2. Description
   As a recipient of federal funds, the Indiana Department of Transportation (INDOT) is requiring local agencies to develop a procedure for gathering statistical data regarding participants and beneficiaries of its federal-aid highway programs and activities (23 CRF §200.9(b)(4)). The City of Michigan City, Indiana is distributing this voluntary survey to fulfill that requirement to gather information about the populations affected by proposed projects. You are not required to complete this survey. Submittal of this information is voluntary. This form is a public document that the City of Michigan City, Indiana will use to monitor its programs and activities for compliance with Title VI and the Civil Rights Act of 1964, as amended and its related statutes and regulations. If you have any questions regarding the City of Michigan City, Indiana’s responsibilities under Title VI of the Civil Rights Act of 1964 or the Americans with Disabilities Act, please contact Carl Ridle, Title VI Coordinator/Human Rights Director, City Hall, 100 East Michigan Boulevard, Michigan City, Indiana 46360; cridle@emichigancity.com; 219-873-1429
4. Project Name
6. Proposed Project Location
8. Gender Identity

   1. Female
   2. Male
   3. Transgender
   4. Other
9. Ethnicity

   1. Hispanic or Latino
   2. Not Hispanic or Latino
11. Racial Identity

    (Check all that apply)

    1. Indigenous American or Alaskan
    2. Indigenous Hawaiian or Other Pacific Islander
    3. Black or African-American

    1. Asian
    2. White
    3. Multi-racial
13. Age
14. Disability

    1. Yes
    2. No
15. US Military Veteran

    1. Yes
    2. No
17. Household Income

    1. $0-12,000
    2. $12,001-24,000

    1. $24,001-36,000
    2. $36,001-48,000

    1. $48,001-60,000
    2. $60,001+
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20. Email address

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