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RESIDENTIAL INTERVIEW FORM <br />CASE ID: - PROJECT: <br />AGE\CY: CONStiLTANT: <br /> <br />OCCUPANT fNFOR1iATION: DWELLING: 11<~JOR EVE\TS: <br />Claimant(s): Monthly Payment: $ Site Movc•In: / / <br /> First Offer: / / <br /> Number of Bedrooms: <br />Address: Initial Interview: ! / <br /> Total Number of Rooms: <br /> U'11L1TIES PAID BY: <br />Home Phone: (_~ Bedrooms Needed: <br /> Gas: ^ Tenant ^ Owner <br />Work Phone: (_) ^ Funtished Dwelling Electric: ^ Tenant ^ O++•tter <br />Social Sec. #: <br />Water: ^ Tenant <br />^ Owner <br />OCCUPA\CY STATtiS: D Rent ^ Lease ^ Mortgage ^ O+vn (Clear) ^ Vacant ^ No Contact <br />DIVELLL\G TYPE: ^ Single Family Residence ^ Duplex ^ Apartment ^ CondolTownhouse D Hotcl/Motel ^ Mobile Home <br />ETHNICITY: ^ White ^ Hispanic ^ Black ^ Asian ^ Other: <br />PRIMARY LANGUAGE: ^ English ^ Spanish ^ Other. <br />OCCUPANT INFORAIATIO\: NOTES/COMMENTS (use back as necessaq•): <br />^ Elderly Household (62 or older) <br />^ Disebkd/Handicapped Household (describe modifications/needs in notes) <br />^ Housing Assislancc -Monthly lenatit portion of rent: $ <br />^ Rent rooms in dx~clling? (describe in notes) <br />^ Willing to Relocate from Community (describe in notes) <br />Special Featurespmprovements: <br />ArealUnit Preference: <br />\Ai•IE (FIRST, LAST) <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />SEX AGE X10\THLY <br /> INC017E <br />M F $ <br />M F $ <br />M F $ <br />MF $ <br />MP $ <br />MF $ <br />MF $ <br />MF <br />''$ <br />Notes (relation, employment, school, transportation, handicap, ete• ) <br />80B-21 <br />