lack of funds No time/too busy •. VI No local address list available Thank you for your comments. We will use them to help improve future LUCA operations. B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION 1. Printed name of Tnbal Chair or Highest Elected Official/Appointed Official —First, middle initial, last Pcndr-tkk.) S fY1a.rh ne.2 2. Signature of Tnbal Chair or Highest Elected Official/Appointed Official 1 lIti1IItIl1oliIi1 Date Month Day Year (-3..-44,.... °.-f\‘‘..a_ 3. Position - (e cv V) g, Tribal Chair, vemor, Commrssro r, Mayor, Supervisor, please do not abbreviate) - Please pnnt o r 4. PhyslcaU Number and street name \ Q Ia0Y4I'h 2_hd rr�* Mailing City I State I ZIP Code address (! (� Lga` le 1 1 20A L -c)5. Telephone 6. Email address Area code Number Extension Ci gir -nu 4 I- mina- C. LIAISON This is the person responsible for ■■■ mcy4-1 n 2 1tzS0-i le-F0u-:11lc© m NFORMATION - Designate your LUCA Liaison. protecting the confidential Census Bureau materials covered by Title 13, U.S. Code. Complete this section only if you are participating in LUCA 1. Name — (Please print) :T ./V 5l -4, -Flee 2. Department, Organization, or Agency name�i— (e g , Planning and Zoning, Regional Planning Agency, please do not abbreviate) W a l Gl9 GGsti` i J4Abwean?n / 3. Position — (e g, Tribal President,Director, Assessor, Planner, please do not ab e) [[ 4. Number and street name Physicail 195 I M1/' J 713. Ars .. 5q,4� 2 Mailings addres City I State I ZIP Code sc� ICb 1411431 5. Telephone Area code Number Extension 6. Emaddress ail CJ Luelelienr. 6,144,t, ,(S}t+W'tef )-51- �t 0 o -L1[5111( I -I I L l I Complete this !flan and ietum It along with the completed, signed copies o/ the Prodr d Preference Form, Self -Assessment Cheoldist and Confdentreidv Agreement Use the enclosed postage -paid envelope addressed to ATM' Geography LUCA Materials 63-E National Processing Center, 1201 East 10th St Jeffersonville IN 47132. As an 1 alternative, you may scan your completed forms, including forms nth sgnatwes, and email them toGEO 2020.UCAncensuacov J FORM D.2005 (4+2017) OMB No 0607-0994 Approval Expires 12/31/2019 2uzu CONFIDENTIALITY U S. DEPARTMENT OFto COMMERCE oonom Eics end Steam ABrinfetratlon AGREEMENT FORM U S. CENSUS BUREAU 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID PL0825280 Government Name Evans A. TERMS. CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION All LUCA lessons, reviewers, and anyone with access to Title 13, United States Code (USC) C) LUCA materials must agree to keep confidential the Title 13 materials to which they have access, including any maps that Contain structure points showing the location of living quarters. They may use this information solely for suggesting improvements to the Census Bureau's address Mt and maps All individuals who will review or have access to Census Bureau Title 13 materials must sign below to Indicate they have read and understand the Census Bureau's Confidentially and Security Guidefmas for LUCA. In addition, those who sign the agreement swear, under penalty of penury, to maintain the confidentiality of Census Bureau materials protected under Title 13. Further, a signature indicates remgnibon that the penalty for wrongful disclosure is a fine of not more than $250,100 or imprisonment for not more than 5 years, or both Although access to the data is temporary, this commitment is permanent You must be at least 18 years of age to sign this agreement By signing this agreement, your government agrees to deshrryi eti Census Bureau Tide 13 materials or ratan them to the Census Bureau at the completion of LUCA Liaison's Printed Name :Tittk $4-,thefr Liaison's Signs re th, Name of L A Liaison's Office, Department, or Agency — (Assessor's Office, Planning Department, Regional Planning Agency, etc) — Please print vrfrutieP f�� f � ehL o�� AC (House / rand street name, RR or HC, and box number) — Please pant Address of LUCA Liaison's Office, Departm Agency B. LIAISON INFORMATION Area code Telephone number Ext I I I I -I I I I- -I 1 1 I I Date Month Day Year 1,1211, [ IIz10 I 1171 City sreG�.