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 740.01-099-3446Fax 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
SuccessFAX
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)