Attachment X Email/Fax Form - Short

Consumer Price Index Update Form: Housing

-5

BLS Contact:

<Enter Name>

Contact Phone:

<Enter Phone>

Please Return Form By:

<Add Date>

Last time contacted:

<Enter date from Collection Instrument>

Contact Fax:

<Enter Fax>

Number of Units:

<Enter Number>

Contact Email:

<Enter Email>

Address:

Unit:

Tenant Name OR Initials

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

<Enter Name of Occupant>

Is the occupancy the same, different, or vacant since ?

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

<Select One>

When did the person, who has lived in this house the longest, move in?

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

<Enter Date>

Is this unit occupied by the owner or is it rented?

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

How much rent is the tenant paying for this house now?

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

What is the rental period?

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

<Select>

Was the rent lowered because the Landlord received a subsidy from the government such as Section 8?

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

If Yes, how much was the subsidy?

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

Was the rent lowered because someone did work for the landlord?

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

If Yes, how much was the work reduction?

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

Total Rent:

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

Does this rent include any optional extra charges?

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

If Yes, what are they and how much is each one?

<Enter Text and Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

<Enter Amount>

Since , has there been any changes to who pays the Utilities? This includes, water, sewer, electricity, air conditioning, heating, and hot water.

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

<Select Yes or No>

Additional Information:

Respondent Comments: