Housing Survey Form


Housing Choice Voucher Program

Please complete all of the information about the housing unit you wish to put on our Referral list. We ask that we have a form for each one of the units that you have available for the program.  The Referral List is updated weekly, usually on Friday.  The list is available from the website, one can be faxed, or you may pick one up from the office at 715 Summit.  The tenants contact  the prospective landlord about their property. The owner/manager of the properties listed determine if the tenant is suitable for their unit. If you have several tenants looking at one of your units you must screen them and decide which would be the right match for you and your property.  Thank you for filling out the Housing Survey Form.

Housing Survey Form

Name                                         

What is your e-mail address?  

Unit Location

Building Name (Optional)              

Unit Address                                Apt #

City, State, Zip                                

Owner Information

Owner Name                            

Owner Phone  #                        

Owner Address                         

                                                  

City, State, Zip                          

Manager Information

Manager Name                       

Manager Phone #                     

Is the Owner/Manager On Site? Yes  No

Size of Unit

# of Bedrooms                           

# of Bathrooms                           

Square Footage (If known)         

Lease Information

Proposed Rent                             

Negotiable?                                 YesNo    

Deposit                                        

Negotiable?                                 YesNo

Available Date                            

Appliances Provided by Owner/Landlord

Do you provide the Refrigerator?         YesNo

Do you provide the Stove?                  YesNo

Please list other appliances that you provide.                                                                                              

Types of Utilities

Select the type of energy used for the Heating, Water Heater, and Stove in the unit. 

Heating:

Electric

 Natural Gas 

Bottle Gas

Water is heated with:

Electric

Natural Gas

Bottle Gas

Stove:

 Electric

Natural Gas

Bottle Gas   

Owner Paid Utilities

Check the utilities that will be paid for by the Owner/Landlord

 Electric      

Natural Gas

Bottle Gas   

 Water         

 Sewer

 Trash Collection    

Structure Type

  Single Family Detached

  Semi-Detached

  Row House/Garden Apt.

  Manufactured Home

  Low-rise

Unit Quality

Describe the overall quality and condition in comparison with other units you have seen.

Below Average

Average

Above Average

Year Built or Renovated

Enter the year built or year renovated.

 

Is the year entered

  Year Built

  Year Renovated

Handicap Accessibility

Check all boxes that apply if the unit has specific features to assist people with the following types of disabilities.

  Hearing               Mobility

  Sight                   Other

If you selected Other Explain:

Amenities, Service and Maintenance

Check all the following that apply to your unit

If you provide the amenity, service and maintenance.

  Air Conditioning   CHA  Window Unit

  Ceiling Fans

  Washer

  Dryer

  Dishwasher

  Garbage Disposal

  Individually Fenced Yard

  Monthly Extermination

  On-Site Laundry Facility

  Quality Flooring

  Range/Microwave

  Refrigerator

  Security Personnel

  Security System/Lighting

  Washer/Dryer Hookups

  Window Dressings (i.e. Mini Blinds, Curtains, etc.)

If you have any other comments you would like to give us about the unit you have available, or you would like to give us a description of the unit, please do so in the area below.