Attachment X Housing Shuggle Form Long Pricing

Consumer Price Index: Housing Survey Form
BLS Contact:	<Enter Name>
Contact Phone:	<Enter Phone>
Contact Fax:	<Enter Fax>
Contact Email:	<Enter Email>
Please Return Form By:	<Add Date>
Number of Units:	1
Address:
				Unit:
Tenant Name OR Initials					<Enter Name of Occupant>
When did the person, who has lived in this house (or apartment) the longest, move in?					<Enter Date>
Is this unit occupied by the owner or is it rented?					<Select>
Is this unit part of an assisted living program?					<Select Yes or No>
Is this unit the primary residence of at least one of the occupants?					<Select Yes or No>
Is anyone living in the household a relative of the landlord?					<Select Yes or No>
How many bedrooms, baths, and other rooms are there?
			<#>
			<#>
			<#>
			<#>
			0
Is this house/apartment under rent control?				<Select Yes or No>
Do you/Does the tenant have a lease or other rental agreement?				<Select Yes or No>
If Yes, How long is the current lease agreement?				<Select>
If 12-months or any other length of time, “In what month and year did the current lease start?”				<Enter Month and Year>
How much rent is the tenant paying for this house now?					<Enter Amount>
What period of time does that rent cover?					<Select>
Is the rent lower because the Landlord receives a subsidy from the government such as Section 8?					<Select Yes or No>
If Yes, how much was the subsidy?				<Enter Amount>
Is the rent lower because someone did work for the landlord?					<Select Yes or No>
If Yes, how much was the work reduction?				<Enter Amount>
			$-
Does this rent include any optional extra charges?					<Select Yes or No>
If Yes, what is the amount of the extra charge?				<Enter Amount>
Does the Landlord provide free off street parking?					<Select Yes or No>
Who pays for the water service?					<Select>
Who pays for the sewer service?					<Select>
Who pays for the electricity?					<Select>
If this is paid by the Tenant, is the cost of electricity included in the rent you reported earlier?				<Select Yes or No>
What type of A/C equipment does this unit have?					<Select>
If Thru-the-wall A/C, how many does this unit have?				<Enter Amount>
If Window A/C, how many does this unit have? How many are provided by the Landlord?				<Enter Each Amount>
What is the primary type of heating fuel used by this unit?					<Select>
Who pays for the heating fuel?					<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>
What is the primary type of hot water fuel used by this unit?					<Select>
Who pays for the heating fuel?					<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>
If the building/structure is a multi-unit, how many units are in the building?				<Enter Number of Units>
If the building/structure is a multi-unit, is there an elevator?				<Select Yes or No>
Additional Information:
Respondent Comments: