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INTERVIEW NOTES (explain all special dwelling /household circumstances, including those noted on page 2) <br />1. Relation: Spouse, Child, Foster Child, Parent, Partner, Sibling, Aunt/Uncle, Cousin, Grandparent, Parent In -Law, Sibling In -Law, Other Relative, Roommate <br />2. Income: Wages /Salaries, Social Security /Dlsab /Pension, Child Support/Alimony, Welfare /TANF /AFDC, Family Subsidy /Gift, Business Income, <br />Interest/Dividends, Unempl. /Workers Comp, AF pay, EITC, Cash Income, Rent Reduction, Other <br />3. Legal Status: Unknown, Citizen /National, Lawful Other, NOT Lawful, Decline to provide. <br />4. Dwelling: SFR, Duplex, 3 -Plex, 4 -Plex, Apartment, Condo/Townhome, Hotel /Motel, Mobile Home, RV, Other <br />5. Loans: Fixed Mortgage, Adjustable Mortgage, Interest Only, Fixed HELOC, Adjustable HELOC, Reverse Mortgage, Other <br />I certify that all occupants have been identified above and that all information <br />provided for this survey is true and complete to the best of my knowled e. <br />Claimant Name: Date: Signature: <br />0 1950 -2012 Overland, Pacific & Cutler, Inc. (Nov -12) Page 3 <br />1* M0-J <br />