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CASE ID: _ <br />AGENCY: <br />Claimant(s): <br />Address: <br />,N41JOR EVENTS: <br />Site Move -In: / / <br />First Offer: I I <br />Initial lnten iew: <br />UTILITIES PAID BY: <br />Home Phone: Bedrooms Needed: <br />Gas: ❑Tenant ❑Owner <br />Work Phone: U ❑ Furnished Dwelling Electric: ❑ Tenant ❑ Owner <br />Water: ❑ Tenant ❑ Owner <br />Social Sec. #: <br />OCCUPANCY STATUS: ❑ Rent O Lease ❑ Mortgage ❑ Own (Clear) ❑ Vacant ❑ No Contact <br />DWELLING TYPE: ❑ Single Family Residence ❑ Duplex ❑ Apartment ❑ Condo(Townhouse ❑ HotcVMotel ❑ Mobile Home <br />ETHNICITY: ❑ White ❑ Hispanic ❑ Black ❑ Asian ❑ Other: <br />PRIMARY LANGUAGE: ❑ English ❑ Spanish ❑ Other: <br />OCCUPANT INFORMATION: NOTESICOMMENTS (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: S <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 />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />RESIDENTIAL INTERVIEW FORM <br />PROJECT: <br />CONSULTANT: <br />OCCUPANT INFORMATION: DWELLING: <br />Monthly P—ent: 5 <br />NAVE (FIRST, LAST) <br />SEX AGE <br />M F <br />MF <br />M F <br />MF <br />M17 <br />MF <br />MF <br />MF <br />Number of Bedrooms: <br />Total Number of Rooms: <br />MONTHLY <br />INCOME <br />S <br />5 <br />'9 <br />r <br />S <br />S <br />Notes (relation, employment, school, transportation, handicap, etc. ) <br />8OB-41 <br />