Form RHFS-01 Rental Housing Finance Survey

Form RHFS-01 (09-19-2011) Draft 8

OMB No. XXXX-XXXX Approval Expires XX/XX/20XX

2012 RENTAL HOUSING FINANCE SURVEY

A. Property

This survey covers all units in the rental property associated with the above address.
A property may include more than one building, postal address, or parcel of land.
The debt financing can help define the property for the purposes of this survey. If there is a
mortgage or similar debt on the property, then the property is defined as the units or
buildings that are covered by a first mortgage. If there is more than one first mortgage, then
the property is defined by the mortgage that covers the above address. If there is no debt
financing, the property is defined as the units and buildings owned in common with the street
address above.

B.

Are you currently the owner or manager of this property?
01

Yes

02

No

Skip to question 1a on page 2.

C. Please provide the name, address, and telephone number of the current owner, manager, or
corporate office of this property.
After obtaining the information below, interview is concluded.
Name:

Title:

Organization:

Address:

City:

State:

Telephone number (including area code):
–

–

ZIP Code:

1a. Is this property—
Mark (X) in only ONE box.
01

Operated by a public housing authority?

02

A manufactured housing community
(prefabricated housing/mobile homes)?

03

If yes, end interview.
If yes, end interview.

None of the above

1b. Is this property—
Mark (X) in only ONE box.
01

A residential property with 2 to 4 units, all of which are RENTAL UNITS?

02

A residential property with 5 or more units, of which approximately 80%
or more are RENTAL UNITS and commonly owned/financed?

03

Some other type of property?

If yes, end interview

2a. How many residential units (separate living quarters) are in each building on this
property?
Number of
residential units

Number of
residential units

Building 1 . . . . . . . . . .

Building 11 . . . . . . . . . . . .

Building 2 . . . . . . . . . .

Building 12 . . . . . . . . . . . .

Building 3 . . . . . . . . . .

Building 13 . . . . . . . . . . . .

Building 4 . . . . . . . . . .

Building 14 . . . . . . . . . . . .

Building 5 . . . . . . . . . .

Building 15 . . . . . . . . . . . .

Building 6 . . . . . . . . . .

Building 16 . . . . . . . . . . . .

Building 7 . . . . . . . . . .

Building 17 . . . . . . . . . . . .

Building 8 . . . . . . . . . .

Building 18 . . . . . . . . . . . .

Building 9 . . . . . . . . . .

Building 19 . . . . . . . . . . . .

Building 10 . . . . . . . . .

Building 20 and higher . .

2b. How many floors are in each building on this property? Please count basements, finished
attics, and all other floors, regardless of their use.
Number of
floors

Number of
floors

Building 1 . . . . . . . . . .

Building 11 . . . . . . . . . . . .

Building 2 . . . . . . . . . .

Building 12 . . . . . . . . . . . .

Building 3 . . . . . . . . . .

Building 13 . . . . . . . . . . . .

Building 4 . . . . . . . . . .

Building 14 . . . . . . . . . . . .

Building 5 . . . . . . . . . .

Building 15 . . . . . . . . . . . .

Building 6 . . . . . . . . . .

Building 16 . . . . . . . . . . . .

Building 7 . . . . . . . . . .

Building 17 . . . . . . . . . . . .

Building 8 . . . . . . . . . .

Building 18 . . . . . . . . . . . .

Building 9 . . . . . . . . . .

Building 19 . . . . . . . . . . . .

Building 10 . . . . . . . . .

Building 20 . . . . . . . . . . . .
01

2

More than 20 buildings on property

3a. In what year was the oldest building on this property constructed?

YEAR

3b. In what year was the most recent building on this property constructed?

YEAR

OR
01

Only one building on property

4a. In what year was this property acquired (if original owner, report year construction
was completed)?

YEAR

4b. What was the purchase price of this property?
$

.00

4c. What do you believe is the current market value of this property?
$

.00

4d. Which of the following best reflects how you determined your estimate of the current
market value in question 4c?
Mark (X) in only ONE box.
Local tax assessment of this property

02

Recent real estate appraisal

03

Insurance replacement cost

04

Original purchase price plus inflation

05

Original purchase price plus improvements and inflation

06

Selling or asking price of similar properties in area

07

Capitalization of current rental revenues

08

Other — Specify

↵

01

5. Of the total residential units identified in question 2a, how many belong to each of the
following categories?
Enter unit count for each box, where appropriate.
0 bedrooms/
efficiency

Renter-occupied . . . . . . . . . . . . . . . . .
Rented—not yet occupied . . . . . . . . .
Vacant—for rent . . . . . . . . . . . . . . . . .
Owner-occupied . . . . . . . . . . . . . . . . .
Occupied by property personnel . . . .
Vacant—intended for
property personnel . . . . . . . . . . . . . . .
Vacant—for sale . . . . . . . . . . . . . . . . .
Sold—not yet occupied . . . . . . . . . . .
Other vacant . . . . . . . . . . . . . . . . . . . .

