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TITLE V1 SURVEY <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act ( PL. 93-579) and the Information Practices Act of 1977 (Civil Code Sections <br />1798, et- 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 fai)ure to provide all or any, pad 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 ipspect all personal information in any <br />recbrd 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 />Alf 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 furnishing of this information is voluntary. <br />Head of household: ❑ Mala ❑ Female <br />Age: t7 Under 40 o 4l-65 o Over 65 <br />Race/Etllnicity:. o White O American Tribe <br />o Black ❑ Pacific islander <br />13 Hispanic bother <br />o Asian Suecifv: <br />Language spoken, if other than <br />Are you or any member of you household suffering any physical disability or medical condition? 0 Yes ONG <br />Are you a low-incoine.family? <br />Enclosure <br />❑Yes ONo <br />75D-145 <br />