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201109462 <br /> Voluntary Race, Ethnicity & Disability Data <br /> Reporting Form <br /> Nebraska Investment Finance Authority(NIFA) requests this information in order to comply with Housing and Economic <br /> Recovery Act of 2008 which requires annual reporting of certain information to the United States Department of <br /> Housing and Urban Development. Although NIFA would appreciate receiving this information,you may choose not to <br /> provide it. You will not be discriminated against on the basis of this information,or on whether or not you choose to <br /> provide it. If you do not wish to provide this information, please check the box and initial below. <br /> Resident/Applicant: ❑ I do not wish to furnish information regarding race, ethnicity and disability. (Initials) <br /> See reverse side for Race, Ethnicity& Disability definitions. Enter both Ethnicity and Race codes for each household <br /> member. <br /> Name of Property Property Address <br /> Name of Owner/Managing Agent Unit# <br /> *More than one race may be checked for each household member <br /> ' � � .. <br /> �,,.,Y fC 41 <br /> '^ u .c <br /> co <br /> C Q v O <br /> Y L � L <br /> p � O Q O <br /> C L �. �. <br /> Y Q � � � � <br /> - J � � - � � �(O"� <br /> 3 c <br /> o ro � Q co f9 <br /> T ' � a u � 2� <br /> N N <br /> " ' � ? '` > = Y >� °1 Disabled? <br /> �c: a ,., � v•.,., ro � '.-• u r <br /> Last Name First Name w = z c� �z � m z a � Y/N <br /> 1 <br /> Z <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> Signature Date <br /> iz/io <br />