3

1 bedroom

2 bedrooms 3 bedrooms 4 bedrooms

5 bedrooms
or more

6. How many residential units identified in question 5 as RENTER-OCCUPIED, RENTED—NOT
YET OCCUPIED, OR VACANT—FOR RENT are offered at each level of rent per month?
Enter unit count for each box, where appropriate.
0 bedrooms/
efficiency

1 bedroom

2 bedrooms 3 bedrooms 4 bedrooms

5 bedrooms
or more

No rent . . . . . . . . . . . . . . . . . . . . . . . . .
Less than $200 . . . . . . . . . . . . . . . . . .
$200 – $224 . . . . . . . . . . . . . . . . . . . . .
$225 – $249 . . . . . . . . . . . . . . . . . . . . .
$250 – $274 . . . . . . . . . . . . . . . . . . . . .
$275 – $299 . . . . . . . . . . . . . . . . . . . . .
$300 – $349 . . . . . . . . . . . . . . . . . . . . .
$350 – $399 . . . . . . . . . . . . . . . . . . . . .
$400 – $449 . . . . . . . . . . . . . . . . . . . . .
$450 – $499 . . . . . . . . . . . . . . . . . . . . .
$500 – $549 . . . . . . . . . . . . . . . . . . . . .
$550 – $599 . . . . . . . . . . . . . . . . . . . . .
$600 – $649 . . . . . . . . . . . . . . . . . . . . .
$650 – $699 . . . . . . . . . . . . . . . . . . . . .
$700 – $749 . . . . . . . . . . . . . . . . . . . . .
$750 – $799 . . . . . . . . . . . . . . . . . . . . .
$800 – $899 . . . . . . . . . . . . . . . . . . . . .
$900 – $999 . . . . . . . . . . . . . . . . . . . . .
$1,000 – $1,099. . . . . . . . . . . . . . . . . .
$1,100 – $1,249. . . . . . . . . . . . . . . . . .
$1,250 – $1,499. . . . . . . . . . . . . . . . . .
$1,500 – $1,999. . . . . . . . . . . . . . . . . .
$2,000 – $2,499. . . . . . . . . . . . . . . . . .
$2,500 or more . . . . . . . . . . . . . . . . . .

7a. Rent concessions are rent discounts offered by landlords to encourage tenants to sign or
renew a lease. If a tenant rented one of the units identified in question 5 today, what is the
equivalent value of the rent concessions that you would be willing to offer?
Mark (X) in only ONE box.
01

No rent concessions

02

Less than 1 month’s rent

03

1 month’s rent

04

Between 1 and 2 months’ rent

05

2 months’ rent

06

Between 2 and 3 months’ rent

07

3 or more months’ rent

7b. How many current tenants received rent concessions as part of their current lease?
Tenants

4

8. Are any residential units identified in question 5 offered only as seniors housing for
tenants aged 55 or older?
01

Yes

02

No

9. Rent control or rent stabilization refers to laws or ordinances, not related to subsidy
programs, that set maximum rental charges for residential housing. How many units
identified in question 5 are subject to rent control or stabilization?
Units

10. How many off-street parking spaces are associated with this property?
Spaces

11. Are the following items included in the rent (answer “No” if services or facilities are
provided for an additional fee)?
Yes

No

Not
Present

A Electricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

B Gas or oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

C Water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

D Trash collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

E Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

Fitness center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

G Laundry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

H Swimming pool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

Other free personal services for tenants . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

F

I

12a. What was the total amount collected from rent for all residential housing units on this
property during calendar year 2011?
$

.00

12b. During calendar year 2011, what would have been the total amount collected from
residential rent if this property were fully occupied and all tenants paid rent on time
(accounting for vacant units and uncollected and unpaid rent)?
$

.00

13. Is there any space specified for commercial uses in this property — i.e., nonresidential
units such as a convenience store, doctor’s office, or any other business establishment
(do not include rental/management office)?
01

Yes

02

No

Skip to question 15a.

5

14a. About what percent of the total floor space in this property is used for commercial
(nonresidential) purposes?

