Form 9620 Race and National Origin Identification

OMB No. 1545-1398
Expires 09/30/05

Race and National Origin Identification
(Please read the instructions and Privacy Act Statement before completing form.)

Agency Use Only

Name (Last, First, Middle Initial)

Birthdate (Month & Year)

Privacy Act Statement and Paperwork Reduction Act Notice
You are requested to furnish this information under the
authority of 42 U.S.C. §2000e-16, which requires that
Federal
employment
practices
be
free
from
discrimination
and
provide
equal
employment
opportunities for all. Solicitation of this information is in
accordance with Department of Commerce Directive 15,
“Race and Ethnic Standards for Federal Statistics and
Administrative Reporting.”

identify your race and national origin by visual
perception.
You are requested to furnish your Social Security
Number (SSN) under the authority of Executive Order
9397 (November 22, 1943). That Order requires agencies
to use the SSN for the sake of economy and orderly
administration in the maintenance of personnel records.
Because your personnel records are identified by your
SSN, your SSN is being requested on this form so that
the other information you furnish on this form can be
accurately included with your records. Your SSN will be
used solely for that purpose. Your furnishing of your
SSN is voluntary and failure to furnish it will have no
effect on you; failure to provide it, however, may result in
it being obtained from other agency sources.

This information will be used in planning and monitoring
equal employment opportunity programs and to identify
employees for inclusion in skill banks and referral pools.
Your furnishing this information is voluntary. Your failure
to do so will have no effect on you or on your Federal
employment. If you fail to provide this information,
however, then the employing agency will attempt to
identify

(Continued on Reverse)

Specific Instructions:
The categories below are
designed to identify your basic racial and national origin
category. If you are of mixed racial and/or national
origin,

origin, identify yourself by the category with which you
most closely identify yourself. Darken the oval next to
the appropriate category. NOTE: Mark only one oval.

DO NOT FOLD STAPLE, TEAR OR PAPER CLIP THIS FORM.
DO NOT SUBMIT PHOTOCOPIES OF THIS FORM.

EXAMPLES

This form can be processed only if you:
1) Use a number 2 lead pencil.
2) Completely blacken the oval corresponding to your response choice.
3) Completely erase any mistakes or stray marks.
WRITE YOUR RESPONSES IN THE BOXES AND
BLACKEN THE APPROPRIATE OVALS.

NAME OF CATEGORY
(Mark ONE Only)

SOCIAL SECURITY
NUMBER

American Indian or Alaskan Native

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0
1
2
3
4
5
6
7
8
9

0 1 2

3 4

0
1
2
3
4
5

0
1
2
3
4
5

0
1
2
3
4
5

0
1
2
3
4
5

0
1
2
3
4
5

JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG

This
year

YES

Next
year

NO
N

Y
Y
Y

N
N
N

DEFINITION OF CATEGORY
Categories for Use in All Jurisdictions Except Hawaii and Puerto Rico
A person having origins in any of the original peoples of North America, and
who maintains cultural identification through community recognition or tribal
affiliation.

Asian or Pacific Islander

A person having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area
includes, for example, China, India, Japan, Korea, the Philippine Islands, and
Samoa.

Black, not of Hispanic origin

A person having origins in any of the black racial groups of Africa. Does not
include persons of Mexican, Puerto Rican, Cuban, Central or South American,
or other Spanish cultures or origins (see Hispanic).

Hispanic

A person of Mexican, Puerto Rican, Cuban, Central or South American, or other
Spanish cultures or origins. Does not include persons of Portuguese culture or
origin.

White, not of Hispanic origin

A person having origins in any of the original peoples of Europe, North Africa,
or the Middle East. Does not include persons of Mexican, Puerto Rican, Cuban,
Central or South American, or other Spanish cultures or origins (see Hispanic).
Also includes persons not included in other categories.

Hispanic

A person of Mexican, Puerto Rican, Cuban, Central or South American, or other
Spanish cultures or origins whose official duty station is in Puerto Rico. Does
not include persons of Portuguese culture or origin.

Not Hispanic in Puerto Rico

A person not of Mexican, Puerto Rican, Cuban, Central or South American, or
other Spanish cultures or origins whose official duty station is in Puerto Rico.

GENDER

Categories for Use in Puerto Rico

Male

Form 9620 (Rev. 02-2003)

Female

Cat. No. 20517S

Department of the Treasury - Internal Revenue Service

Privacy Act Statement and Paperwork Reduction Act Notice (continued)
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or
its instructions must be retained as long as their
contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code
section 6103.

The time needed to complete this form will vary
depending on individual circumstances. The estimated
average time is: 3 minutes. If you have comments
concerning the accuracy of these time estimates or
suggestions for making this form simpler, we would be
happy to hear from you. You can write to the Tax Forms
Committee, Western Area Distribution Center, Rancho
Cordova, CA 95743-0001. DO NOT send the form to
this address. Instead, return it to the Internal Revenue
Service Center personnel office that has been
designated for your use.