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DWELLING <br />HOUSEHOLD <br />Wiling Address: <br />❑ residence daft f <br />Pram-ry ooa+pan's.p rKt,cWain innctes) <br />C4,5t 2m <br />❑ Can wreone reaMunderstrid Engfrh? If not, la=iage: <br />Canon copyAla m: <br />FaceZfn t .. ❑ Amkcan lydan'Ala>kan ❑ Asan <br />❑ EladVAMcar Ameican ❑ Ham lariPaac Isander <br />❑ F%,pulicllatilo ❑ Pdrte ❑ Olhe ❑ Wed <br />C)" 5~ aF: <br />DwENmq Type Tist4): <br />Eed'oanG <br />;6m6ity5mrage: <br />typu eq Ft <br />SiMxnbto: ❑Landphxe ❑TVsertce ❑tnterd <br />0.mm <br />Basemen <br />eaTtncma <br />❑lkm?based butiroac:s?(dwmbn rrles) <br />tionparrily rims <br />wrg=_ SRaces <br />❑ Fent moms in dweDing? (dasebe in rotes) <br />Rnng nom <br />cmezm <br />taRcn sNc <br />❑ On bed in=e a Wbric a earcx?(des3e inOccupents) <br />De05L-- <br />Taw Rooms: <br />Tot" pnpicatand <br />aontmit mine to <br />mmv: <br />Fagg spaces <br />0Dsaded0omWx?(dc-scdbenndd,;atmmane:dsin0xwants) <br />ttAroer clans <br />Replacement site soeeial needs (mark and desmbe in Notes) <br />❑EnRloymlentaxem ❑Shtppfng <br />❑Pubic banspod ❑Religious <br />❑ kremcal wriities'semms ❑ SodatPub5c sermes <br />❑ SdW nerds ❑ Re'atvnEdidc <br />❑Wdewe ❑ Other spedai reeds <br />0. CwT CceftN r1wa rosav llm atGuap ❑Evapj-%anp riNme <br />Headrg: ❑FVj ❑RZ4= Mmolvi7-r iiep KF 13Wx r7rencvrp <br />Nelimg Condtim ❑ Good ❑ Fa ❑ PDa <br />NeigataMod Ccndton: ❑ Gool ❑ Fair ❑ Poot <br />Amaeus: <br />❑ AD occlrants to move to the wins dueling? (d net, eglah in rates) <br />TENANT <br />Fepla-anal dtelfry prefaranx: ❑ Red ❑ EW <br />Reit terns: ❑ Mmtn-M" ❑ Lease. rrcrEhs tat <br />Can re xate from: ❑ NelrboftW ❑ City ❑ County ❑ State <br />❑ Rerd reduced in ezctan}for sn;Ace ❑ Und furdstadby tenard <br />Prefered rekc.-tim ales: <br />kfmDdyari2ctrent5 swirity dep=$ <br />HOMEOWNER <br />Lardudinaage nema#L <br />Lct time (sq h): <br />Datepuctased <br />I Ag_dms <br />❑ Y.W ten mmil aTww; avi llakle? ❑ Rerd receipts ava&aNe? <br />❑ 0M dear, m mmg7oa11s 1 ❑ Nopfve egity <br />I mef stories <br />13Rewi•8•g Sec6at8 or other hming assste? <br />isl Loan lnfomution 2nd Loan Wormation <br />Cmemd:er namaxh: <br />Lender. Lader. <br />mint tauntpati a rent 5 <br />Loan Type gist 5): Loan Type(fst5): <br />An^ueI@m7y'a.Ddc5ree)pamstoa0onraedc 5 <br />Cuneri%Rate: Cunari%Rate: <br />Arnual nm4i emh,rs5dtlMicel eVenses $ <br />Pdecpal Balm: b Prv4 I Balance: E <br />Arraa'. nm4emb. hanioapped assistance erpereces: 5 <br />O.—W Date. Crgna Date <br />Utilities paid by tenant <br />❑Gas: E <br />Pets: <br />RernalmN non : Ramanng maths: <br />kbnwy P&I parent MmHyP81pafr&rt <br />❑Beeim E <br />❑ water. S <br />❑Sewer S <br />13 Trash: $ <br />❑NAVE <br />Energy solace: Gas Becb 0? 0dner <br />Ck'A Slava: ❑ ❑ Cl <br />W-Ier Heafar. ❑ ❑ ❑ <br />Space Heat ❑ ❑ ❑ <br />/arCa*Afc ,4 ❑ ❑ ❑ <br />MOBILE HOME <br />Pal space: ❑ Rent ❑ Gan Ocack ❑ Red ❑ Om <br />Pairnt$ k"akAlodal: <br />Ccadt rength (N: Year. <br />Coadrvfdh(h): Decal 9: <br />75B-40 <br />