Form OS-2000 Private Rental Survey, Hourses - Apartments - Mobile Hom

PRIVATE RENTAL SURVEY
HOUSES – APARTMENTS – MOBILE HOMES

Office of the Secretary (OS)
Form 2000

OMB Control Number 1084-0033
Expires mm-dd-yyyy

Survey Community and State :
Street Address of Housing Unit:
City and State:
Name of Owner/Agent:

Zip Code:

Community Code:

Address of Owner/Agent:

Phone of Owner/Agent:

Survey I.D. Number:

HOUSING DATA (FILL IN APPROPRIATE BLANKS AND CHECK BEST CHOICE)
1. Year Constructed

10. Central Cooling System
None

2. Gross Finished Floor Space of Each
Individual Housing Unit (square feet)
Basement

Refrigerated Air
Evaporative Air
Both Refrigerated & Evaporative

First Floor

11. Window Cooling Units
No. of Refrigerated Air Units

Other Floors
3. Gross Unfinished Basement Space

No. of Evaporative Air Units
12. Garage/Carport

15. Services Paid for by Landlord
Water (incl. well)
Sewer (incl. septic)
Garbage
Lawn Care
Cable TV
Satellite Dish
Electricity
Heating Fuel
Firewood
Snow Removal

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No

None
4. Number of Bedrooms
5. Number of Bathrooms

Garage – Single Car

.

(note: .25 per fixture; shower only = .75)

6. Number of Rooms

Garage – Double Car

Working Fireplace

13. Rent Class

No Fireplace or Not Working

(excludes bathrooms)

7. Exterior Condition
Excellent
Good
Fair
Poor
8. Interior Condition
Excellent
Good
Fair
Poor
9. Primary Heating Energy
Natural Gas
Liquid Propane Gas
Fuel Oil
Electricity – resistance heat
Electricity – heat pump
Coal
Wood
Solar
None

(enter # of furnished rooms)

17. Fireplace

Carport

House

16. Furnishings Provided by Landlord

Plexed

Apartment
Mobile Home

18. Free Standing Stove (i.e., a stove that is
not inside of, attached to, in front of or
vented through a fireplace)
Yes

No

14. Appliances Furnished by Landlord
(Insert #)

19. Monthly Contract Rent
(round to nearest dollar)

Refrigerator
Range
Dishwasher
Washer
Dryer
Freezer
Microwave Oven
Trash Compactor

OS-2000

Office of the Secretary (OS)
Form 2000

PRIVATE RENTAL SURVEY
HOUSES – APARTMENTS – MOBILE HOMES

OMB Control Number 1084-0033
Expires mm-dd-yyyy

Paperwork Reduction Act Statement: This information is being used to determine private sector rental rates for houses,
apartments and mobile homes, and subsequently to establish rental rates for occupants of government-furnished quarters.
Response to this request is voluntary. No action may be taken against you for refusing to supply the information requested.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a current valid Office of Management and Budget (OMB) control number.
Estimated Burden Statement: Public reporting burden for this form is estimated to average 6 minutes per response, including
the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments
regarding the burden estimate, or any other aspect of this form, to the U.S. Department of the Interior, Office of the Secretary,
Office of Acquisition and Property Management, 1849 C Street NW, MS 4262, Washington, DC 20240.
Privacy Act Statement: Your participation is voluntary. If you do participate, you do not have to give us personal information
in order to complete this form. The data obtained from you will be treated anonymously, and will be used only for statistical
purposes – to measure private rental rates in your community and region. However, we reserve the right to contact you to
clarify this information or to verify our contractor’s performance. We will not disclose this information; it is published only in
aggregate form. We do not give, sell or transfer any personal information to a third party. It will not be shared with other
property managers or rental companies. Direct comments regarding the Privacy Act, or any other aspect of this form, to the
U.S. Department of the Interior, Office of the Secretary, Office of Acquisition and Property Management, 1849 C Street NW,
MS 4262, Washington, DC 20240.

Completed By:________________________________________________

Printed Name:________________________________________________

Date:_______________________________

OS-2000