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m ail I e.i Y { em <br />L' <br />{jf+iy,1.�h 2 4 ri�v"e!3 Ma 1y�r11 dP.rra�(r��/s/� y j tdi4n,5,� r# vSS; `r4 moo.. <br />�... <br />..m.. ...J xa'acr' yea .i 3�.., <br />.I:Am <br />OVERLAND, PACIFIC & CUTLER, INC. - RESIDENTIAL INTERVIEW FORM <br />Interview Date: Site Move -In: Initiation of Negotiations: interviewer: <br />Head of Household <br />ETHNICITY: <br />n AFDC /TANF, Pension /SS, SSI <br />Address: #----------- <br />o White o Asian <br />o Other Public Assistance <br />------ — ---- <br />o Hispanic /Latino <br />(ask for Entitlement Letter) <br />Site Telephone # ---------- ------ Work /Cell # --------- - ------ <br />o African American <br />o Elderly Household <br />D Other______ <br />Fax # _---- __---- Email ------ _ --- — ----- _---------- <br />—_____ <br />o Handicapped Household: <br />Social Security Number <br />-- ------ '— '---- '---- '--- - - - - -- <br />• English o Spanish <br />• Other: <br />Need Barrier -Free: Yes o No 0 <br />Occupancy Status: o Own o Rent <br />o Need access to public trans? <br />Describe mode: — <br />Dwelling Type Approx. Sq.Ft.______ <br />Did all occupants move In at <br />.................. _... <br />the same time? <br />Approximate Age of Unit: yrs. <br />o Yes n No <br />o Need to live near medical facilities? <br />Describe location: <br /># Bedrooms # Bathrooms # Rooms______ o Laundry Fac. <br />----- - -_ <br />If not, when? <br />o Garage o Carport o pets: If so, describe <br />Occupant #1 <br />— ------ - -- <br />Condition of unit: o Excellent o Good o Fair o Poor <br />nSpecial needs /servlce used: <br />Occupant #2 <br />Describe: -------- —____ <br />Owners: o Mortgage o Own Clear <br />Monthly Payment: Principal $ ------- ---- $ - -_ <br />__ <br />Occupant #3 - - - -- <br />--- - - - - -- <br />Occupant #4 .... — ... <br />Loan Balance(s) as of ----------- : $__— ________ _____ —__ <br />Own Car? Yes n No 0 <br />Loan Type! nFlxed nVarlable Annual % Rate - ------ <br />Occupant #5 —___ —_ <br />Monthly Utilities: <br />Loan Type: nFlxed nVarlable Annual% Rate________ <br />Occupant #6 <br />Gas: 0Tenant o Owner <br />Original Date(s) of Current Loan(s) : <br />What <br />Rem. Loan Term _— __Months Rem. Loan Term __—_Months <br />Occupant 97 ... —.... <br />What ______________________ <br />Renters: o Total Monthly Rent:$ --- - ---- Landlord -------- - -_ <br />Preferred Relocation Area: <br />Electricity: o Tenant n Owner Water: <br />o Written Agreement Date — __________ <br />— <br />o Tenant o Owner <br />Other: <br />o M il o ease o scan a ontac <br />Home business? <br />_______ <br />Appliances Owned by Tenant: <br />M obile Homa: Size: Flx @ <br />Description: <br />oStove cRefrigerator oW /D <br />Year: ------- Model: ____________ Pad Rent: $ ________- <br />o Other___ <br />If SecL6, Total Tenant Rent. <br />—___ <br />Caseworker: --- _ ---------- — _— ------- _— --- —__ Telephone <br />o Unit Furnished o Unit Unfurnished oSecurity Deposit? $ - - - - -- <br />Do you rent out any rooms in the dwelling? uYes o No <br />If so, names: ...... —_ <br />If so, Is person or persons conslde red part of household? o Yes o No <br />M F <br />2 <br />M F <br />3 <br />M F <br />4 <br />M F <br />5 <br />M F <br />6 <br />M F <br />7 <br />M F <br />Notes: <br />I certify that all the information on this survey is true and correct. <br />Respondent ----- ___— __--- - - - - -7-69 D ate: __— �__----- - - - ___ Effective 8103 <br />