*1.Where do you currently live?
a. Town of __________________________
b. Rural (farm/acreage) community of __________________
c. Outside of the area: ______________________________(Required.)

2.How long have you lived in the community/area that you live in?

Less than 1 year

1 - 5 years

6 - 10 years

More than 10 years

3.What is the age group of adult household members?

Less than 62 years

63 – 80 years

80 years and over

4.What income bracket does your household fall under?

$19,999 or less

$20,000 - $39,999

$40,000 - $59,999

$60,000 - $80,999

5.Is anyone in your home identify themselves as disabled or a Veteran?

Yes. Disabled

Yes. Veteran

Both

None of the above

6.What is your current living situation?

Own my home

Rent my home/apartment

Live with family

Assisted Living

Other (please specify)

7.If you live in the City of Coon Rapids, do you plan to remain in this community as you age?

Yes

No

Unsure

I do not live in the City of Coon Rapids

8.Would you consider moving to a senior rental housing unit in Coon Rapids?

Yes

No

Maybe

9.Do you have a family member or someone you know that would be interested moving into a senior rental housing unit in Coon Rapids?

Yes

No

10.If new senior housing was available in the City of Coon Rapids, would you likely stay in town or in the area?

Yes

No

11.Are you currently on a waiting list for senior housing?

Yes

No

12.Would you like to be contacted if this project moves forward?

Yes

No

13.If yes above, please provide your name and contact information below.

14.Do you believe the City of Coon Rapids needs senior rental housing?

Yes

No

Unsure

15.Do you belong to a service organization, club or community group that might be willing to contribute in some way to the development, building and/or operation of a housing project for seniors?

Yes

No

16.If yes above, please name the organization and/or community group and contact information.