�-� Email address ,t 5t1e./ State ZIP Code Bi 43 C. INFORMATION FOR REVIEWER(S),and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Printed name KAtt P ` l n Signatur At cS Area code Telephone number 9rld-L15-2Zvii- Date Month Day Year - t t 12f 1 12011 Address, K different from LI (Ho number and street name, RR or HC, and box number) - Please print I lad 3V7i`% sirref City Email address State Ca Ext ZIP Code 1‘O(, 20 Printed name Signature Area code Telephone number Ext I-1 I I- I I I I- - Date Month Day Year III Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please print City State ZIP Code E-mail address Section C continued on the reweave 1 FORM D•2002 (2 22 2017) OMB No 0607-0994 Approval Expires 12/31/2019 1 U S DEPARTMENT OF COMMERCE Economics b"g�u� Entity ID PL0825280 SIDS REGISTRATION FORM 2020 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Government Name Evans A. PARTICIPATION RESPONSE (Submission Deadline December 15, 2017) 1. [g] YES Our government is registenng for LUCA — Complete Sections B and C 2. ❑ NO Our government Is not registering for LUCA — Complete Section B and made an (X) for each reason that applies a. ❑ Another level of government (state or county) f. ❑ Concerns about Census Bureau Title 13 matenals that includes our junsdiction is participating in LUCA g. ❑ Restrictions on using Census Bureau Tale 13 materials for other purposes b. ❑ Insufficient staff h. ❑ Other reason — Specify (Please punt) 7 e. ❑ Lack of funds d. ❑ No time/too busy e. ❑ No local address list available Thank you for your comments. We will use them to help improve future LUCA operations. B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION of Tribal Chair orHighest Elected Official/Appointed Official — First, middle initial, last 1. Pnnted name / /N, -/ ,m 1L 4'- -/-; ! = ice/; 2. Signature of Tnbal Chair or Highest Elected Official/Appointed Official I G Date Month Day Year I /I/II J/It L I.I7I 3. n — (e g , Tribal Chair, Governor, Commissioner, Mayor, Supervisor, please do not abbreviate) — Please print Itrr Number and street name 4. Physical/ /100 ?7F4 15..r- Mailing address City I State 1 ZIP Code V✓A(/Il I I 00690 6. Telephone P 8. Email address Area code Number Extension G']IlMI - L►JVI!ta - m7nCn - �l■■ C. LIAISON INFORMATION - Designate your LUCA Liaison. This is the person responsible for protecting the confidential Census Bureau materials covered by Title 13, U.S. Code. Complete this section only if you are partiapating in L CA i. Name — (Please punt) _`� WeAci Cnun-�y %_ Ar3-0AHe✓ 2. Department, Organization, or Agency name - (e g, Planning and Pt) hit' C aace.{ Ir1cn,rmaOio'1 Tedrine)Ico Zoning, Regional Planning Agency; please do not abbreviate) . 3. Position - (e g , Tribal President; Director, Assessor, Planner, please do not abbreviate O�Pra-1a0s t- anck., 4. Number and street name oZ Physical/ 15F\ N. 11*"" ivt JCS i-k.Mailing address City I State I ZIP Code (-iratey S. Telephone Area code N mber Extension 6. Email address 'ska-4-lee@ Wele 9elv. earn R-71— n — • . - 2 5 41 - Complete tie form and return it along with the completed, sided copies of the Product P Form, Seff.Assessment Cheat aril! Ag Use the enclosed postagwpaid envelope addressed to ATTN. Geography LUCA Materials 63-E, National Amassing Center, 1201 East 10th SLC a (N 4732 As an .aftemabve, you may scan your completed forms, Including forms with signatures, and email them to GE02020 LUCA Ooeneus.Aov OMB No 0607-0994 Approval