Laserfiche WebLink
RELOCATION NEEDS ASSESSMENT FORM <br />PAGE 3 <br />Check the appropriate box for each household within unit. <br />Marital Status <br />Race Status <br />Single <br />White <br />Married <br />Black <br />Divorced <br />American Indian <br />Separated <br />Hispanic <br />Widowed <br />Asian/Pacific Islander <br />Other <br />HOUSING CONDITION <br />NOTE: Verification will be required. <br />1. How many bedrooms are there in the unit you presently occupy? [ ] <br />2. How many people are living with you in the unit? [ ] <br />3. Does the unit in which you are currently living have any of the following problems? <br />Please check the following? <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 />