Form Hud-27061 - Race And Ethnic Data Reporting Form
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3Race and Ethnic Data
U.S. Department of Housing
OMB Approval No. 2535-0113
and Urban Development
(exp. 01/31/2011)
Reporting Form
Office of Administration
Program Title:
Grantee/Recipient Name:
Grantee Reporting Organization:
Reporting Period From (mm/dd/yyyy):
To (mm/dd/yyyy):
Total Number of
Total Number of Race
Racial Categories
Hispanic or Latino
Responses
Responses
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
American Indian or Alaska Native and White
Asian and White
Black or African American and White
American Indian or Alaska Native and Black or African
American
* Other multiple race combinations greater than one
percent:
[Per the form instructions, write in a description
using the box on the right]
Balance of individuals reporting more than one race
Total:
0
0
* If the aggregate count of any reported multiple race combination that is not listed above exceeds 1% of the total
population being reported, you should separately indicate the combination. See detailed instructions under “Other
multiple race combinations.”
Public reporting burden for this collection is estimated to average 1.15 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering the data needed, and completing and reviewing the information
collection instrument. HUD may not collect this information, and you are not required to complete this form unless it displays a
currently valid OMB control number.
1
form HUD-27061 (10/31/2009)
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