Attachment IX Email/Fax Form

Consumer Price Index Housing Survey

ATT IX_Housing Survey Final - LP.xlsx

OMB: 1220-0163

Document [xlsx]
Download: xlsx | pdf
Consumer Price Index Update Form: Housing





















BLS Contact: <Enter Name>





















Contact Phone: <Enter Phone>
















Please Return Form By: <Add Date>


Contact Fax: <Enter Fax>
















Number of Units: <Enter # of Units in IG>


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>
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>
Is this unit part of an assisted living program? <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>
Is this unit the primary residence of at least one of the occupants? <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>
Is anyone living in the household a relative of 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>
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 is the amount of the extra charge?



<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>
Does the Landlord provide free off street parking? <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>
Who pays for the water service? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
Who pays for the sewer service? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
Who pays for the electricity? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
If this is paid by the Tenant, is the cost of electricity included in the rent you reported earlier?



<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>
What type of A/C equipment does this unit have? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
If Thru-the-wall A/C, how many does this unit have?



<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>
If Window A/C, how many does this unit have? How many are provided by the Landlord?



<Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount> <Enter Each Amount>
What is the primary type of heating fuel used by this unit? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
Who pays for the heating fuel? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
If this is paid by the tenant, is the cost of heat fuel included in the rent you reported earlier?



<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>
What is the primary type of hot water fuel used by this unit? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
Who pays for the heating fuel? <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select> <Select>
If this is paid by the tenant, is the cost of heat fuel included in the rent you reported earlier?



<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>
How many bedrooms, baths, and other rooms are there?






















Bedrooms 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



Full Baths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



Half Baths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



Other 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



Total: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0





Additional Information:






























































Respondent Comments:
























































































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