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CASE ID: - _ <br />AGE\CY: <br />Claimant(s): <br />Address: <br />Number of Bedrooms: <br />Total Number of Rooms: <br />~41JOR EVE\TS: <br />Site Move-In: / / <br />First Offer: / / <br />lnitiallnterview: / / <br />ti'1'ILITIES PAID B1': <br />Home Phone: ~~ Bedrooms Needed: <br />Gas: ^Tcnant ^ Owner <br />Work Phone: U ^ Furnished Dwelling L-lectric: ^Tcnant ^ O~nter <br />Rater: ^Tcnant ^ Owner <br />Social Sec. #: <br />OCCUPANCY STATCS: D Rent D Lease ^ Mortgage O Own (Clear) ^ Vacant ^ No Contact <br />D~VELLLIG TYPE: ^ Single Family Residence ^ Duplex ^ Apartment D Caido/Toa•nhouse ^ HotcUNlotel ^ Mobile Home <br />ETHNICITY: ^ R'ltite ^ Hispanic ^ Black D Asian ^ Other: <br />PRIMARY LANGUAGE: ^ English ^ Spanish ^ Other: <br />OCCtiPANT INFOR1IATi0\: NOTES/COMMENTS (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 de•elling? (describe in notes) <br />^ Willing to Relocate front Community (describe in notes) <br />Slxcial Features/Improvements: <br />Area/Unit Preference: <br />\A11E (FIRST, LAST) <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />M f' <br />MF <br />MF <br />MF <br />S <br />S <br />Notes (relation, emt~loyment, school, transportation, bandlcap, etc. ) <br />SEX AGE <br />M F <br />MF <br />M F <br />MF <br />JIONTHLY <br />I\CO\1E <br />S <br />5 <br />RESIDENTIAL INTERVIEW FORM <br />PROJECT: <br />CONStiLTA\T: <br />OCC[;PANT Il~FOR~iATIO\; DIVELLI\G: <br />Monthly Pay~ttenh S <br />S <br />80B-41 <br />