%
14b. During calendar year 2011, what were the total actual receipts from commercial rent for
all such units in this property?
$

.00

15a. Who has the responsibility for the day-to-day management of this property?
Mark (X) in only ONE box.
01

Property owner or unpaid agent of owner (such as a family member)

02

Management agent directly employed by owner

03

Management company

04

Other — Specify below

Skip to question 16.

Skip to question 16.

↵

and Skip to question 16.

15b. On a monthly basis, how many hours does the owner (or owner agent) spend in the
management of this property?
Hours

16. In calendar year 2011, how much did you spend on each of the following operating
expenses for this property (do not include capital expenses)?
OR
Yearly Cost
A Payroll costs for employees hired directly by owner . . .
B Real estate property taxes . . . . . . . . . . . . . . . . . . . . . . . . .
C Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D Utilities paid by the owner. . . . . . . . . . . . . . . . . . . . . . . . .
E Maintenance and repairs . . . . . . . . . . . . . . . . . . . . . . . . . .
F

Management company . . . . . . . . . . . . . . . . . . . . . . . . . . . .

G Other professional services (legal, accounting). . . . . . . .
H Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I

Grounds/landscaping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J

Other operating expenses — Specify below

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

↵

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

6

$

.00

$

.00

None
00

00

00

00

00

00

00

00

00

00

17. During calendar years 2010 and 2011, were any of the following capital improvements or
upgrades/replacements made at this property? If so, what were their associated costs?
Mark (X) for ALL that apply.
Associated Cost
Heating or air conditioning system . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

02

Roof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

03

Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

04

Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

05

Flooring/carpeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

06

Exterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

07

Plumbing system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

08

Electrical system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

09

Kitchen facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

Bathroom facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

Security system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Swimming pool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

Playground or play area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

Handicapped/universal access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

Other capital improvements or upgrades — Specify

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

$

.00

↵

01

18. How would you best describe the current ownership entity?
Mark (X) in only ONE box.
Individual investor, including joint ownership by two or more individuals, such as husband and wife

02

Trustee for estate

03

Limited liability partnership

04

Limited liability company

05

Tenant in common

06

General partnership

07

Real Estate Investment Trust (REIT)

08

Life insurance company

09

Financial institution other than life insurance company

10

Pension fund or retirement fund

11

Real estate corporation

12

Corporation other than real estate corporation

13

Housing cooperative organization or stock cooperative

14

Nonprofit organization (including religious institution, labor union, or fraternal organization)

15

Other kind of institution — Specify

↵

01

7

19a. A Housing Choice (or Section 8) Voucher is a HUD program that pays all or part of the
rent and allows the tenant to take the voucher to a different unit. Do any tenants hold
Housing Choice (or Section 8) Vouchers?
01

Yes

02

No

03

Don’t know

Skip to question 20a.

19b. How many tenants hold Housing Choice (or Section 8) Vouchers?
Tenants

20a. A Section 8 Housing Assistance Payment (HAP) contract covers all or most of the units in
a (usually larger) property and is an agreement in which HUD pays some or all of the rent.
Does this property have a Section 8 HAP contract?
01

Yes

02

No

03

Don’t know

Skip to question 21a.

20b. How many Section 8 HAP units are on this property?
Units

21a. A project-based voucher is an agreement with a public housing agency to keep a Section 8
Voucher attached to a unit to pay some or all of the rent, even when the low-income
tenants move out and are replaced by other qualified tenants. Are any units subsidized
with project-based Section 8 Vouchers?
01

Yes

02

No

03

Don’t know

Skip to question 22.

21b. How many project-based vouchers are associated with this property?
Vouchers

8

22. Does this property benefit from any of the following?
Mark (X) for ALL that apply.
A government-sponsored, below-market interest rate loan

02

A federal government rental subsidy OTHER than Section 8 payments
to project or tenants — Specify

03

Housing for the elderly direct loan program (Section 202)

04

Low-Income Housing Tax Credit Program (Section 42)

05

A government grant (HOME, CDBG, HOPE VI)

06

Federal income tax credit for old or historic properties (Section 38)

07

Accelerated federal income tax depreciation for low- and moderate-income properties

08

Subsidy from a private entity

09

Other — Specify

10

No, not subsidized

11

Don’t know

↵

↵

01

23. For calendar year 2011, have any real estate tax reductions, abatements, or refunds
been received on this property for any of the following reasons?
Yes

No

Don’t
Know

A For historic preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

B Because this property houses low-income tenants. . . . . . . . . . . . . . . . . . . .

