1. House address: 1671 Nelson Street 2. Is this house on a farm (or ranch)? No 3. If no in item 2: Is this house on a place of three or more acres? No
For All Persons:
4. Name (last name first): Coxen, Noximilien
· What is the name of the head of household? Noximilien Coxen · What are the names of all other persons who live here? · List in this order: - The head: Noximilien Coxen - His wife: Olivia Armstrong - Unmarried sons and daughters and their families (in order of age): Emmett Brown, that one girl. - Married sons and daughters and their families: None. - Your least favorite color:
Orange
5. Species (underline applicable):
Human (H) Animal (A) Communist (☭) Wizard (W) Catgirl (CG) God/Goddess (G) Other (please specify)
6. Sex (underline applicable):
Male (M) Female (F)
7. Are you now married, widowed, divorced, separated, or never married? (Mar, Wd, D, Sep, Nev) Wd
8. What State (or foreign country) were you born in? Amakna
9. What is your deepest secret? I am not as desensitized as I should be.
10. If foreign born: Are you naturalized? (Yes, No, or AP for born abroad of American parents) No
11. What are you most ashamed about? Being responsible for the death of my family.
For Persons 14 Years of Age and Over:
12. What were you doing most of last week: working, keeping house, or something else? (Wk, H, Ot, or U for unable to work) Wk
13. If H or Ot in Item 12: Did you do any work at all last week, not counting work around the house? (Include work for pay, in own business, profession, on farm, or unpaid family work) (Yes or No)
14. If No in Item 13: Were you looking for work? (Yes or No)
15. If No in Item 14: Even though you didn't work last week, do you have a job or business? (Yes or No)
16. If No in Item 15: Do you have a good explanation for why you are being so utterly useless to the prosperity of our great town? (Yes, Female, or No, elaborate. Yes is not a valid answer.)
For All Persons:
17. What country were your father and mother born in? (Enter US or name of Territory, possession, or foreign country)
Father: Amakna Mother:
Amakna
18. If anything but America in Item 17, justify your right to be here (maximum 100 words): Your failure to provide an exit, and my failure to make one.
19. What is your most embarrassing memory? Producing the same defect in my entire stock of "Fantasmal Foresight Alarm Clocks".
20. What is more important- laughter (L) or medicine (M)? L
21. Please list all of the following diseases you have been afflicted by, if any: Measles (M), Mumps (U), Chicken-Pox (C), Polio (P), Tuberculosis (T), Smallpox (S), Communism (R)
For All Males in the Household:
22. Did you ever serve in the U.S. Armed Forces during (specify Y or N):
22a. World War II N
22b. World War I N
22c. Any other time, including present service
N
23. If No to any question in Item 22, justify your reasons for being so reprehensibly unpatriotic (maximum 100 words): You never asked!
24. Are you a Communist? Are you? How could I even think of being one if I don't know what that is?
For All Persons:
25. Is there an afterlife and how do you know this isn't it? (maximum 100 words) The gods each provide a heaven for their followers. Xelor would be demanding for a lot of answers from me.
no subject
1. House address: 1671 Nelson Street
2. Is this house on a farm (or ranch)? No
3. If no in item 2: Is this house on a place of three or more acres? No
For All Persons:
4. Name (last name first): Coxen, Noximilien
Orange
5. Species (underline applicable):
6. Sex (underline applicable):
7. Are you now married, widowed, divorced, separated, or never married? (Mar, Wd, D, Sep, Nev) Wd
8. What State (or foreign country) were you born in? Amakna
9. What is your deepest secret? I am not as desensitized as I should be.
10. If foreign born: Are you naturalized? (Yes, No, or AP for born abroad of American parents) No
11. What are you most ashamed about? Being responsible for the death of my family.
For Persons 14 Years of Age and Over:
12. What were you doing most of last week: working, keeping house, or something else? (Wk, H, Ot, or U for unable to work) Wk
13. If H or Ot in Item 12: Did you do any work at all last week, not counting work around the house? (Include work for pay, in own business, profession, on farm, or unpaid family work) (Yes or No)
14. If No in Item 13: Were you looking for work? (Yes or No)
15. If No in Item 14: Even though you didn't work last week, do you have a job or business? (Yes or No)
16. If No in Item 15: Do you have a good explanation for why you are being so utterly useless to the prosperity of our great town? (Yes, Female, or No, elaborate. Yes is not a valid answer.)
For All Persons:
17. What country were your father and mother born in? (Enter US or name of Territory, possession, or foreign country)
Amakna
18. If anything but America in Item 17, justify your right to be here (maximum 100 words): Your failure to provide an exit, and my failure to make one.
19. What is your most embarrassing memory? Producing the same defect in my entire stock of "Fantasmal Foresight Alarm Clocks".
20. What is more important- laughter (L) or medicine (M)? L
21. Please list all of the following diseases you have been afflicted by, if any: Measles (M), Mumps (U), Chicken-Pox (C), Polio (P), Tuberculosis (T), Smallpox (S), Communism (R)
For All Males in the Household:
22. Did you ever serve in the U.S. Armed Forces during (specify Y or N):
N
23. If No to any question in Item 22, justify your reasons for being so reprehensibly unpatriotic (maximum 100 words): You never asked!
24. Are you a Communist? Are you? How could I even think of being one if I don't know what that is?
For All Persons:
25. Is there an afterlife and how do you know this isn't it? (maximum 100 words) The gods each provide a heaven for their followers. Xelor would be demanding for a lot of answers from me.