Expires 12/31/2019 i U S DEPARTMENT OF COMMERCE vniteastates CONFIDENTIALITY 1°'Mes and St"" A "'ta" e"°" FORM U S CENSUS BUREAU Entity ID UenSUS2020 AGREEMENT 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Government Name A. TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING 'IN THE 2020 CENSUS LUCA OPERATION Ail LUCA liaisons, reviewers, and anyone wdh access to Title 13, United States Code (USC) C ) LUCA to which they have access, Including any maps that contain structure points showing the location of improvements to the Census Bureau's address hst and maps AO individuals who will review or have access to Census Bureau The 13 materiels must sign below to Confidentiality and Seamfy Guidellnesfor LUCA. In addition, those who sign the agreement swear, materials protected under Title 13 Further a signature indicates recognition that the penalty for wrongful more than 5 years, or both. Although access to the data is temporary, this commitment is permanent By signing this agreement, your government agrees to destroy all Census Bureau Title 13 materials B:LIAISON INFORMATION. Liaison's Pnnted Name materials must agree to keep confidential the Title 13 materials riving quarters They may use this information solely for suggesting indicate they have read and understand the Census Bureau's under penalty of perjury, to maintain the confidentiality of Census Bureau disclosure is a the of not more than 5250,000 or imprisonment for not You must be at least 18 years of age to sign the agreement or return them to the Census Bureau at the completion of LUCA Area code Telephone number Ext J,4- k S1-aAlev' r e- 141 o16I - I2I'1' ► I — I III Liaison's Signatu Date Month Day Year li }2A/ 1sIIZip I i 171 Name of L Liaison's Office, Department, or Agency — (Assessor's Office, Planning Department, Regional Planning Agency, lye ( Q (44A--Kaorw , %cl c . etc) — Please pant Address of LUCA Liaison's Office, DepaNnent, or Agency — (House number and street name, RR or HC, and box number) — Please /VO/ N.l11:ifWrjAe. pant City State V er1rAt es ZP . , . I,e..,A__ _ ,.., ....___ , - Email address 1,4„,..,„ _ 0, (-, ...., c .. o . ecovt- C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Pnnte • name Area code Telephone number Ext. —3—e_Str, 7(',c e'_. 7 0 4/ 5V! - - -13I '1- Signature Date Month Day Year ii a0laoll 71 eilss, if difreAde..--e"---e------- m Liaison - (House number and street name, RR or HC, and box number) - Please pnnt Qa 3 F;6 5 I- 3 -f -re - Crty State ZIP Code Email address q Prin ed name Area code Telephone number Ext Signature Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please pent City State ZIP Code I I E-mail address Section C continued on the reverse FORM D.2002 (2 22 2017) OMB No 0607-0994 Approval Expires 12/31/2019 r— U S DEPARTMENT OF COMMERCE Eoonomke and CENSUS BUREAU S S REGISTRATION FORM 2020 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID Government Name A. PARTICIPATION RESPONSE (Submission Deadline December 15, 2017) 1. IF1 YES Our government is registerng for LUCA —Complete Sections B and C 2. ❑ NO Our government is not registering for LUCA —Complete Section B and mark an (X) for each reason that applies a. ❑ Mother level of government (state or county) 1. ❑ Concerns about Census Bureau Title 13 materials that includes our jurisdiction is participatingin LUCA 9• ❑ Restrictions on using Census Bureau Title 13 matenals for other purposes b. ❑ Insufficient staff h. ❑ Other reason — Specify (Please pnnt) . C., ❑ Lack of funds d. ❑ No time/too busy e. ❑ No local address list available Thank you for your comments. We will use them to help Improve future LUCA operations. B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION 1. Pnnted name of Tribal Chair or Highest Elected Offiaal/Appointed Official —First, middle initial, last 2. ) Sign est Elected Official/Appointed Official Date Month Day Year 1)1►1- 3IaI(.1'171 3 Positio - = . , Tn a!! Chair, Governor, Commissioner, Mayor, Supervisor, please do not abbreviate) - Please pnnt —1---1-1/ n fiATYi/Y)I'4-rQ'1'ar Number and street name 4. Physical/ :22,,D3-_, 7 1 —i- (-+' Mailing City I State I ZIP Code address E\ ; cC) ; -Wes\---5 S. Telephone Area code Number Extension Extension 6. Email address I I sa-man-I3. 