New Applicant For Eligibility Form - State Of California Department Of General Services

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STATE OF CALIFORNIA
DEPARTMENT OF GENERAL SERVICES
OFFICE OF FLEET AND ASSET MANAGEMENT
RACIAL AND NATIONAL ORIGINS CERTIFICATION
SASP 204 (Rev 11/14)
STATE OF CALIFORNIA
NEW APPLICATION FOR ELIGIBILITY
STATE & FEDERAL SURPLUS PROPERTY PROGRAM
Pursuant to Federal Regulation 28 C.F.R. §§ 42.401 - 42.415, a recipient is mandated to report to the Federal Government the
racial and national origins of all persons within your service area. You are therefore asked to supply the Office of Fleet and
Asset Management with the race and national origins of individuals you serve in your service area (it may be helpful to refer
to the US Census to determine the racial makeup of your service area at ). This form must be
completed and returned with the rest of the eligibility packet in order to qualify for the Federal Surplus Property Program.
Your answers on this form in no way affect your eligibility; however, not returning the form will delay the processing of your
application.
Persons having origins in any of the tribal people of North America, and who maintain
American Indian or
0%
cultural identification through tribal affiliation or community recognition.
%________
Alaskan Native
Persons having origins in any of the original peoples of the far east, Southeast Asia,
Asian / Pacific
Pacific Islands, or the Indian Subcontinent. This includes China, Japan, Korea, The
0%
Islander
%________
Philippines, and Samoa.
Persons having origins in any of the black racial groups of Africa.
0%
Black
%________
Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
0%
culture or origin, regardless of race.
Hispanic
%________
Person having origins in any of the original people of Europe, North Africa, or the
0%
Middle East.
%________
White
0%
(Specify) ________________________________________________________________
0%
%________
Other
Print Name _________________________________________
Title _________________________
Signature
_________________________________________
Date _________________________
OFFICE OF FLEET AND ASSET MANAGEMENT
| State of California | Government Operations Agency
1700 National Drive | Sacramento, CA 95834 | t 916.928.2550 f 916.928.7965

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