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CASE ID: <br />AGENCY: <br />Claimant(s): <br />Address: <br />RESIDENTIAL INTERVIEW FORM <br />PROJECT: <br />CONSULTANT: <br />OCCUPANT INFORMATION: DWELLING: <br />Monthly Payment: S <br />Number of Bedrooms: <br />Total Number of Rooms: <br />MAJOR EVENTS: <br />Site Move-1n: <br />First Offer: 1 / <br />Initial Interview: <br />UTILITIES PAID BY: <br />Home Phone: �_� Bedrooms Needed: <br />Gas: ❑Tenant ❑ Owner <br />Work Phone: (_� ❑ Furnished Duelling Electric: ❑ Tenant D Outter <br />Water: ❑ Tenant ❑ Owner <br />Social Sec. #: <br />OCCUPANCY STATUS: ❑ Rent ❑ Lease ❑ Mortgage ❑ Own (Clear) ❑ Vacant ❑ No Contact <br />DWELLING TYPE: ❑ Single Family Residence ❑ Duplex ❑ Apartment ❑ CondofTov.-Ithouse ❑ HotelfMotel D Mobile Home <br />ETHNICITY: D Wltite ❑ Hispanic ❑ Black ❑ Asian ❑ Other: <br />PRIMARY LANGUAGE: ❑ English ❑ Spanish ❑ Other: <br />OCCUPANT INFORIMATION: 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 dwelling? (describe in notes) <br />❑ Willing to Relocate from Community (describe in notes) <br />Special Features/Improvements: <br />Area/Unit Preference: <br />NAME (FIRST, LAST) <br />SEX AGE <br />MF <br />MF <br />M F <br />MF <br />MF <br />MF <br />MF <br />MF <br />MONTHLY Notes (relation, employment, school, transportation, handicap, etc.) <br />INCOME <br />80B-21 <br />