01

02

03

C Because this property is in a low-income area . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

D Because this property is in a targeted economic development area . . . . .

01

02

03

E Because of real estate tax appeal or assessment . . . . . . . . . . . . . . . . . . . . .

01

02

03

01

02

For some other reason — Specify below

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

↵

F

24a. Is there a mortgage or similar debt on this property?
01

Yes

02

No

Skip to 24c

24b. Why is there no mortgage or similar debt on this property?
01

I prefer not to carry any debt on this property or do not want a mortgage - End interview

02

I have tried to get a mortgage, but was denied - End interview

03

Other — Specify below then End interview

24c. How many mortgages or similar debts are on this property?
Mortgages or similar debts

9

25. Is the debt on this property—

Yes

No

A A mortgage, deed of trust, or trust deed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

02

B A contract to purchase, land contract, or purchase agreement?. . . . . . . . . . . . . . . . . . 01

02

C A line of credit secured by this property or a property equity loan? . . . . . . . . . . . . . . 01

02

. . . . . . . . . . . . . . . . . . . 01

↵

D Some other loan secured by this property
(not personal loans or consumer finance loans)? — Specify

26. Regarding the debt on this property—

Yes

No

02

Don’t
Know

A Was a personal guarantee required? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

B Was there cross-collateralization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01

02

03

C Were any other properties included in this first mortgage? . . . . . . . . . . . .

01

02

03

27a. When did the CURRENT FIRST mortgage loan on this property originate?

MONTH

YEAR

27b. What was the original mortgage amount on the CURRENT FIRST mortgage?
$

.00

27c. What was the appraised value of this property at the time of the CURRENT FIRST
mortgage’s origination?
$

.00

OR
01

Don’t know

28. Is the CURRENT FIRST mortgage on this property—
Mark (X) in only ONE box.
01

A new mortgage that was placed when this property was acquired?

02

A refinancing of a previous loan?

03

A mortgage placed on a property previously owned free and clear of debt?

04

A construction loan converted to permanent financing?

05

The same mortgage that was assumed from the previous owner when this
property was acquired?

10

Skip to question 30.

29. Where did you get the CURRENT FIRST mortgage on this property?
Mark (X) in only one box.
Commercial bank or trust company

02

Savings and loan association, federal savings bank, mutual savings bank

03

Life insurance company

04

Mortgage bank or mortgage company

05

Real Estate Investment Trust (REIT)

06

Pension fund or retirement fund

07

Credit union

08

Finance company (including consumer discount company, industrial bank, cooperative bank)

09

State or municipal government

10

State or local housing finance agency

11

Individual or individual’s estate

12

Other — Specify

13

Don’t know

↵

01

30. Who do you make your CURRENT FIRST mortgage payments to?
Mark (X) in only ONE box.
Commercial bank or trust company

02

Savings and loan association, federal savings bank, mutual savings bank

03

Mortgage bank or mortgage company

04

Life insurance company

05

Private mortgage pool

06

Loan servicing company

07

Credit union

08

Finance company (including consumer discount company, industrial bank, cooperative bank)

09

State or municipal government

10

State or local housing finance agency

11

Individual or individual’s estate

12

Other — Specify

13

Don’t know

↵

01

31a. What is the term of the loan on this property’s CURRENT FIRST mortgage?
Years

31b. Is there a large payment due at the end of the loan term (a “balloon payment”), or is the
loan paid in full after a period of time (“fully amortized”)?
01

Balloon payment

02

Fully amortized

11

32. What is the current annual interest rate on the CURRENT FIRST mortgage?

.

%

33. Is the CURRENT FIRST mortgage on this property—
01

A fixed-rate, level payment

02

An adjustable rate mortgage (ARM)

Skip to question 35a.

34a. How frequently can the interest rate of the ARM change? Once every—
Mark (X) in only ONE box.
Month

02

3 months

03

6 months

04

Year

05

3 years

06

5 years

07

Other — Specify

↵

01

34b. Is the interest rate tied to an index?
01

Yes

02

No

Skip to question 35a.

34c. What is the market index?
For Treasury security rate or LIBOR rate, specify the term of the rate, such as 3-year or 3-month rate.
01

Treasury rate
Years

02

LIBOR

03

Prime rate

04

11th District cost-of-fund index

05

National average cost of funds

06

OTS contract mortgage rates

07

Adjustment not based on index

08

Other — Specify

↵

Months

34d. What is the margin over index?

.

