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TITLE Vl SURVEY <br />PARSONAL I ' ORMA.TION NOTICE <br />Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of I977 (Civil Code Sections <br />1798, et sec,), 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 force. No <br />disclosuro of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of <br />1977. Barb individual has the right upon request and proper identification, to inspect all 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 (SA) <br />NON DISCRIMINATION <br />All persons affected by State transporfatien 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 oublosad eovetope. The furnishing of this information is voluntary. <br />Hand of household: <br />Malo <br />Female <br />Age: <br />—Under40 <br />41-65 , Over 65 <br />Race/Ethnicity: <br />_ White <br />•,_,American Triba <br />Black <br />—Paolino Islander <br />Hispanic J Other <br />_Asian Specify: <br />Language spoken, if other than English: <br />Are you or any member of your household suffering any physical disability or medical condition?_Yes _No <br />Aro you a low-income family? <br />Enclosure <br />Yes _No <br />750-44 <br />