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STATE OF CALIFORNIA <br /> DEPARTMEPlT OF GENERAL SERVICES <br /> OFFICE OF FLEET AND ASSET MANAGEMENT <br /> RACIAL AND NATIONAL ORIGINS CERTIFICATION <br /> SASP 204(Rev 11/14) <br /> STATE OF CA�IFORNIA <br /> NEW APPLICATION FOR ELIGIBILITY <br /> STATE 8�FEDERAL SURPLUS PROPERTY PROGRAM <br /> Pursuant to Federal Regulation 28 C.F.R.§§42.401 -42.415,a recipient is mandated to report to the Federal Government the <br /> racial and national origins of all persons within your service area. You are therefore asked to supply the Office of Fleet and <br /> Asset Management with the race and national origins of individuals you serve in your service area(it may be helpful to refer <br /> to the US Census to determine the racial makeup of your service area at www.factfinder.census.gov/). This form must be <br /> completed and returned with the rest of the eligibility packet in order to qualify for the Federal Surplus Property Program. <br /> Your answers on this form in no way affect your eligibility; however, not retuming the form will delay the processing of your <br /> application. <br /> American Indian or Persons having origins in any of the tribal people of North America,and who maintain <br /> Alaskan Native °/a 2% cultural identification through tritial affiliation or community recognition. <br /> Persons having origi�s i�a.n.y;;qf_ttiiR.original peoples of the far east,Southeast Agia, <br /> Asia�/Pacific ��a�o Pacific Islands,or the Indi�lif`gtib��r�ent. This includes China,Japan,Korea,The <br /> Islartder °/a Philippines,and Samoa,:;,:;;::z;;;;. <br /> BlaCk �/a 3% Pe�ons having origiris:;1#�;al�iy of the black racial groups of Africa. <br /> Persons of NjRxican,Pue1'�o Rican,Cuban,Central or South American,or other Spanish <br /> Hispanic %38% culture or orig�n,regardljf�s of race. <br /> Per�n having o#�gins in any of the original people of Europe,North Africa,or the <br /> Whlt@ %46% Mid[��Eest. <br /> Other %p% (Specify) 0% <br /> Print Name Michael J.Giari Title Executive Director <br /> Signature ` f L� . � `� % Date �Z�23/2015 <br /> OFFICE OF FLEET AND ASSET MANAGEMENT�State o/Cali/ornia�Govemment Operatfons Rgertcy <br /> 1�00 Nafiona/Drive�5acramenfo,CA 95834�t 916.928.2550 f 978.928.79B5 RE SO P-23 03 <br />