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RESIDENTIAL INTERVIEW FORM <br />CASE Ill: PROJECT; <br />AGENCY: CONSULTANT: <br />OCCUPANT INFORMATION: DWELLING: MAJOR EVENTS: <br />Claimmri(s): Monthly PaymcnC $ Site Movo-hn <br />First Offer; <br />Number of➢edromns: <br />Address: <br />i Iuitinl Lrtcniew; / / <br />Total Number of Rooms: <br />UTILITIES PAID BY; <br />Homo Phone: (_� Bedrooms Needed: <br />Gas: ❑Tenant 11 Owner <br />Work Phone: (_} ❑ Furnished Dwelling Electric; ❑ Tenant ❑ Owner <br />Social Sec. U: Water. ❑ Truant ❑ Owner <br />OCCUPANCY STATUS: ❑ Rent ❑ Lease ❑ Mortgage ❑ Own (Clear) ❑ Vacant Cl No Contact <br />DWELLING TYPE: - - ❑ Single Fmnily Residence ❑ Duplex 17 Apannrem ❑ Condo/Townhouse ❑ Hotel/Motel Mobile Home <br />ETHNICITY: © White ❑ Hispanic El Block ❑ Asian ❑ Othe:: <br />PRIMARYLANGUAGE: ❑ English ❑ Spanish ❑ Other: <br />OCCUPANT INFORMATION: NOTFS /COMMENTS (use back as necessary): <br />❑ Elderly Household (62 or older) <br />❑ Disabled /Handicapped Household (describe nrodificationshroeds in notes) <br />❑ Housing Assistance - Monthly tenant portion of rent: S, <br />Rent rooms in dwelling? (describe In notes) <br />❑ Willing to Relocate from Community (describe in notes) <br />Special Feanuos /Improvements: <br />Area[UnitPreference: <br />NAME (FIRST, LAST) <br />SEX <br />AGE <br />MONIIILY <br />INCOME <br />Notes (rclNion, mnployment, school, uauspo tnHOn, nnndicap, etc.) <br />g <br />_. <br />M F <br />1• <br />M F <br />S <br />S <br />4 <br />M F <br />— — <br />S <br />5 <br />M1' <br />6 _ <br />M � <br />$ <br />MF <br />S <br />__ <br />8 j <br />MP <br />1S <br />4 -22 <br />