1. Are you a citizen of the United States?

2. In what city do you live?

3. In what state do you live?

4. What is your age?

5. What is your gender?

6. Are you a registered voter?

7. If you can only select one of the following, which term do you prefer to use to refer to yourself?

8. Which term do you suggest should be used to refer to the living descendants of African heritage people who were enslaved in the United States?

9. Did one of your maternal lineage ancestors survive the middle passage from Africa across the Atlantic to the Americas?

10. From which modern-day country in Africa did your maternal ancestor that survived the middle passage across the Atlantic Ocean come from?

(If you don’t know answer “I don’t know”.)

11. If provided to you free of charge, would you take the African Ancestry matrilineal DNA test to find out your maternal ancestry?

12. Did one of your paternal lineage ancestors survive the middle passage from Africa across the Atlantic to the Americas?

13. From which modern-day country in Africa did your paternal ancestor that survived the middle passage across the Atlantic Ocean come from?

(If you don’t know answer “I don’t know”.)

14. If provided to you free of charge, would you take the African Ancestry patrilineal DNA test to find out your paternal ancestry?

15. Do you believe that black people in America experience and interpret shared historical events the same way as white people in America?

16. Do you believe that black people in America are fully integrated into American society?

17. Do you believe that black people in America constitute a “nation within a nation”?

18. Do you believe black people in America should have a government of their own like all other free peoples?

19. If forced to choose only one option, which of the following would you choose?

20. Do you believe that Reparations are owed to the descendants of Africans who were enslaved in the American colonies and later the United States of America?

21. Do you believe that Reparations are owed to African Americans because of the legacy of slavery such as Jim Crow laws and other systemic forms of racism?

24. Do you consent to be governed by the United States of America?

25. Do you consider yourself a citizen of the United States?

26. Are you a citizen of any other country besides the United States?

(Please answer yes or no. If yes please identify the country.)

27. Are you a member of any of the federally recognized Native American peoples?

If yes please identify

28. If you can only choose one, which citizenship would you choose?

29. Would you participate in a plebiscite recognized by the United Nations or the African Union that would give you the a chance to choose among the four options: (1) US citizenship, (2) return to Africa, (3) emigration to another country and (4) the creation of a new African nation on American soil?

30. How much would you be willing to contribute to a plebiscite campaign?

31. Please identify your class status:

32. Are you currently enrolled as a student?

33. Please list your highest level of educational attainment:

34. Have you ever been convicted of a misdemeanor or felony?

This question is intended to give some evidence to the extent of how much the criminal justice system touches the lives of our community and affects our views

35. Have you ever been incarcerated?

This question is intended to give some evidence to the extent of how much the criminal justice system touches the lives of our community and affects our views

36. Have you traveled to Africa before?

(If yes, please list the countries you have visited)

37. Do you believe that a new nation of descendants of African people, occupying territory currently within the United States, with an independent government recognized by the United Nations and receiving reparations, could better protect the human rights of black people in America?

38. If housing and employment were provided, would you migrate to territory ceded to a recognized new state and government of descendants of Africans enslaved in the United States?

39. Are you willing to engage in non-violent, civil disobedience or direct action and risk getting arrested while exercising your right to self-determination?

40. Are you prepared to defend your right to self-determination with arms?

(Note: you can only answer yes to this question if you currently own a firearm)

41. Please feel free to make any comments:

Email

If you don't wish to be contacted or kept informed, you do not need to give your email. If you do wish to receive updates on the Plebiscite Campaign or join it as an organizer, you must give your email.