Site Occupant Record - Residential
|Site Occupant Record - Residential |Project Name: |
| |Project #: |
| |Relocation Case #: |
| |Acquisition Parcel #: |
|LOCALITY/AGENCY | |
|Date of Initial Interview: Interviewer: | |
|NAME OF OCCUPANT |CHECK: FAMILY INDIVIDUAL |
|ADDRESS |OWNER TENANT |
|TELEPHONE NUMBER CENSUS TRACT | |
| | |
| |DATE OF GENERAL INFORMATION NOTICE |
| |EFFECTIVE DATE OF NOTICE OF ELIGIBILITY FOR RELOCATION ASSISTANCE |
| |DATE PRIVACY ACT STATEMENT EXECUTED |
| | |
| |(INCLUDE COPY OF NOTICES AND SIGNED PRIVACY ACT STATEMENT IN CASE FILE) |
| | |
|IS THIS ADDRESS LOCATED IN A HUD DESIGNATED RENEWAL COMMUNITY OR EMPOWERMENT ZONE? YES NO | |
| | |
|DATE OCCUPANT FIRST OCCUPIED THIS DWELLING | |
|RACIAL/ETHNIC CLASSIFICATION |HOUSING COSTS AND CHARACTERISTICS OF DISPLACEMENT DWELLING |
|(CHECK ALL THAT APPLY) |TENANT: |OWNER: |
|AMERICAN INDIAN OR ALASKAN NATIVE |MONTHLY CONTRACT RENT $ |MONTHLY MORTGAGE |
|ASIAN |AVERAGE MONTHLY |PAYMENT (P&I) $ |
|BLACK OR AFRICAN AMERICAN |UTILITY COSTS $ | |
|HISPANIC OR LATINO |MONTHLY HOUSING COSTS $ |AVERAGE MONTHLY |
|NATIVE HAWAIIAN OR OTHER PACIFIC | |UTILITY COSTS $ |
|ISLANDER | |REAL PROPERTY TAXES $ |
|WHITE | |MONTHLY HOUSING COSTS $ |
|AMERICAN INDIAN OR ALASKAN NATIVE | | |
|AND WHITE | | |
|ASIAN AND WHITE | | |
|BLACK OR AFRICAN AMERICAN AND | | |
|WHITE | | |
|AMERICAN INDIAN OR ALASKAN NATIVE | | |
|AND BLACK OR AFRICAN AMERICAN | | |
|OTHER MULTI-RACIAL | | |
| |NO. OF ROOMS NO. OF BEDROOMS |
| |UNIT IS: HOUSEKEEPING NON-HOUSEKEEPING |
| | |
RELOCATION FORM F
|SURNAME, GIVEN NAME(S)/SSN(S) |RELA- |SEX |AGE |OCCUPATION |SOURCE OF INCOME |GROSS |NAME OF EMPLOYER AND |
| |TION- | | | | |MONTHLY |TELEPHONE NUMBER |
| |SHIP | | | | |INCOME | |
| | | | | |EMP. |
| |RE-HOUSING PREFERENCES: |RE-HOUSING REQUIREMENTS: |
| |PURCHASE RENT SUBSIDIZED HOUSING NONE |NO. OF ROOMS |
|SPECIAL CHARACTERISTICS |LOCATION/NEIGHBORHOOD CONSIDERATIONS: |NO. OF BEDROOMS |
|OF HOUSEHOLD (E.G., | |MAX. MONTHLY |
|DISABLED, ELDERLY, ETC.) |PETS, GARAGE, ETC.: |HOUSING COSTS $ |
| | |MAX. PURCHASE |
| | |PRICE $ |
|HOUSING REFERRALS |
| |
| |
| |
| |
| |
| |
|Date |
|DATE OF MOVE ADDRESS CENSUS TRACT |
|IS THIS ADDRESS LOCATED IN A HUD DESIGNATED RENEWAL COMMUNITY OR EMPOWERMENT ZONE? YES NO |
|MONTHLY HOUSING COST (MHC) | D. S. & S NOT D. S. & S |RELOCATION PAYMENT(S) |
|RENTAL PURCHASE | | |
|MONTHLY RENT $ MORTGAGE PAYMENT (P&I) $ |DATE OF INSPECTION ________ |MOV.EXP. RHP |
|EST. AVERAGE REAL ESTATE TAXES $ |DATE OF REINSPECTION |TYPE ACTUAL RENTAL |
|MONTHLY EST. UTILITY COSTS $ |NO. OF ROOMS |FIXED DOWNPMT |
|UTILITY COSTS $ TOTAL MHC $ |NO. OF BEDROOMS |180-DAY HO |
|TOTAL MHC $ SALES PRICE $ |(Include copy of Inspection |AMOUNT $ ________ $ _________ |
| |Report in case file.) |DATE CLAIM FILED _______ ________ |
| | |DATE CLAIM PAID _______ ________ |
| | |(Include copy of Claim Forms in Case File) |
|IS UNIT IN AREA OF LOW-INCOME OR |TEMPORARY HOUSING | |
|MINORITY CONCENTRATION? |DATE |APPEAL FILED: YES NO |
|YES NO |REASON _ |IF YES, INDICATE TYPE: |
| |ADDRESS RENTAL $ |PAYMENT(S) |
|IS UNIT SUBSIDIZED? |DATE OF MOVE TO PERMANENT DWELLING |HOUSING |
|YES NO |OUT-OF-POCKET EXPENSES PAID: |OTHER |
| |MOVING EXPENSES $ | |
|Identify: |INCREASED HOUSING COSTS $ |(Include copy of Appeal in Case File) |
| | | |
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