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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