Laserfiche WebLink
Attachment D <br />PART VIII. HOUSEHOLD DEMOGRAPHICS <br />Please complete for each household member. See below for Ethnicity, Race, and Other codes that <br />characterize the household composition. <br /> <br />HH Sex Î <br />Race Disabled <br />Mbr # enter M or F Ethnicity <br />Enter up to 5 categories <br /> <br />1 <br /> <br />2 <br /> <br />3 <br /> <br />4 <br /> <br />5 <br /> <br />6 <br /> <br />7 <br />The Minnesota Housing Finance Agency is required to comply with HUDÓs reporting requirements; however, <br />you are not required to provide this information. You may not be discriminated against on the basis of this <br />information, or on whether or not you choose to furnish it. If you do not wish to furnish this information, please <br />initial below. <br />RESIDENT/APPLICANT: I do not wish to furnish information regarding ethnicity, race, sex, and disability status. <br />(Initials) __________ <br />Ethnicity: Enter each household memberÓs ethnicity by using one of 1. Hispanic or Latino <br />the following coded definitions: 2. Not Hispanic or Latino <br />3. Tenant did not respond <br />Enter each household memberÓs race by using, at least one, 1. White <br />Race: <br />of the following coded definitions (up to 5 categories may 2. Black/African American <br />be selected): 3. American Indian/Alaska Native <br /> 4. Select from the following: <br />4a Asian India <br />4b Chinese <br />4c Filipino <br />4d Japanese <br />4e Korean <br />4f Vietnamese <br />4g Other Asian <br />5. Select from the following: <br />5a Native Hawaiian <br />5b Guamanian or Chamorro <br />5c Samoan <br />5d Other Pacific Islander <br />6. Other <br />7. Tenant did not respond <br /> B-2-3 <br />12519391v3 <br /> <br />