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TITLE A 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; 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, 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 inspect all personal information in any <br />record maintained do 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 furnishing of this information is voluntary. <br />Head of household: <br />❑Male <br />Age: <br />❑ Under 40 <br />RacelEthnicity:. <br />❑ White <br />Cl 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 of your household suffering any physical disability or medical condition?, O Yes ONO <br />Are you a low-income family? <br />Enclosure <br />❑ Yes ❑ No <br />75D-80 <br />