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CASE ID: <br />AGENCY: <br />Claimant(s): <br />Address: <br />Monthly Pa)•menC S <br />Number of Bedrooms: <br />Total Number of Rooms: <br />\i<-JOR EVE\TS: <br />Site Mos~e-!n: / / <br />First Offer: / ! <br />Initial Interview: / / <br />U•1'ILITIES PAID Bl': <br />Home Phone: ~_~ Bedrooms Needed: <br />Gas: ^ Tenant ^ Ow•ner <br />Work Phone: (_~ ^ Famished Dwelling Electric: ^ Tenant ^ Ow~xr <br />Water: ^ Tenant ^ O~~•ner <br />Social Scc. #: <br />OCCUPA\CY STATCS: ^ Rent ^ Lease ^ Mortgage ^ Own (Clear) ^ Vacant ^ No Contact <br />D\YELLL\G TYPE: ^ Single Family Residence ^ Duplex ^ Apartment ^ CrnidofTo~~~ihouse ^ HotcUMotel D Mobile Home <br />ETHNICITY: ^ R'Itite ^ Hispanic ^ Black ^ Asian ^ Other: <br />PRIItIARY LANGUAGE: ^ English ^ Spanish ^ Other: <br />OCCUPANT INFORIiATIO\: NOTESlCOMMENTS (use back as necessary): <br />^ Elderly Household (62 or older) <br />^ Disabled/Handicapped Household (describe modifications/needs in notes) <br />^ Housing Assistance -Monthly tenant portion of rent: $ <br />^ Rent rooms in dwelling? (describe in notes) <br />^ Willing to Relocate from Community (describe in notes) <br />Special Features/Improvements: <br />Area/Unit Preference: <br />RESIDENTIAL INTERVIEW FORM <br />PROJECT: <br />CONStiLTANT: <br />OCCUPANT INPORDiATIO\: DR'ELLI\G: <br />\A1IE (FIRST, LAST) <br />SEX AGE <br />JIO\THL1' Notes (relation, empbyment, school, trensportatioa, handicap, etc. ) <br />Il\CO\IE <br />MF <br />MF <br />M F <br />MF <br />MF <br />MF <br />MF <br />MF <br /> <br />$ <br />$ <br />$ <br />$ <br />80B-21 <br />