3c -I (d'3� - ' _ ,&....o C. LIAISON INFORMATION - Designate your LUCA Liaison. This is the person responsible for protecting the confidential Census Bureau materials covered by Title 13. U.S. Code. Complete this section only If you are participating in LUCA 1. Name - (Please pnnt) 7-4146I-Ae 2. Department, Organization, or Agency name - (e g , Planning and Zoning, Regional Planning Agency, please do not abbreviate) ski / Sij .4 D r didiraici 3. Position - (0 g, Tnbal President, Director, Assessor, Planner; please do not ebb vii Otibt, UP'� S /'1/. AIWA f5 A ---A- 4. Number and street name ,c PhysMaiical/ /...(‘/ /() 'l7 Af' 54 r tt Z address City / I State I ZIP Code Atee 117 ! S. Telephone Area code Number Extension 6. Email address "I 1 44 (etewe yoyre'o 1111 IoI—Iklo ID —I2-Is lid I —I I I I Complete this form and retum rt along with the completed, signed copies of the Product Preference Form, Self -Assessment Checklist, and Cor fidenbaldy Agreement. Use the endosed postage -paid envelope addressed to ATTN Geography LUCA Materials 63.E, National Processing Center, 1201 East 10th Si, Jeffersonvile IN 47132 As en Vemethie, you may scan your completed forms, including forms with signatures, and email them toGEO 2020 LUCARcensus Oov J FORM 0-2006 (5-24-2017) OMB. No. 0607-0994: Approval Expires 12/31/2019 Census 2020 U.S. DEPARTMENT OF COMMERCE Economics and Statistics Adminiske4ion U.S. CENSUS BUREAU SELF -ASSESSMENT CHECKLIST 2020 CENSUS LOCALUPDATE OF CENSUS . ADDRESSES OPERATION (LUCA) Entity ID 08123 Government Name WELD COUNTY COLORADO PROTECTING CENSUS BUREAU TITLE 13 MATERIALS Confidentiality & Security Guidelines • Reference Circle Y, N or. NA 1, r: Do you understand that the: Census. Bureau's Title 13 data, including addresses and latitude longitude coordinate data (structure points), cannot be used to create, update, nor modify: a tribal, state, or local jurisdiction address'data base? 3 N Will you store Title 13 materials in secure location? 4.1, 4.2 N 3.: Will you secure Title 13 materials to prevent unauthorized staff from: accessing these materials? This includes staff members other than those who signed the Confidentiality Agreement, that have access to the offices, cabinets,' or other areas where Title 13 materials are: stored 4. 'Will you construct electronic' security profiles to allow only those who signed the • Confidentiality Agreement to access the Census Bureau's'Title 13 materials, if the Title 13 information is placed 'on a shared computer system?:Required if you are selecting GUPS, the digital address list, or,the Paper/PDF. maps. 5. Will you ensure: that your IT system restricts the read 'write, delete, and execute functions applicable to the Census: Bureau's Title 13 materials to only those individuals that signed • the Confidentiality Aggreement? Required if you are selecting CUPS the digital address list, or. the :Paper/PDF 6 Will you assign an: encrypted,'unique user -ID and password for each LUCA liaison, reviewer, an anyone with access to Title: 13 materials? Required if you are selecting CUPS, the digital address` list,. or; the Paper/PDF;inaps 7" Will,you keep Title'13 data.separate from your other; data? Title 13 data cannot be • backed -up, mixed with, nor' stored .with other data? Required if you are selecting GUPS the digital address list, . or : the. Paper/PDF:•maps 4.1, 4.2 N 4.1 Y N NA 4.1 N NA 4.1 Y N NA 4.1 N NA r t 9..Do you understand that the Census Bureau may conduct on -site visits to your office to inspect your security measures regarding the Census Bureau's Title materials? 