This survey is being conducted to determine the needs of your community, the needs of your family, and how we can help. Please fill out with as much detail and accuracy as possible. Your assistance is greatly appreciated. 

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* 1. Name(s) on Lease:

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* 2. Your full name: 

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* 3. What is your street address?

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* 4. About how long have you lived in this house?

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* 5. How many people currently live in your household?

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* 6. How many adults (over 18) live at this address?

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* 7. How many children live in your household (aged 17 or younger only)?

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* 8. What school do the children attend?

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* 9. How important is it for them to remain at this school?

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* 10. How many Adults over 60 years of age?

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* 11. Does a household member have disabilities?

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* 12. If yes, how many, and what disability?

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* 13. Do you currently have a pet where you live, or not?

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* 14. Do you plan on purchasing the house where you live in?

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* 15. If your lease is not renewed, do you have any ideas on where you would live?

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* 16. Would you consider living in multi- tenant (apartment style) housing?

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* 17. If no, is there a reason you cannot live in multi-tenant housing?

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* 18. If you were to move to another house / apartment, what other neighborhoods or areas would you live in?

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* 19. Have you ever applied for housing vouchers or assistance? Or are you currently on a list for housing assistance?

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* 20. If yes, have you ever been denied for housing assistance? (please list reason if answer is yes)

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* 21. What is your current monthly rent? 

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* 22. How much do you pay in utilities per month?

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* 23. Which utilities do you pay every month?

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* 24. What is the maximum rent your household could afford each month?

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* 25. If financing could be provided to help you own this rental home or one like it, would you be interested?

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* 26. What is your approximate annual household income?

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* 27. Do you have any questions regarding immigration, work status, Citizenship?

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* 28. If yes, please describe

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* 29. Do you want a referral to help for any of your open needs?

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* 30. If yes, please describe

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* 31. Do you have any other comments, questions, or concerns?

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