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U.S. Office of Personne! Management ETHNICITY AND RACE IDENTIFICATION Guide to Personnel Data Standards (Please read the Privacy Act Statement and instructions before completing form ) Name (Las, Firs, Middle Initial) ‘Social Security Number Birthdate (Month and Year) Ute 1-36 SIMMONS I, TORREY Lv yiusus py sjudlicee | 04/2009 ‘Agency Use Only Privacy Act Statement Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance with the Office of Management and Budget's 1997 Revisions to the Standards for the Ciassification of Federal Data on Race ‘and Ethnicity. Providing this information is voluntary and has no impact on your employment status, but in the instance ‘of missing information, your employing agency will tempt to identify your race and ethnicity by visual observation, ‘This information is used as necessary to plan for equal employment opportunity throughout the Federal government. It is also used by the U. S. Office of Personnel Management or employing agency maintaining the records to locate individuals for personnel research or survey response and in the production of summary desorintive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies, Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be used for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary and failure to do so wil have no effect on your employment status. if SSN is not provided, however, other agency sources may be used to obtain i Specific Instructions: The iwo questions below are designed to Kentfy your ethnicity and race. * ardless of your answer to question 1, go to question 2. ‘Question 1. Are You Hispanic or Latino? | ‘ {irl Areriean, or ober Spanish etre or origin, rogarless of race.) Ee Ca ‘Question 2. Please select he racial calagon sing an Inthe appropriate Box. Check as many 28 aly RACIAL CATEGORY = (Bf American Indian or Alaska Native Wel 8 of North and South America feleome To tribal affiliation or community Social See Asian " unity dies of the Far East, Southeast ane Impl, Cambodia, China, Ina, WESUPALM 168, Thailand, and Vietnam. BEACH FL 1 Black or Atican American ups of Aca Your ticket 1 Native Hawaiian or Other Pacific Islander number is 3 of Hawaii, Guam, Samoa, or C108 J White 's of Europe, the Middle East, or ‘Thank you. Please wait 10 be called i aaa Standard Form 161 Revised August 2005 Previous edons nat usable online services at wuw.socialsecurit: 222016 09:15:38 42 USC, Section 2000-16 AM NSN 740.01-099-3446 Fax Call Report HP LaserJet M3035 MFP Series Page 1 Fax Header Information 31-Dec-2015 U7 AM Job Date/Time Type 983. Sl-Dec-2015 07:32 AM Send Identification 9, 12023853888 Duration 457 Pgs 2 Result Success FAX From LATRISE SIMMONS. c/o Box 8445 Port St. Lucie, Florida [34985] Total Number of Pages 12 including the cover sheet Message PRIORITY Date December 31, 2015 To OFFICE OF MANAGEMENT AND BUDGET 725 17" Street Northwest Washington DC 20503, FAX: 202-395-3888 Phone: 773-531-3304 Pursuant to the herein documents immediate correction in ALL RECORDS. Standard Form 181 (1 Page) H. Res. 194 (4 Pages) S. Con. Res 26 (6 Pages)