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<br /> <br />OVERLAND, PACIFIC & CUTLER, INC. - RESIDENTIAL INTERVIEW FORM <br /> <br />Interview Date: <br /> <br />Site Move-In: <br /> <br />Initiation of Ne otiations: <br /> <br />interviewer: <br /> <br />Head of Household ETHNICITY: D AFDC/TANF, Pension/SS, SSI <br />------------------------------------------ <br /> D White D Asian D Other Public Assistance <br />Address: -------------------------------------- # --------- D Hispanic/Latino (ask for Entitlement Letter) <br />Site Telephone # _________ Work/Cell # D African American <br /> ----------------- D Other________ D Elderly Household <br />Fax # ----------- Email ----------------------------- D Handicapped Household: <br /> PRIMARY LANGUAGE: Describe: ------ <br />Social Security Number _____________________ D English D Spanish <br /> D Other: Need Barrier-Free: Yes D No D <br /> ------ <br />Occupancy Status: DOWn D Rent D Need access to public trans? <br /> Describe mode: ------- <br />Dwelling Type ___________ Approx. Sq.Ft.__ Old all occupants move In at <br />the same lime? <br />Approximate Age of Unit: ____yrs.____ DYes DNa D Need to live near medical facilities? <br /> Describe location: <br /># Bedrooms --- # Bathrooms -- # Rooms ___ D Laundry Fac. If not, when? <br /> --------- <br />D Garage D Carport D Pets: If so, describe________ <br /> Occupant #1_______ ---------------- <br />Condition of unit: D Excellent D Good D Fair D Poor DSpecial needs /service used: <br /> Occupant #2 _____ Describe: ---------- <br />Owners: D Mortgage D Own Clear <br /> Occupant #3 ____ ------------- <br />Monthly Payment: Principal $------ $---- --------------------- <br /> Occupant #4 ____ <br /> Loan Balance(s) as of ___: $______ Own Car? Yes D No D <br /> Loan Type: DFixed DVariable Annual % Rate --- Occupant #5 ___ Monthly Utllllles: <br /> Loan Type: D Fixed DVariable Annual % Rate --- Occupant #6 ___ Gas: D Tenant D Owner <br /> Original Date(s) of Current Loan(s) : __________ What --------- <br /> Rem. Loan Term Months Rem. Loan Term Months Occupant #7 ___ What <br /> ---- -- -------------------- <br />Renters: D Total Monthly Rent:L_____ Landlord______ Preferred Relocation Area: Electricity: D Tenant D Owner Water: <br />D Written Agreement Date___________ D Tenant D Owner <br /> Other: ---- <br />D M/M D Lease D Vacant/No Contact Home business? <br /> ---- Appliances Owned by Tenant: <br />Mobile Home: Size: ---- ftx ---- ft <br /> Description: DStove DRefrigerator DW/D <br />Year: ---- Model: ----- Pad Rent: $ _____ D Other____ <br />If Sect.8, Total Tenant Rent. $ <br />Caseworker: ------------- Telephone <br />#: -------- <br />D Unit Furnished D Unit Unfurnished DSecurity Deposit? $---- <br />Do you rent out any rooms in the dwelling? DYes DNa <br />Ifso, names:_________________ <br />If so, is person or persons considered part of household? DYes DNa <br />1 M F <br />2 M F <br />3 M F <br />4 M F <br />5 M F <br />6 M F <br />7 M F <br />Notes: <br /> <br />I certify that all the information on this survey is true and correct. <br /> <br />Respondent; <br /> <br />Date: <br /> <br />Effective 8/03 <br /> <br />80A-37 <br />