Laserfiche WebLink
CASE Ill: <br />AGENCY: <br />RESIIDENTIAL INTERVIEW FORM <br />PROJECT: <br />CONSULTANT: <br />OCCUPANT INFORMATION: DWELLING: <br />bfAJ ' <br />OR EVENTS: <br />Claimant(s): <br />Monthly Payment: $ Site Movedn: <br />i <br />First Offer: <br />Number of Bedrooms: <br />Address: <br />Enitinllntervlev: / / <br />Total Number of Rooms: _..,....... _ <br />UTILITIES PAID DY: <br />1-101110 Phone: <br />Bedrooms Needed: <br />.' Gas: ❑ Tenant ❑ Owner <br />Work Phone: <br />❑ Furnished Dwelling Electric: ❑ Tenant ❑ Owner <br />Social Scc, ri: _ <br />Water: EJ Tenant ❑ Owner <br />OCCUPANCY STATUS: ❑ Reat ❑ Lease ❑ Mortgage ❑ <br />Own (Clear) ❑ Vacant L1 No Contact <br />DWELLING TYPE: d Single Fondly Residence ❑ Duplex <br />❑ Apartment ❑ Condo/1•wvnh0use ❑ Hotcl/Motel ❑ Mobile Home <br />ETHNICITY: ❑ White ❑ Hispanic <br />❑ Block ❑ Asian ❑ Other <br />PRIMARY LANGUAGE: ❑ English ❑ Spanish <br />❑ Other. <br />OCCUPANT INFORMATION: <br />NOTES /COMMENTS (use back as necessary): <br />❑ Elderly Household (62 or older) <br />❑ Disabled /Handicapped Household (describe rnodificationshleeds in notes) <br />❑ Housing Assistance - Monthly tenant portion of rent: $ <br />❑ Rent rooms in dwelling? (describe in notes) <br />❑ Willing to Relocate from Community (describe in notes) <br />Special Features /Improvements: <br />ArWUnit Preference: <br />NAME (FIRST, LAST) ! SEX <br />AGE <br />MONTHLY Notes ("elation, eng)[nyment, school, flauspoalation, hm:dicap etc.) <br />- _.. <br />INCOME <br />I �M F <br />- <br />_... <br />__.'. <br />I[ <br />$ <br />3 <br />M F <br />4 <br />M F <br />i $ <br />M F <br />$ <br />_ <br />M <br />$ <br />_.._ <br />