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DWELLING <br />HOUSEHOLD <br />Mailing Address: <br />❑ Primary residence of all occupants? (If not, explain in notes) <br />City, St, ZIP: <br />❑ Can someone read /understand English? If not, language <br />Carbon Copy Address: <br />Race /Ethnicity: ❑ American Indian /Alaskan ❑ Asian <br />❑ Black /African- American ❑ Hawaiian /Pacific Islander <br />❑ Hispanic /Latino ❑ White ❑ Other ❑ Mixed <br />City, St, ZIP: <br />Dwelling Type (list 4): <br />Bedrooms, <br />Attic /Utility /Storage: <br />Approx Sq Ft: <br />Subscribe to: ❑ Land phone ❑ TV service ❑ Internet <br />Kitchen: <br />Basement, <br />Bathrooms: <br />❑ Home -based business? (describe in notes) <br />Living /family rooms: <br />Garage, <br />Garage Spaces: <br />❑ Rent rooms in dwelling? (describe in notes) <br />Dining room: <br />Other /Extra: <br />Carport Spaces: <br />❑ On fixed income or public assistance? (describe in Occupants) <br />Den /Office, <br />- -- <br />Total Rooms: <br />Total physical and <br />content rooms to <br />move: <br />Parking Spaces: <br />❑ Disabled occupants? (describe modifications /needs in Occupants) <br />- <br />Number of cars: <br />Replacement site I lal needs (mark and describe in Notes) <br />❑ Employment access El Shopping <br />❑ Public transport ❑ Religious <br />❑ Medical facilities /services ❑ Social /Public services <br />❑ School needs ❑ Relatives /Ethnic <br />❑ Childcare ❑ Other special needs <br />AirCond: ❑Central ❑Wall /Window ❑Heat Pump ❑Evap. /Swamp ❑None <br />Heating, ❑FAU ❑Radiant ❑Hot Water ❑SpaceHtr ❑Solar ❑Heat Pump <br />Dwelling Condition: ❑ Good ❑ Fair ❑ Poor <br />Neighborhood Condition: ❑ Good ❑ Fair ❑ Poor_ <br />Amenities: <br />❑ All occupants to move to the same dwelling? (if not, explain in notes) <br />TENANT <br />Replacement dwelling preference: ❑ Rent ❑ Buy <br />Rent terms: ❑ Month -Month ❑ Lease, months left: <br />Can relocate from: ❑ Neighborhood ❑ City ❑ County ❑ State <br />❑ Rent reduced in exchange for service <br />❑ Unit furnished by tenant <br />Preferred relocation areas: <br />Monthly contract rent: $ <br />Security deposit: $ <br />HOMEOWNER <br />Landlord /manager name /ph: <br />Lot size (sq ft): Date purchased: <br />Age (yrs): <br />❑ Written rental agreement available? <br />❑ Rent receipts available? <br />❑ Own clear, no mortg /loans <br />❑ Negative equity <br /># of stories: <br />❑ Receiving Section 8 or other housing assistance? <br />let Loan Information <br />2nd Loan Information <br />Caseworker name/ph: <br />Lender: <br />Lender: <br />Monthly tenant portion of rent: $ <br />Loan Type (list 5): <br />Loan Type (list 5): <br />Annual family /child care expenses to allow work: $ <br />Current % Rate: <br />Current % Rate: <br />Annual non - reimbursed medical expenses: $ <br />Principal Balance: $ <br />Principal Balance: $ <br />Annual non- reimb. handicapped assistance expenses: $ <br />Original Date: <br />Original Date: <br />Utilities paid by tenant: <br />❑ Gas: $ <br />Pets, <br />Remaining months: <br />Remaining months: <br />Monthly P &I payment: <br />Monthly P &I payment: <br />❑ Electric $ <br />❑ Water: $ <br />❑ Sewer: $ <br />❑ Trash: $ <br />❑ NONE <br />Energy source: Gas Electr Oil Other <br />Cooking Stove: ❑ ❑ ❑ <br />Water Heater ❑ ❑ ❑ <br />Space Heat: ❑ ❑ ❑ <br />Air Conditioning: ❑ ❑ ❑ <br />MOBILE HOME <br />Pad space: ❑ Rent ❑ Own <br />Coach: ❑ Rent ❑ Own <br />Pad rent: $ <br />Make /Model: <br />Coach length (ft): <br />Year: <br />Coach width (ft): <br />Decal #: <br />+01980 -2012 Overland, Pacific 8. Cutler, Inc. (Nov -12) Papal <br />55A -48 <br />