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) |

| | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download