8. Will,: you; report to ;the Census Bureau all violations ofunauthorized viewing orloss of :.• Title 13 materials within 24 hours of:discovery? Confidentiality &' Security Guidelines Reference 4.3 Confidentiality :&• Security ; Guidelines Reference 4.4 DESTRUCTION.; OR RETURN OF CONFIDENTIAL` MATERIALS Confidentiality .Security Guidelines Reference N N N 10 Will you destroy (the preferred method) or return the Title 13 materials according to the approved:destructin or return ethodmoms outlined the Confidentiality:and;Security Guidelines? 4.5, 4.6 LUCA Liaison S' atu LUCA Liai n` Name (Print) JACK ATLER Date 12=22-2017 Complete this form and return it along with the completed, signed copies of. the: Registration Form, :Confidentiality Agreement, and the Product Preference Form. Use the enclosed postage -paid envelope addressed to AATTN: Geography LUCAMaterials 63-E, National Processing Center, 1201 : East 10th: St, Jeffersonville /'N 47132. Rather than mailing you may scan yourcompleted forms, including `forms : with signatures, and email them to us at GEO.2020.LUCA ®census. qov C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS Pnnted name Jacob Mundt TO TITLE 13, U.S.C. MATERIALS - Continued Area code Telephone number Ext 9 7 0- 4 0 0- 2 5 2 1 - Signature Date Month Year Day (I I IZI ) IIaIof)l7 Address, event from Liaison - (House number and street name, RR or HC, and box number) - Please pnnt 1401 N 17th Ave City State ZIP Code Greeley CO 180631 Email address lmundt@weldgov corn Printed name Area code Telephone number Ext Signature Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please punt City State ZIP Code I I E-mail address Pnnted name Area code Telephone number Ext Signature Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please print City State ZIP Code I I E-mail address - Pnnted name Area code Telephone number Ext — I I 1 I — _ Signature Date Month Day Year Address, if different from Liaison - (House number and street name, RR or HC, and box number) - Please pnnt City State ZIP Code I I E-mail address Complete this form and return it along with the completed, signed copies of the Registration Preference Form Use the enclosed postage -paid envelope addressed to ATTN Geography Jeffersonville IN 47132 Rather than mailing, you may scan your completed forms, including GEO2020 WCA @census qov Form, Self -Assessment Checklist and the Product WCA 63-E, National Processing Center, 1201 East 10th St, forms with signatures, and email them to us at - - FORM D-2005 (4-5 2017) FORM D-2005 (4 5 2017) OMB No 0607-0994 Approval Expires 12/31/2019 U S DEPARTMENT OF COMMERCE .United States CONFIDENTIALITY Economics and U StatisticsAdministration BBUREAU Xensus ILOCAL Entity ID 08123 2020 2020 C NSUS UPDAENT TE OF CENSUS ADDRESSES OPERATION (LUCA) Government Name Weld County A. TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020•CENSUS LUCA OPERATION All LUCA liaisons, reviewers, and anyone with access to Title 13, United States Code (U S C ) LUCA matenals must agree to keep confidential to which they have access, Including any maps that contain structure points showing the location of living quarters They may use this information improvements to the Census Bureau's address list and maps All indmduals who will review or have access to Census Bureau Title 13 matenals must sign below to indicate they have read and understand Confidentiality and Security Guidelines for LUCA In addition, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality materials protected under Title 13 Further, a signature indicates recognition that the penalty for wrongful disclosure is a fine of not more than $250,000 more than 5 years, or both Although access to the data is temporary, this commitment is permanent You must be at least 18 years of age to By signing this agreement, your government agrees to destroy all Census Bureau Title 13 matenals or return them to the Census Bureau at the the Title 13 materials solely for suggesting the Census Bureau's of Census Bureau or imprisonment for not sign this agreement. completion of WQA. B. LIAISON INFORMATION Liaison's Pnnted Name Area code Telephone number Ext Jack Stater IkI7 I0I—I41010I—I 2J5 J4 I 1I—IIIII Liaison's Signature ,iiZIZ Date Month Day Year I I IZII I I3IIZIo II 171 Name of LUC aison's Office, Department, or Agency — (Assessor's Office, Planning Weld County Information Technology Department, Regional Planning Agency, etc) — Please pent Address of LUCA Liaison's Office, Department, or Agency — (House number and street 1401 N 17th Ave name, RR or HC, and box number) — Please pnnt City Greeley State CO ZIP Code 80631 Email address lstatler@weldgov corn C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Pnnted name Area code Telephone number Ext Troy Puchan 9 7 0- 4 0 0- 2 5 4 3 - Signature Date Month Year ` �1 I2�'Day'1S 20 l 7 Address, if different from Liaison — (House number and street name, RR or HC, and box 1401 N 17th Ave City Greeley number) — Please pnnt State CO ZIP Code 80631 Email address tpuchan@weldgov corn Printed name Area code Telephone number Ext Dan Huerter 9 7 0,— 4 0 0— 2 5 2 2— . a re C4.5----- Date Month Day Year .Cot- cz zoa0t7 Address, if di Brent from Liaison — (House number and street name, RR or HC, and box number) — Please pnnt 1401 N 17th Ave City State ZIP Code Greeley CO 80631 E-mail address Section C continued en �dhuerter@weldgov corn the reverse FORM D-2002 (2-22-2017) OMB No. 0607-0994: Approval lies iyi2019 United States Census 2020 20 U.S. DEPARTMENT OF COMMERCE Economiceend.St tstiosAdministration U:S.!?G +lSU BUREAU REGISTRATION :PP „ NSUS LOCAL UPDATE OI CENSUS ESSES 'OP „ TION (LUCA) 1, Entity ID 08123 ;° en). Weld County it A. PARTICIPATION RESPONSE (Submission Deadline .ecember 15, 2017) YES ©urngovernment is registering for LUCA. —Complete Sec r,s. B and C. NO Our government is not eg tering for LUCA. —Complete Section B. atirtinarfc an (X) for each reason that a 1p/ a. ❑ Another level bf garrlment (state or county) f. LI Concepts about Census Bureau i il1e;13 riaterilals° Alit includes our jurisdiction is participating 6•.' Restrictions on using :Census Title 13 materia '.y . other purppses q:. :.: b..E,.insufficient staff c. ❑ Lack of funds ... d. [] No tinie/too busy �ess.li vallable h. ❑F Other reason = Specify (Plea'se print) le. r Thank you fortyourramients. We will use them to help Ihrprcve future LL A opi ttoas. B. SIGNATURE OF TRIBAL CHAIR OR HIGHEST ELECTED/APPOINTED OFFICIAL RESPONDING TO THE LUCA INVITATION 1 Printed name of Tribal Chair or Steve Moreno E Official/Appointed Official --First, rnidd n last Signaturrr of Tribal Chair or Highest* Electeci Ofii elf po1h.tad Official Date, Month ° 3a Year (OMI0I3Ilaloli I8 F osition -- (e g , Tcfhal Chair, Governor, Comm loner, Mayor, Supervisor;; please do not ahbidviate) —Pie Commissioner Chair print ical/ Number arid street name 1150 O Street PYLY Greeley State CO i ZIP Code 80631 5. Telepl Area ne Number 9 7 0 3 3 6 FIE 0 El Extension 6. Email address smoreno@weldgov.com C. LIAISON INFORMATION - Designate your LUCA Liaison. This is the person responsible for protecting the confidential Census Bureau materials covered by Title 13, U.S. Code. replete this secftc acne•-•(P(case Prin Jack Statler if are: L 2. Department, Organization, or Agency name —(e.g., Planning and Zoning, Regional Planning Agency, please, do not abbre Weld County Information Technology ''"Position - (e.g., Tribal F sT ht, Director;= ssessor, Planner, please do not abbreviate) Operations Manager Public Safety Information Technology Number and street name Physical 1551 N 17th Ave Ste 2 fling dress City.'. Greeley 5. Teleptione ,'..,'Area code Number 9 l7 I 0 I...� 3i 3_16 J_l215 14 Extension 1I—JIII State Co 6. Email address jstatler@weldgov.com lZW,Code I 80631 it akxrg with ttie completed, signed r o s t7 ►e Fr?xfuct Preference fonn, Self -Assessment Checklist and Confident addressed to ATTN: Geography LUCA Materials 63-E, National Processing Cent 4201 East 10th Si, forr»s, including forms with signatures, and email the n ?oGE0:2020.LUCAi cehSus.pov. FORM D-2005 (4-5-2017) OMB No. 0607-0994: Approval Expires 12/31/2019 r U.S. DEPARTMENT OF COMMERCE United States. CONFIDENTIALITY Economics and Statistics Administration Census AGREEMENT FORM U.S. CENSUS BUREAU 2020 2020 CENSUS LOCAL UPDATE OF CENSUS ADDRESSES OPERATION (LUCA) Entity ID 08123 Government Name Weld County A. TERMS, CONDITIONS, AND RESPONSIBILITIES FOR PARTICIPATING IN THE 2020 CENSUS LUCA OPERATION All LUCA liaisons, reviewers, and anyone with access to Title 13, United States Code (U.S.C.) LUCA materials must agree to keep confidential the Title 13 materials to which they have access, Including any maps that contain structure points showing the location of living quarters. They may use this information solely for suggesting improvements to the Census Bureau's address list and maps. All individuals who will review or have access to Census Bureau Title 13 materials must sign below to indicate they have read and understand the Census Bureau's Confidentiality and Security Guidelines for LUCA. In addition, those who sign the agreement swear, under penalty of perjury, to maintain the confidentiality of Census Bureau materials protected under Title 13. Further, a signature indicates recognition that the penalty for wrongful disclosure is a fine of not more than $250,000 or imprisonment for not more than 5 years, or both. Although access to the data is temporary, this commitment is permanent. You must be at least 18 years of age to sign this agreement. By signing this agreement, your government agrees to destroy all Census Bureau Title 13 materials or return them to the Census Bureau at the completion of LUCA. B. LIAISON INFORMATION Liaison's Printed Name Area code Telephone number Ext Jack Stater 191710-1410101-I 215 14 11 1—I 1 1 I I Liaison's Signature Date Month Day Year ,Ici I i 1 z l TI I ZIo Ii I7 I Name of LUC 'aison's Office, Department, or Agency — (Assessor's Office, Planning Department, Weld County Information Technology Regional Planning Agency, etc.) - Please print Address of LUCA Liaison's Office, Department, or Agency — (House number and street name, 1401 N 17th Ave RR or HC, and box number) — Please print City Greeley State CO ZIP 80631 Code Email address jstatler@weldgov.com C. INFORMATION FOR REVIEWER(S) and PERSON(S) WITH ACCESS TO TITLE 13, U.S.C. MATERIALS Printed name Area code Telephone number Ext. Troy Puchan 9 7 0- 4 0 0- 2 5 4 3 - Signature Date Month Day Year 1 2_ I 5- 2_ 0 1 7 Address, if different from Liaison — (House number and street name, RR or HC, and box number) — Please print 1401 N 17th Ave City State Greeley CO ZIP Code 180631 Email address tpuchan@weldgov.com Printed name Area code Telephone number Ext. Dan Huerter 9 7 0— 4 0 0— 2 5 2 2 — . a re Date Month Day Year ortn, ,(pc9rL-- i Z 2_O a01 7 Address, if di erent from Liaison - (House number and street name, RR or HC, and box number) - Please print 1401 N 17th Ave City State ZIP Code Greeley CO 80631 E-mail address Section C continued on __dhuerter@weldgov.com the reverse J Hello