Common use of RACIAL DESIGNATION Clause in Contracts

RACIAL DESIGNATION. Indicate number of family members in each individual category below: "To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." Print Name Date Sign Name If you need assistance completing this form, please check with the Joplin Area Chamber of Commerce Foundation for assistance. Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Non-LMI Families (e) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS 1. TOTAL NUMBER OF SURVEYS DISTRIBUTED: 2. TOTAL NUMBER OF HISPANIC OR LATINO: 3. RACIAL DESIGNATION NUMBER OF INDIVIDUALS NUMBER OF HISPANIC (All Races Can Also Be Hispanic) X. XXXXX B. BLACK/AFRICAN AMERICAN C. ASIAN D. AMERICAN INDIAN /ALASKA NATIVE E. NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER F. AMERICAN INDIAN/ALASKAN NATIVE & WHITE G. ASIAN &WHITE H. BLACK/AFRICAN AMERICAN & WHITE I. AM. INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AM K. OTHER MULTI-RACIAL NUMBER PERCENT 4. ELDERLY/AGE 62 OR OLDER 5. HANDICAPPED/DISABLED

RACIAL DESIGNATION. Indicate (select one or more) for each household, enter the number of family members in by each individual category below: applicable race. □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Other Pacific Islander □ American Indian/Alaskan Native & White □ Asian & White □ Black/African American & White □ American Indian/Alaskan Native & Black/African American □ Other "To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." Print Name Date Sign Name If you need assistance completing this form, please check with the Joplin Area Chamber of Commerce Foundation Grantee for assistance. Name of Grantee: Appendix Attachment B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Non-LMI Families (e) TOTAL Non-LMI PERSONS (e)*(a) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS 1. TOTAL NUMBER OF SURVEYS DISTRIBUTED: 2. TOTAL NUMBER OF HISPANIC OR LATINO: 3. RACIAL DESIGNATION NUMBER OF INDIVIDUALS NUMBER OF HISPANIC (All Races Can Also Be Hispanic) X. XXXXX B. BLACK/AFRICAN AMERICAN C. ASIAN D. AMERICAN INDIAN /ALASKA NATIVE E. NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER F. AMERICAN INDIAN/ALASKAN NATIVE & WHITE G. ASIAN &WHITE H. BLACK/AFRICAN AMERICAN & WHITE I. AM. INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AM K. OTHER MULTI-RACIAL NUMBER PERCENT 4. ELDERLY/AGE 62 OR OLDER 5. HANDICAPPED/DISABLED

RACIAL DESIGNATION. Indicate number of family members in each individual category below: "White Black/ African American Asian American Indian/ Native Hawaiian/ Other American Indian/ Alaskan Alaskan Native Pacific Islander Native & White Asian & White Black/African American American Indian/ Alaskan & White Native & Black/ African “To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." ” Print Name Date Sign Name If you need assistance completing this form, please check with the Community Clinic of Joplin Area Chamber of Commerce Foundation for assistance. Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Non-LMI Families (e) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS 1. TOTAL NUMBER OF SURVEYS DISTRIBUTED: 2. TOTAL NUMBER OF HISPANIC OR LATINO: 3. RACIAL DESIGNATION NUMBER OF INDIVIDUALS NUMBER OF HISPANIC (All Races Can Also Be Hispanic) X. XXXXX B. BLACK/AFRICAN AMERICAN C. ASIAN D. AMERICAN INDIAN /ALASKA NATIVE E. NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER F. AMERICAN INDIAN/ALASKAN NATIVE & WHITE G. ASIAN &WHITE H. BLACKX. XXXXX/AFRICAN AMERICAN & WHITE I. AM. INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AM K. OTHER MULTI-RACIAL NUMBER PERCENT 4. ELDERLY/AGE 62 OR OLDER 5. HANDICAPPED/DISABLED

RACIAL DESIGNATION. Indicate (select one or more) for each household, enter the number of family members in by each individual category below: applicable race. □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Other Pacific Islander □ American Indian/Alaskan Native & White □ Asian & White □ Black/African American & White □ American Indian/Alaskan Native & Black/African American □ Other "To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." Print Name Date Sign Name If you need assistance completing this form, please check with the Joplin Area Chamber of Commerce Foundation Sub-Recipient Agreement for assistance. Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Non-LMI Families (e) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS Non-LMI TOTAL Non-LMI PERSONS 1. TOTAL NUMBER OF SURVEYS DISTRIBUTED: 2. TOTAL NUMBER OF HISPANIC OR LATINO: 3. RACIAL DESIGNATION NUMBER OF INDIVIDUALS NUMBER OF HISPANIC (All Races Can Also Be Hispanic) X. XXXXX B. BLACK/AFRICAN AMERICAN C. ASIAN D. AMERICAN INDIAN /ALASKA NATIVE E. NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER F. AMERICAN INDIAN/ALASKAN NATIVE & WHITE G. ASIAN &WHITE H. BLACK/AFRICAN AMERICAN & WHITE I. AM. INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AM K. OTHER MULTI-RACIAL NUMBER PERCENT 4. ELDERLY/AGE 62 OR OLDER 5. HANDICAPPED/DISABLED

RACIAL DESIGNATION. Indicate (select one or more) for each household, enter the number of family members in by each individual category below: applicable race. □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Other Pacific Islander □ American Indian/Alaskan Native & White □ Asian & White □ Black/African American & White □ American Indian/Alaskan Native & Black/African American □ Other "To the best of my knowledge, the above information is true and can be verified if requested by proper officials of the Grantee, City of Joplin and HUD." Print Name Date Sign Name If you need assistance completing this form, please check with the Joplin Area Chamber of Commerce Foundation Sub-Recipient Agreement for assistance. Name of Grantee: Appendix B CITY OF JOPLIN COMMUNITY DEVELOPMENT 2015/2016 INCOME/DEMOGRAPHIC SUMMARY FORM FAMILY SIZE (a) LMI Families (See 2nd Page for Income Limits) TOTAL LMI PERSONS [(b)+(c)+(d)] * (a) Non-LMI Families (e) 1 PERSON 2 PERSONS 3 PERSONS 4 PERSONS 5 PERSONS 6 PERSONS 7 PERSONS 8 PERSONS Non-LMI TOTAL Non-LMI PERSONS 1. TOTAL NUMBER OF SURVEYS DISTRIBUTED: 2. TOTAL NUMBER OF HISPANIC OR LATINO: 3. RACIAL DESIGNATION NUMBER OF INDIVIDUALS NUMBER OF HISPANIC (All Races Can Also Be Hispanic) X. XXXXX B. BLACK/AFRICAN AMERICAN C. ASIAN D. AMERICAN INDIAN /ALASKA NATIVE E. NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER F. AMERICAN INDIAN/ALASKAN NATIVE & WHITE G. ASIAN &WHITE H. BLACK/AFRICAN AMERICAN & WHITE I. AM. INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AM K. OTHER MULTI-RACIAL NUMBER PERCENT 4. ELDERLY/AGE 62 OR OLDER 5. HANDICAPPED/DISABLED