Race and Ethnic Form

Race and Ethnic Data
Reporting Form

U.S. Department of Housing
and Urban Development
Office of Housing

Name of Property

Contract/Project Number

OMB Approval No. 2502-0204
(Exp. 3/31/2014)

Address of Property

Name of Owner/Managing Agent

Type of Assistance or Program Title:

Name of Head of Household

Name of Household Member

Date (mm/dd/yyyy): _____________________

Ethnic Categories (select one)
 Not of Hispanic, Latino/a, or Spanish Origin
Hispanic, Latino/a, or Spanish Origin (select sub-category below)





Puerto Rican
Mexican, Mexican American, Chicano/a
Cuban
Another Hispanic, Latino/a or Spanish Origin

Racial Categories (select one or more)
 American Indian or Alaska Native
Asian (select sub-category below)








Asian India
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian

 Black or African American
Native Hawaiian or Other Pacific Islander (select sub-category below)





Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

 White
 Other
There is no penalty for persons who do not complete the form.
_____________________________________
Signature

____________________________
Date

Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This
information is required to obtain benefits and voluntary. HUD may not collect this information, and you are not required to complete this form,
unless it displays a currently valid OMB control number.

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form HUD-27061-H