Title 4 U.S.C.

1-4; Article 55 and 56 United Nations Charter;

Congressional Record Page A32220 of May 11, 1955

lnter-American Declaration On

the Rights of lndigenous Peoples

Title 50 U.S.C., Appendix Sections 7(cl,7lel, 9,L2.

1917 Trading with the Enemy Act

Title 42 U.S.C. 1985.

45 Stat. 40L;54 Stat.670

Title 28 U.S.C. 1333.

To: The Office of Management and Budget

725t7tn Street, NW
Washington,
DC

20503 FAX: 202-395-3888

From: Nicole Tamara Nicholas

Re: SF FORM 181

Pages in this fax including cover sheet: 13

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U. S. Office of Personnel Management

Guide to Personnel Data Standards Narne (Last, First, Middle lnitial)

ETHNICITY AND RACE IDENTIFICATION

(Please read the Privacy Act Statement and instructions before completing form.) Social Security Number Birthdate (Month and Year)

Agency Use Only

; ULCyE T

010,-b,L-b CIO >

7-t-7r

Pfivac! 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 Classification 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 attempt 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. tt 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 descriptive 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 will have no effect on your employment status. If SSN is not provided, however, other agency sources may be
used to obtain it. Specific lnstructions: The two questions below are designed to identify your ethnicity and race. Regardless of your answer to question 1, go to question 2. Question

l.
2.

Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other

Spanish culture. or origin, regardless of race.)

Yes

fl

tto

Question

box. Check as many as apply.

Please select the racial category or categories with which you most closely identify by placing an "X" in the appropriate

MCIAL CATEGORY (Check as many as apply)

@EAmerican lndian or Alaska Native

DEFINITION OF CATEGORY

A person having origins in any of the original peoples of No(h and South America
(including Central America), and who maintains tribal affiliation
attachment.

or

community

fl ff D

Asian

A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the lndian subcontinent including, for example, Cambodia, China, lndia,
Japan, Korea, Malaysia, Pakistan, the Philippine lslands, Thailand, and Vietnam.

Black orAfrican American Native Hawaiian or Other Pacific lslander

A person having origins in any of the black racial groups of Africa. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific lslands.

BWhite

A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa. Standard Form 181
Revised August 2005 Previous editions not usabk

42 U.S.C. Section 2000e-1( NSN 7540-01-099-3446

In the Houee of Repreeentatiues,

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I sscrrox L AcKNowLEDGEIIEIST AIvD ApoLocy. 'l'lrt, I'rritr,rl Slrrtls, ru.l ilrg tlrrorrglr ( 'urrgrr,ss2 ( I ) r't.r.ogrtizr's tlrt. spt't.irrl lcgirl rrtrtl 3 lxrliiit.rtl rtlrrtiorr4 slrip tlrt, Irrrlirrrr trilrt,s lrirvc ruitlr tlrt, Urrittrl !.itirlcs rrrrtl 5 tlrt'soh,lrtr rovlrrrurt u'ith tlu' larrrl u't, slrrrrt.: 6 li) r'utrttttr,tttls irtrrl lrotrrit's llrl Nirtirt l'r'o1rh,x l'rrt' llrt' 7 tltottxitrtrls oi'r',,at's tlrat tltr..r'lrrrvl str.rrltrltrl arul llrrrtr'r.tr.rl I this lrrrrrl: I lill lr.krrorvltrlpn .rt*r's of' oftlt.ill th,ilrrrlrrtiorrs. ill[0 (.r)nrf ivr.tl 1xrlir.it.s. rttttl tlrt, lrt't,rtkitrg nf ({}\l,nrults lr.v tlur I I Urrittrl Stirtt,s (hx'('r'unlr.'ut tr.gartlirrg Itrtli;trt trilxrsl (-[) lgxrlugizes titr lx'lurll'of tlu, puu;tlr of llre' Iirritr.tl 12 l3 l'ititt|s to rrll Iratir'1' l>111;111.s ttir tlrt' [liut.v irrstilrrrt,s ilf YiilI4 lt.Il{rrt, ulrrltl'rruttttrrtt, it}l{l n{'glcrt irrflirttrl ott l{tttivr, [)r.rrl5 lrlus h1' ritizt,rrx uf ttrt.. [.'rritr:tl Statt's: I6 i.'r) (.stlr1.$s('s iis rr,Sl'('1. firr llrr litrrrifiratirurs rrl'
17 titnrrcr uf't't'nu,s rrrul its ronrrrrilrrx'rrt to Iruiltl otr tlrt. gxrxi-

l8 l9
20

tir-e rrlittiorrsltips of tlrt' past

alxl presorrt to

nrof

it torvittrl

a lrriglrtr,r' hrtrn'r, n'h<.r'c

lll

thr. p.opkr rlf tlris larrrl

lirl

rt,r.-

olu'ik,rl rts lrrr:ltlrlrs an(l sist(,r's. lul(l lrrrnlloltiottxll' stt,rrittrl

2l irn(l l)r'otc(:t tlris larrtl trigr..tltlr'; 22 tii) rrrges tlrt, l)rrsitk'nl t{, il(.knorvltrlgt tlrc oi'ti,trst's 2l rrf tlr(. IIrrit,'rl Statex irgrliust Irrrlirrrr trillex irr tlte ltistru'r'
?4 ol'tlrr, Ilrrillrl
Slirtr,s irr orrllr to lrrirrg lrt'ulirrg l.o this Iurrrl
lx,-

