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VOLUNTARY TITLE VI PUBLIC INVOLVEMENT SURVEY <br /> As a recipient of federal funds,the Indiana Department of Transportation(INDOT)is requiring cities and <br /> other local agencies to develop a procedure for gathering statistical data regarding participants and <br /> beneficiaries of its federal-aid highway programs and other city services,programs,and activities(23 CRF <br /> §200.9(b)(4)).The City of South Bend is distributing this voluntary survey to fulfill that requirement to <br /> gather information about the populations affected by proposed projects and by all city programs. <br /> You are not required to complete this survey.Submittal of this information is voluntary.This form is a public <br /> document that the City of South Bend will use to monitor its programs and activities for compliance with <br /> Title VI and the Civil Rights Act of 1964,as amended and its related statutes and regulations.These laws <br /> protect citizens from government discrimination in services,programs,and activities based on race,color, <br /> gender,national origin,age,disability,religion,income status,or Limited English Proficiency(LEP). <br /> If you have any questions regarding the City of South Bend's responsibilities under Title VI of the Civil <br /> Rights Act of 1964 or the Americans with Disabilities Act,please contact Aladean DeRose,ADA/Title VI <br /> Coordinator,1200 County-City Building,South Bend,IN,46601,aderose@southbendin.gov. <br /> You may return the survey by folding it and placing it on the registration table or by mailing or e-mailing it <br /> to the address below. <br /> Date: <br /> Project/Program Name: <br /> Proposed Project or Program Location: <br /> Gender:❑ Female❑ Male Ethnicity: r Hispanic or Latino ❑ Not Hispanic or Latino <br /> Race: (Check one or mor <br /> it, American Indiana or Alaska Native ❑ Asian <br /> ❑ Native Hawaiian or Other Pacific Islander ❑White <br /> ❑ Black or African-American ❑ Multiracial <br /> Age: Disability: <br /> ❑ 1-21 ❑ 22-40 1:1Yes <br /> 1241-65 El65+ ❑ No <br /> Household Income: <br /> 0$0-512,000 0 512,001-524,000 13 524,001-536,000 <br /> ❑$36,001-$48,000 1:1 548,001-560,000 ❑$60,001+ <br /> Aladean DeRose,ADA/Title VI Coordinator <br /> 1200 County-City Building <br /> South Bend,IN,46601 <br /> (574)235-9241 <br /> aderose@southbendin.gov <br /> Attachment 4-A <br />