Name of Occupant:	enter text	Project ID:	enter text
Address:	address	Project No.:	enter text
City, ST, Zip	Parcel No.:	enter text
Telephone No.:	enter text	Attach pictures of present dwelling/relocation issue

Type of Relocation:	☐ Residential	☐ Business, Farm or Non-Profit

RESIDENTIAL PARCEL:	☐ Owner	☐ Tenant

Describe Relocation Issues:	enter text
Occupancy meet 90-day requirement?	☐ Yes	☐ No	Occupancy Confirmed by:	Choose an item
Minority Group?	☐ Yes	☐ No	# of occupants over 62:	Under 62:
Occupants	☐ Husband	☐ Wife	☐ Boys	Boys ages	☐ Girls	Girls ages
Family Income	Husband	Wife	Others
If Tenant
Present Rent:	☐ Furnished	☐ Unfurnished	☐ Other
Utilities provided by landlord:	☐ None	☐ Heat	☐ Water	☐ Elec	☐ Other
Total Rooms	# of Bedrooms	Age of dwelling
1st Floor Area	Habitable Area	Adequate for family?
2nd Floor Area	Basement Area	D.S.&S.?
Living Room	Other Room	Tubs	Rec Room
Dining Room	Other Room	Showers	Daylight
Family Room	No. of Baths	Wash Basin	Toilet
Kitchen	Toilets	Basement	Shower
Garage	☐ 1-car	☐ 2-car	☐ 3-car	☐ 3+ cars	☐ Carport
Heat	☐ Wood	☐ Gas	☐ Electric	☐ Oil	☐ Wood Stove	☐ Fireplace
Approx. Lot Size	Dist. To Grade School	Dist. To High School
Type of neighborhood
Adequate for family	☐ Yes	☐ No	D.S.&S.	☐ Yes	☐ No
Accessibility to employment services:

BUSINESS, FARM OR NON-PROFIT:	☐ Business	☐ Farm or Ranch	☐ Non-Profit

Type of business or non-profit
Relocation issues

Comments: