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I CASE ID: , <br />AGEYCY: <br />RESIDENTIAL INTERVIEW FORM <br />_- PROJECT: <br />CONSULTANT. <br />OCCUPANT INFOR~fATIO\; DIVELLING: MAJOR EVENTS: <br />Claimant(s): Monthly Payment: $ Site Movc-In: / / <br /> First Offer: / / <br /> Number of Bedrooms: <br />Address: lnitialIntcrvie+v: ! / <br /> Total Number of Rooms: <br /> UTILITIES PAID BY: <br />Home Phone: () - Bedrooms Needed: <br /> Gas: ^ Tenant ^ O+vner <br />Work Phone: ~~ ^ Furnished Dwelling Electric: ^ Tenant ^ Owner <br /> <br />$OCIAI SCC. ~: Rater: ^ Tenant ^ Owner <br />OCCUPANCY STATUS: ^ Rent ^ Lease ^ Mortgage ^ O+en (Clear) ^ Vacant ^ No Contact <br />DIVELLL~G TYPE: ^ Single Family Residence ^ Duplex ^ Apartment ^ Condollow~thouse ^ HotcUMotel ^ Mobile Home <br />ETHNICITY: ^ White ^ Hispanic O Black ^ Asian ^ Other. <br />PRI,VIARY LANGUAGE: ^ English ^ Spanish ^ Other. <br />OCCUPANT INFORAIATIO\: NOTES/COMMENTS (use back as necessary): <br />^ Elderly Household (62 or older) <br />^ Disabkd/Handicapped Household (describe modifications/needs in notes) <br />^ Housing Assistance -Monthly tenant portion of rent: $ <br />^ Rent rooms in d+selling? (describe in notes) <br />^ Willing to Relocate from Community (describe in notes) <br />Special Features/Improvements: <br />AreaJUnit Preference: <br />1 <br />2 <br />3 <br />NADIE (FIRST, LAST) <br />6 <br />7 <br />8 <br />MF <br />M F <br />M F <br />Mr• <br />MF <br />MONTHLY <br />L\COIIE <br />$ <br />i$ <br />$ <br />MF $ <br />MF $ <br />SEX AGE <br />M F <br />80A-20 <br />(Votes (relation, emplo~•ment, school, traasportatlaa, handicap, etc. ) <br />