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RESIDENTIAL INTERVIEW FORM <br />CASE ID: PROJECT: <br />AGENCY: CONSULTANT: <br />OCCUPANT INFORMATION: DWELLING: <br />AIAJOR EVENTS: <br />Claimant(s): Monthly Payntenl: $ <br />"',, Site Move•he / / <br />First Offer: <br />Number of Bedrooms: <br />Address: <br />� <br />Initial Interview: <br />Total Number of Rooms: <br />UTILITIES PAID BY: <br />Honor Phone: (_) Bedrooms Needed: <br />Gas: D Tenant D Owner <br />Work Phone: D Furnished Dwelling <br />Electric: D Tenant D Owner <br />Social See. 7{: <br />Water: D Tenant D Owner <br />OCCUPANCY STATUS: D Rent D Lease D Mortgage D Own (Clear) ❑ Vacant D No Contact <br />DWELLING TYPE: D Single Family Residence D Duplex D Apartment D Coado/Townhuuse D Hotcl/Motel D Mobile Home <br />ETHNICITY: D White D Hispanic O Black D Asian ❑ Other: <br />PRIMARY LANGUAGE: D English D Spanish D Other: <br />OCCUPANT INFORMATION: NOTES /COMMENTS (use back as necessary): <br />D Elderly Household (62 or older) <br />D Disabled /Handicapped Household (describe nrodificationshmeds is notes) <br />❑ Housing Assistance • Monthly tenant portion of rent: $ <br />D Rent roams in dwelling? (describe in notes), <br />D Willing to Relocate from Community (describe in notes) <br />Special FeatllreS/hrlprovements: <br />Area/Unit Preference: <br />NAME (FIRST, LAST) <br />SEa <br />AGE <br />MONTHLY <br />� Notes (relation, employment, school, trnnspoilation, Imndicap, etc.) <br />INCOME <br />2 <br />m F, <br />M P <br />M F <br />$ <br />_- <br />3 <br />4 <br />_ <br />6 M F <br />$ <br />$ <br />MF <br />8 <br />M <br />