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Race and Ethnic Data Reporting Form: Hispanic or Latino Not-Hispanic or Latino

This document is a race and ethnic data reporting form used by the U.S. Department of Housing and Urban Development (HUD) along with instructions for completing the form. The form collects information about the race and ethnicity of individuals applying for or currently receiving housing assistance through HUD programs. It includes two ethnic categories and five racial categories for individuals to select themselves. The instructions define each category and state that the form is to be completed by applicants at initial application or lease signing and by current tenants during annual or interim recertification.

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106 views2 pages

Race and Ethnic Data Reporting Form: Hispanic or Latino Not-Hispanic or Latino

This document is a race and ethnic data reporting form used by the U.S. Department of Housing and Urban Development (HUD) along with instructions for completing the form. The form collects information about the race and ethnicity of individuals applying for or currently receiving housing assistance through HUD programs. It includes two ethnic categories and five racial categories for individuals to select themselves. The instructions define each category and state that the form is to be completed by applicants at initial application or lease signing and by current tenants during annual or interim recertification.

Uploaded by

Anonymous oxms9Dz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Race and Ethnic Data U.S. Department of Housing OMB Approval No.

2502-0204
Reporting Form and Urban Development (Exp. 3/31/2014)
Office of Houi!"
Name of Property Proect No. !ddress of Property
Name of "#ner$%anaging !gent &ype of !ssistance or Program &itle'
Name of Head of Household Name of Household %ember
Date (##/$$/%%%%)'
Ethnic (ategories)
Select
"ne
Hispanic or Latino
Not-Hispanic or Latino
Racial (ategories)
"ne or
%ore
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
*Definitions of these categories may be found on the reverse side.
There is no penalty for persons who do not complete the form.
************************************* ****************************
Signature Date
Public reporting burden for this collection is estimated to average 1 min!tes per response" incl!ding the time for reviewing instr!ctions"
searching e#isting data so!rces" gathering and maintaining the data needed" and completing and reviewing the collection of information$ %his
information is re&!ired to o'tain 'enefits and vol!ntar($ H)* ma( not collect this information" and (o! are not re&!ired to complete this form"
!nless it displa(s a c!rrentl( valid O+B control n!m'er$
%his information is a!thori,ed '( the )$-$ Ho!sing Act of 1./0 as amended" the Ho!sing and )r'an 1!ral 1ecover( Act of 1.2/ and Ho!sing
and 3omm!nit( *evelopment %echnical Amendments of 1.24$ %his information is needed to 'e incompliance with O+B-mandated changes to
5thnicit( and 1ace categories for recording the 66. *ata 1e&!irements to H)*$ Owners7agents m!st offer the opport!nit( to the head and co-
head of each ho!sehold to 8self certif(9 d!ring the application interview or lease signing$ In-place tenants m!st complete the format as part of
their ne#t interim or ann!al re-certification$ %his process will allow the owner7agent to collect the needed information on all mem'ers of the
ho!sehold$ 3ompleted doc!ments sho!ld 'e stapled together for each ho!sehold and placed in the ho!sehold9s file$ Parents or g!ardians are to
complete the self-certification for children !nder the age of 12$ Once s(stem development f!nds are provide and the appropriate s(stem !pgrades
have 'een implemented" owners7agents will 'e re&!ired to report the race and ethnicit( data electronicall( to the %1A3- :%enant 1ental
Assistance 3ertification -(stem;$ %his information is considered non-sensitive and does no re&!ire an( special protection$
form HUD-27061-H (9/2003)
1
+nstructions for the Race and Ethnic Data Reporting ,Form H&'-2(0)1-H)
A. General Instructions:
%his form is to 'e completed '( individ!als wishing to 'e served :applicants; and those that
are c!rrentl( served :tenants; in ho!sing assisted '( the *epartment of Ho!sing and )r'an
*evelopment$
Owner and agents are re&!ired to offer the applicant7tenant the option to complete the form$
%he form is to 'e completed at initial application or at lease signing$ In-place tenants m!st
also 'e offered the opport!nit( to complete the form as part of the ne#t interim or ann!al
recertification$ Once the form is completed it need not 'e completed again !nless the head of
ho!sehold or ho!sehold composition changes$ %here is no penalt( for persons who do not
complete the form$ However" the owner or agent ma( place a note in the tenant file stating
the applicant7tenant ref!sed to complete the form$ Parents or guardians are to complete the
form for children under the age of !.
%he Office of Ho!sing has 'een given permission to !se this form for gathering race and
ethnic data in assisted ho!sing programs$ 3ompleted doc!ments for the entire ho!sehold
sho!ld 'e stapled together and placed in the ho!sehold9s file$
. %he two ethnic categories (o! sho!ld choose from are defined 'elow$ <o! sho!ld check one
of the two categories$
. "ispanic or #atino. A person of 3!'an" +e#ican" P!erto 1ican" -o!th or 3entral
American" or other -panish c!lt!re or origin" regardless of race$ %he term 8-panish
origin= can 'e !sed in addition to 8Hispanic= or 8Latino$=
$. %ot "ispanic or #atino. A person not of 3!'an" +e#ican" P!erto 1ican" -o!th or
3entral American" or other -panish c!lt!re or origin" regardless of race$
$. %he five racial categories to choose from are defined 'elow> <o! ma( mark one or more$
1$ American Indian or Alas&a %ative. A person having origins in an( of the original
peoples of North and -o!th America :incl!ding 3entral America;" and who maintains
tri'al affiliation or comm!nit( attachment$
?$ Asian. A person having origins in an( of the original peoples of the @ar 5ast"
-o!theast Asia" or the Indian s!'continent incl!ding" for e#ample" 3am'odia" 3hina"
India" Aapan" Borea" +ala(sia" Pakistan" the Philippine Islands" %hailand" and
Cietnam$
/$ 'lac& or African American. A person having origins in an( of the 'lack racial gro!ps
of Africa$ %erms s!ch as 8Haitian= or 8Negro= can 'e !sed in addition to 8Black= or
8African American$=
(. %ative "awaiian or )ther Pacific Islander. A person having origins in an( of the
original peoples of Hawaii" D!am" -amoa" or other Pacific Islands$
*. +hite. A person having origins in an( of the original peoples of 5!rope" the +iddle
5ast or North Africa$
form HUD-27061-H (9/2003)
?

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