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-'ASE ID: <br />1GENCY: <br />RESIDENTIAL INTERVIEW FORM <br />OCCUPANT INFORMATION' <br />PROJECT: <br />CONSULT, <br />NAME (FIRST, LAST) <br />SEX AGE INIONTHLY Notes (rclmiea, maployotent, school, hausponaflon, Ilnndlcnp, etc.) <br />INCOME <br />M F 1 _ $ _._ <br />M F <br />M P $ — <br />MF <br />MF $ <br />5 -50 <br />UNYLLLING: <br />' MAJOR EVENTS: <br />Clainrant(s): <br />Monthly Payment: $ <br />Site Move-III: <br />First Offer: <br />Address: <br />Number of Bedrooms: <br />Initial Interview: <br />Total Number of Rooms: <br />UTILITIES PAID BY: <br />140110 Phone: L_) <br />'', Bedremns Needed: <br />Gas: L1 <br />Tenant <br />❑ Owner <br />Work Phone: <br />p Famished Dwelling <br />Electric: ❑ Tetanl <br />❑ Owner <br />Social Sec. h: <br />i <br />Water: El Tenant <br />❑ Owner <br />OCCUPANCY STATUS: ❑ Rent ❑ Lease ❑ Mortgage ❑ <br />Own (Clear) ❑ Vacant ❑ No Contact <br />DWELLING TYPE: Cl Single Pemly Residence ❑ Duplex <br />❑ Apartment ❑ Conde/Townhouse <br />❑ Hotel/[vtolel Mobile Home <br />ETFNICITY: ❑ White Ei llispanio ❑ Black ❑ Asian ❑ oalcm: <br />PRIMARY LANGUAGE: ❑ English © Spanish ❑ Other: <br />OCCUPANT INFORMATION. <br />NOTES /COMMENTS (use back as necessary): <br />Elderly Household (62 or older) <br />❑ Disabled /Handicapped Household (describe modifications /needs in notes) <br />:1 Housing Assistance - Monthly tenant portimt of rent: $ <br />:1 Rent rooms in dwelling? (describe in notes) <br />:1 Willing to Relocate fi om Community (describe in notes) <br />ipecial Features /Improvements: <br />area/Unit Prefbrenee: <br />NAME (FIRST, LAST) <br />SEX AGE INIONTHLY Notes (rclmiea, maployotent, school, hausponaflon, Ilnndlcnp, etc.) <br />INCOME <br />M F 1 _ $ _._ <br />M F <br />M P $ — <br />MF <br />MF $ <br />5 -50 <br />