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Interview, Date: Site Move -In: Initiation of Negotiations: interviewer <br />Head of Household___________ _________________________ ______ <br />ETHNICITY: <br />o AFDC /TANF, Pension /SS, SSI <br />Atldress:__________________ #________ <br />o While D Asian <br />o Other Public Assistance <br />_________________ _— - -_ <br />D Hispanic /Lallno <br />(ask for Entitlement Letter) <br />Site Telephone # _______ Work /Cell # - - - -- <br />o African American <br />o Elderly Household <br />o Other_ <br />Fax # --------- __ Email ------ ___ –_ <br />-- <br />o Handicapped Household: <br />Social Security Number <br />PRIMARY LANGUAGE: <br />Describe: ----------- _ ---- <br />......... __ ..... _ ... ___ ... _..... <br />o English D Spanish <br />D Other:_______ <br />Need Barrler -Free: Yes a No o <br />Occupancy Status: a Own n Rent <br />D Need access to public trans? <br />Describe mode: <br />Dwelling Type .................. _... Approx. Sq.Ft.___ <br />Did all occupants move in at <br />—_ <br />the same time? <br />Approximate Age of Unit: ...... yrs.______ <br />oyes nNo <br />D Need to live near medical facilities? <br />#Bedrooms____ #Bathrooms #Roams______ ❑Laundry Fee. <br />Describe location: <br />____ <br />If not, when? <br />D Garage n Carport ❑Pets: If so, describe ________________ _ <br />Occupant #1 <br />-------------------- <br />Condition of unit: n Excellent n Good n Fair n Poor <br />----- ___ <br />DSpecial needs /service used: <br />Occupant #2_....... <br />Owners: o Mortgage o Own Clear <br />Monthly Payment: Principal $ $_________ <br />ccupanl 3_________ <br />_---- - -__ –_ __ <br />_____ _______ <br />Occupant #4 _________ <br />Loan Belan as of ...... _ ... : $ <br />ce(s) <br />Own Car? Yes D No n <br />Loan Type: nFixed invariable Annual % Rate----- <br />Occupant #5_________ <br />Monthly Utilities: <br />Loan Type: oFixed oVariable Annual % Rate ..... —__ <br />Occupant #6 <br />Gas: o Tenant n Owner <br />Original Date(s) of Current Loan(s) : ...... _ <br />What <br />Rem. Loan Term Months Rem. Loan Term Months <br />Occupant #7 ... _.... <br />What <br />Renters: n Total Monthly Rent:$--------- Landlord___________ <br />Preferred Relocation Area: <br />Electricity: o Tenant o Owner Water: <br />• Written Agreement Dale_______________ <br />o Tenant D Owner <br />• M/M o Lease o Vacant /NO Contact <br />Home business? <br />Other: <br />Appliances Owned by Tenant: <br />Mobile Home: Size: ft ft <br />Description: <br />oStove oRefrigeralor oW /D <br />Year: Model: Pad Rent: $ <br />D Other_____ <br />If Sect.8, Total Tenant Rent. <br />Caseworker ___ ----- ________ —_____ Telephone <br />#: <br />u Unit Furnished n Unit Unfurnished nSecurily Deposit? <br />Do you rent out any rooms In the dwelling? oyes o No <br />If so, names: <br />If so, Is person or persons considered part of household? n Yes n No <br />1 <br />M F <br />2 <br />M F <br />3 <br />M F <br />4 <br />M F <br />a <br />M F <br />6 <br />M F <br />7 <br />M F <br />Notes: <br />I <br />I certify that all the information on this survey is true and correct. <br />Respondent: 7-103 Date:__ Effacuva 8/03 <br />