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TITLE VI SURVEY <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections <br />1798, at seq.), notice is hereby given for the request of personal information by this form. The requested personal <br />information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this <br />form -The failure to provide all or any part of the requested information may delay processing of this form. No <br />disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of <br />1977. Each individual has the right upon request and proper identification, to inspecfall personal information in any <br />record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to <br />your IPA Office. <br />Expenditure Authorization (EA) <br />NON-DISCRIMINATION <br />All persons affected by State transportation projects are requested to provide information with regard to race, color, <br />national origin, sex, disability, age or income status. Please check the items below which best describe you and <br />return this form in the enclosed envelope. <br />The famishing of this information is voluntary. <br />Head of household: <br />Age: <br />Race/Ethnicity: <br />❑ Male <br />❑ Under 40 <br />❑ White <br />❑ Black <br />❑ Hispanic <br />❑ Asian <br />Language spoken, if other than English: <br />❑ Female <br />❑ 41=65 ❑ Over 65 <br />❑ American Tribe <br />❑ Pacific islander <br />❑ Other <br />Specify: <br />Are you or any member ofyour household suffering any physical disability or medical condition? ❑ Yes ❑No <br />Are you a low-income family? ❑ Yes ❑No <br />Enclosure <br />75E-57 <br />