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AmeriCorps Housing Questionnaire

In order to serve the community better, the AmeriCorps Housing Team would appreciate it if you would answer the following questions about housing situations. Please answer all questions that apply to you.

Where do you live now?
How many people live with you?
How many bedrooms are there in the apartment?
Is the apartment large enough?
Are you currently receiving Section 8?
What are your main concerns about your current housing situation?
What is your current source(s) of income? Check all that apply.	SSI SSDI Public assistance Wages/salary Other
What is your current income per month?
What is your current rent per month?
Do you pay your own gas?
Do you pay your own electric?
How much do you pay in utilities each month?
Considering your income, how much rent is "affordable"?
Do you owe any back rent?
If yes, how much?
Have you received any notices about back rent?
Have you been to housing court?
Did you take your landlord to Housing?
If yes, for what reason?
Did you sign a stipulation in housing court?
If yes, what are the terms of the stipulation?
Please list below any other questions or comments you may have about housing:
Your name, please?
Today's date:

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