Sample Data Form

SAMPLE DATA COLLECTION FORM
DEMOGRAPHIC INFORMATION OF APPLICANT AND CO-APPLICANT
The purpose of collecting this information is to help ensure that
all applicants are treated fairly and that the housing needs of
communities and neighborhoods are being fulfilled. For
residential mortgage lending, Federal law requires that we ask
applicants for their demographic information (ethnicity, race, and
sex) in order to monitor our compliance with equal credit
opportunity, fair housing, and home mortgage disclosure laws.
You are not required to provide this information, but are
encouraged to do so. You may select one or more
designations for “Ethnicity” and one or more designations for
“Race.”

The law provides that we may not discriminate on the basis of
this information, or on whether you choose to provide it.
However, if you choose not to provide the information and you
have made this application in person, Federal regulations require
us to note your ethnicity, race, and sex on the basis of visual
observation or surname. If you do not wish to provide some or all
of this information, please check below.

Applicant:

Co-Applicant:

Ethnicity: – Check one or more
Hispanic or Latino
Mexican
Puerto Rican
Cuban
Other Hispanic or Latino – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on:

Ethnicity: – Check one or more
Hispanic or Latino
Mexican
Puerto Rican
Cuban
Other Hispanic or Latino – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on:

Not Hispanic or Latino

Not Hispanic or Latino

I do not wish to provide this information

I do not wish to provide this information

Race: – Check one or more
American Indian or Alaska Native – Print name of enrolled
or principal tribe:

Race: – Check one or more
American Indian or Alaska Native – Print name of enrolled
or principal tribe:

Asian
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – Print race, for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on:

Asian
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – Print race, for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on:

Black or African American
Native Hawaiian or Other Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race, for example, Fijian,
Tongan, and so on:

Black or African American
Native Hawaiian or Other Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race, for example, Fijian,
Tongan, and so on:

White

White

I do not wish to provide this information

I do not wish to provide this information

Sex:
Female
Male
I do not wish to provide this information

Sex:
Female
Male
I do not wish to provide this information

To Be Completed by Financial Institution (for an application taken in person):
Was the ethnicity of the applicant collected on the
basis of visual observation or surname?
Yes
No

Was the ethnicity of the co-applicant collected on the
basis of visual observation or surname?
Yes
No

Was the race of the applicant collected on the basis
of visual observation or surname?
Yes
No

Was the race of the co-applicant collected on the basis
of visual observation or surname?
Yes
No

Was the sex of the applicant collected on the basis
of visual observation or surname?
Yes
No

Was the sex of the co-applicant collected on the basis
of visual observation or surname?
Yes
No