75 lrr' ;rruvitlittg it l)trrln,t' tirttttrlrttiotr tirt' tlt'otrriliatiorr ?6 tnrr,rr llrr, ilrritrrl Stitlr.s irtrrl ltrtliirtr tt'ilx'sr ittrrl
oHJ

I lH

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I
7

(71 (,{)nlnl(,n(l$ tlur l{trrte

g{rvt

nlnlt

nt* tllut lttrt'e

Irulitn trilxrs

bcgurr rrtorreililtir"rrr r:tttrrtx rvitlr nr:ogrriz.cxl

Itr.attrtl irr

tlttir

txunulflrit,x llrul (,u(.oln'rrgr.s

tll Sttte gyrv-

4 cnuncuts xirnil*r'[v
5

to rrurk tolr':url luconcilirrg rulittiou-

shipx rviflr Inrlinrr trilx,s rvitlrirr tlrt'ir lxlrrrtlaries.

6 gEC. g. DISCI.AIMEB"
7

),lollrirrg irr tlrix'loirrt. lll.solutiotr rurtltoriet,s ittrl' rluinr

I I

ttgiiittst ilr.' L]rritr.l Stitt.';' rrr'

Nt,l \-(.rt

irr. ir st.ttlrtrrr.rrt ,rl'arr.I'

tlninr ag$irrst tho I'nitcd St*tr's.

(-)

rllrl I lH

ffi
afq$r#rr{.ryJ trrFl ri?drfrLF5ffStrTi-Sffi

'ff 'FS;}jS-iff }ell*lrlrg'gjf f f f p;i*affitrjprris,rr@?iffi 'ysffiJ{J}";}str1;gt

rrlHl.rff tEprrt u1[.r ,ituzu

3,s$ 5n.'$

I aqt u! FHr]rT sB.$ u * Holinu]su{}J

.t.].{"I3

*r,{I 14 pErH]t

,{}u*tpny sq,1

},}rlg ,{irr*rr"r&}l{

11rrr-rp {?f##r.{*x5.

it{l ul ll prll} [8131 5r.{ {r{}nntrxt1TH}'$ s-q'' u$ tsv $rlt"&{T .,il5l*qlny' Faiti uru satrp sr{Jt 'mfmB$I[ff.n@';i.i
&?ff{I$Jrr "}''.}tr-filJr i};}s'i=JstrEt{:}

ffi8q55ry

-r,.ru

pue
S

"s{in

rtrnE

el$-lal rWHlr+ u.*rl aABr{ r$Hur u{ilt$[t;r*][Ju",itgp11r,r r:qt uo Eurpl,r*p

**pn: .iuy :ir,tu*pu*.1rr splitt

lt{t.gr: ."iur rp1,n slE}F rltIE,H .Sfhl

**u{s ss*xfur;r;-} dq unrt*1srfr*; 1u ril ,{Jddu iir,tr .urluuogfttpsrrr:r;7 .ir) If;.?t .srN" " ql '{t]ffiT-fl/ilif}{rsf#fir $u6,r/$,\ partq? *}Er.t;?r

5'-,,

r51

irl) tH&Suflt

$HIR;'tltti'!t i{{l qlltr ilHtrrru.f S.LIJB}I ltl*pi$}Jr[

.1{fl r.*q }

tq prufrm !"iil$,r_f) rrTi siilirgg5r?;riff Tiary

1

'itr;rr.r

lH-i5iigtlliS*l6q; pu* Sg n"lfl$$t'V ur grunrli ;rJn asii{l '1-#,riit,rr1J prFffi3r{rfrEr*ffiS

r+

:;, *"rr.rddx

ir* Flu irr+u

{rJ#i-lBN IH'l1.ql r*Ii'

lit*Jirfi#J?jhj": .'glnssFrra.lr! liFlsu

;r:l-a*{}

ul sTQSElS-ui{Erili al*ulrr*rj

tlr 3*r1{:U i:sr$ffitlE11 *t{l 'Jsprirt t*6 ts$l "{1ur: sU 'qJ.},qr*ul Fu,rteg}taF}

t$ ut.ls.ris lgrrnuflllt$Lin* xlr iq prln$rt .laEurrl tlc

5r sr*"rBuril;1

fiur):t:tu eHt utlc

suftilBg p5fruri

\_ Jt

Hffilr r*rr*{i3