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<br />:> ,. ,.'." <br /> <br />. . <br /> <br />- <br /> <br />, ' ' <br /> <br />RELOCATION NEEDS ASSESSMENT FORM <br />PAGE 3 <br /> <br />Check the appropriate box for each household within unit. <br />d Marital Status J Race Status <br /> Single White <br /> Married Black <br /> Divorced American Indian <br /> Separated Hispanic <br /> Widowed Asian/Pacific Islander <br /> Other <br /> <br />HOUSING CONDITION <br /> <br />NOTE: Verification will be required. <br /> <br />1. <br /> <br />How many bedrooms are there in the unit you presently occupy? [ <br /> <br />] <br /> <br />2. <br /> <br />How many people are living with you in the unit? [ <br /> <br />] <br /> <br />3. <br /> <br />Does the unit in which you are currently living have any of the following problems? <br />Please check the following? <br /> <br />[ ] <br />[ ] <br />[ ] <br />[ ] <br />[ ] <br />[ ] <br />[ ] <br /> <br />Rats/roaches <br />Inoperable plumbing/toilet/shower <br />Unsafe electrical service <br />Inadequate source of heat <br />Does not have a kitchen or cooking facilities <br />Has been declared unfit for habitation by the <br />City of Redwood City or another unit of government. <br />Other <br /> <br />24 <br /> <br />..,.......,.._,--'.... <br />