%

12

1
35a. Are there regularly
required payments on this property’s CURRENT FIRST mortgage?
01

Yes

02

No

Skip to question 36.

35b. What was the amount of the most recent regularly required payment, including tax
and insurance, if required?
$

.00

35c. How often are these payments required to be made?
Mark (X) in only ONE box.
Biweekly (every 2 weeks)

02

Monthly

03

Quarterly

04

Other — Specify

↵

01

35d. What does this regular payment include?
Mark (X) for ALL that apply.
Principal

02

Interest

03

Property insurance

04

Private mortgage insurance (PMI)

05

Property taxes

06

Other — Specify

↵

01

36. Is the CURRENT FIRST mortgage on this property insured or guaranteed by—
Mark (X) in only ONE box.
The Federal Housing Administration (FHA)?

02

The Department of Veterans Affairs (VA)?

03

The Rural Housing Service/Rural Development (formerly FmHA)?

04

A private mortgage insurance company?

05

A state or municipal government?

06

A state or local housing finance agency?

07

Other — Specify

08

Mortgage is not insured or guaranteed

09

Don’t know

↵

01

13

If the answer to question 24b is MORE than one, proceed to
question 37. Otherwise, end interview.

Second Mortgage

Third Mortgage

Fourth Mortgage

YEAR

YEAR

YEAR

37. In what year was the
mortgage placed/
assumed? . . . . . . . . . . . . .
38. What was the original
amount of the loan? . . . .

$

.00

$

.00

$

.00

39. What is the regularly
required payment? . . . . .

$

.00

$

.00

$

.00

40. How often do you
make this payment?
Mark (X) in only ONE box
for each mortgage.

01

41. What does this regular
payment include?
Mark (X) for ALL that
apply for each mortgage.

02

Biweekly

01

01

Biweekly
Monthly

Monthly

03

Quarterly

03

Quarterly

03

Quarterly

04

Other — Specify
below

04

Other — Specify
below

04

Other — Specify
below

01

Principal

01

Principal

01

Principal
Interest

02

↵

↵

Monthly

02

↵

42 Is this loan insured or
guaranteed by the—
Mark (X) in only ONE box
for each mortgage.

Biweekly

02

03

Other — Specify
below

03

Other — Specify
below

03

Other — Specify
below

01

Federal Housing
Administration
(FHA)?

01

Federal Housing
Administration
(FHA)?

01

Federal Housing
Administration
(FHA)?

02

Department of
Veterans
Affairs (VA)?

02

Department of
Veterans
Affairs (VA)?

02

Department of
Veterans
Affairs (VA)?

03

Rural Housing
Service/Rural
Development

03

Rural Housing
Service/Rural
Development

03

Rural Housing
Service/Rural
Development

↵

(formerly FmHA)?
04

None of the
above

↵

Interest

02

↵

Interest

02

(formerly FmHA)?
04

None of the
above

(formerly FmHA)?
04

None of the
above

THANK YOU VERY MUCH FOR YOUR COOPERATION
END SURVEY

14

ADMINISTRATIVE USE ONLY
1a. Who answered the questions on this form?
Mark (X) for all that apply.
01

Property owner

02

Property manager

03

Other agent of owner

1b. Please enter the name, address, and telephone number of the person who answered the
questions on this form.
Name:

Title:

Organization:

Address:

City:

State:

ZIP Code:

Telephone number (including area code):
–

–

2. How were the questions on this form completed?
Mark (X) for all that apply.
01

By self-response

02

By personal interview

03

By telephone interview

3. Were administrative records used to complete any of the questions on this form?
Mark (X) in only ONE box.
01

No

02

Yes, some administrative record information was used

03

Yes, all responses were obtained from administrative record information

4a. Have all questions on this form been answered?
01

Yes

02

No

End survey.

15

4b. Please provide the name, address, and telephone number of a person who can assist with
the unanswered questions:
Name:

Title:

Organization:

Address:

City:

State:

ZIP Code:

Telephone number (including area code):
–

–

Notes:

Reason (code 547):

Final Outcome Codes
Mark (✗) in only ONE code box below to indicate
the final outcome of the case. If code 547 is
marked, explain the reason in the space provided.

Interview
01
02

501
503

Noninterview
01
02
03
04
05
06
07
08
09

513
514
515
516
517
518
519
520
521

10
11
12
13
14
15
16
17
18

522
524
529
533
540
541
543
546
547

I have reviewed the questionnaire for completeness.
FR’s name

FR’s code

Date of interview
/

/
MONTH

16

DAY

YEAR