Race and Ethnic Reporting Form

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Public reporting burden for this collection is estimated to average 10 minutes per response, including the time of reviewing instructions, making a selection, and providing additional information, if necessary. Comments regarding the accuracy of this burden estimate and any aspect of this collection of information, including suggestions for reducing this burden can be sent to the Reports Management Officer, REE, US. Department of Housing and Urban Development, 7th Street SW, Room 8210, Washington, DC 20410. Do not send completed forms to this address.
Privacy Act Statement: Authorities: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543).Principal Purpose: This information is being collected by HUD to comply with the OMB Statistical Policy Directive No. 15 (SPD-15), issued under the Civil Rights Act of 1964 (Title VI), Equal Employment Opportunity Act of 1972, and the Paperwork Reduction Act of 1995 which mandates the uniform collection and reporting of racial and ethnic data by federal agencies to govern the enforcement of nondiscrimination in federally assisted programs and services. Routine Uses: The information collected by Form 27061-H will be used by HUD to record race and ethnicity categories from individual applicants. The data compiled is reported on the HUD 50059. The information provided will not be disclosed outside of the agency and used solely for internal statistical compliance purposes, except as required by law or as allowed by the System of Records Notice cited below. Disclosure: Providing this information is voluntary. Failure to provide the information will have no impact on an individual’s housing assistance.
SORN ID/URL: https://www.federalregister.gov/documents/2023/09/13/2023-19782/privacy-act-of-1974-system-of-records.




Name/Address of Property

Project Number (HAP Contract/FHA Number
Name of Owner/Managing Agent

Type of Assistance or Program
Name of Head of Household

Name of Household Member
Date (mm/dd/yyyy)


What is your race and/or ethnicity?
Select all that apply and enter additional details in the spaces below.
☐
American Indian or Alaska Native. Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.


☐
Asian. Provide details below.

    • Chinese	❑ Asian Indian	❑ Filipino
    • Vietnamese	❑ Korean	❑ Japanese
Enter, for example, Pakistani, Hmong, Afghan, etc.


☐
Black or African American. Provide details below.

    • African American	❑ Jamaican	❑ Haitian
    • Nigerian	❑ Ethiopian	❑ Somali
Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.


☐
Hispanic or Latino. Provide details below.

    • Mexican	❑ Puerto Rican	❑ Guatemalan
    • Cuban	❑ Dominican	❑ Salvadoran
Enter, for example, Colombian, Honduran, Spaniard, etc.


☐
Middle Eastern or North African. Provide details below.

    • Lebanese	❑ Iranian	❑ Egyptian
    • Syrian	❑ Iraqi	❑ Israeli
Enter, for example, Moroccan, Yemeni, Kurdish, etc.



☐
Native Hawaiian or Pacific Islander. Provide details below.

    • Native Hawaiian	❑ Samoan	❑ Chamorro
    • Tongan	❑ Fijian	❑ Marshallese
Enter, for example, Chuukese, Palauan, Tahitian, etc.


☐
White. Provide details below.

    • English	❑ German	❑ Irish
    • Italian	❑ Polish	❑ Scottish

Enter, for example, French, Swedish, Norwegian, etc.


☐
I do not wish to provide my race and/or ethnicity.
There is no penalty for persons who do not complete this form.



Signature

Date