Number of years lived in [TownName]

Please identify your level of satisfaction with the following housing needs.

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Don't Know
There is enough suitable housing to rent in [TownName]
There is sufficient housing for the elderly in [TownName].
There is adequate availability of housing for low income families.
The availability of moderate priced housing is adequate.

Have you experienced any of the following difficulties related to finding or purchasing housing for yourself or your family?

Shortage of affordable rental housing
Limited numbers of affordable homes for sale
Available, affordable homes are poor quality or too small
Don't have enough money for required down payment on a home
Can't qualify for a mortgage at today's interest rates and home prices
Trouble qualifying for home financing because of credit rating.
Finding housing that is both accessible for my disability and affordable.
Other (please specify):

How long have you lived at your current address?

Less than 6 months
6 months-1 year
1-5 years
6 or more years

Do you rent or own your residence?

Rent/Lease
Own

If you currently rent, why have you chosen to rent?

Little or no upkeep
Can't afford a home
Do not currently rent residence
Not staying long term in the community
Other (please specify):

What type of housing do you live in now?

Single Family Housing (frame construction with foundation)
Apartment
Duplex
Mobile Home
Modular Home
Other (please specify):

How many bedrooms are in your home?

0 bedrooms (efficiency)
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 plus bedrooms

What is your current monthly rent or mortage payment?

$100 - $200
$201 - $300
$301 - $400
$401 - $500
$501 - $600
$601 - $700
$701 - $800
Over $801
No mortgage, own outright

Will you be looking for different housing to purchase or rent within the next:

0 to 2 years
2 to 4 years
Not thinking about moving

What amenities will you be looking for in a rental unit?

Garage
Private yard
Not Applicable
Other (please specify):

If you chose to move, what type of housing would you prefer?

Single Family Housing (frame construction with foundation)
Apartment
Duplex
Mobile Home
Modular Home
Other (please specify):

How many bedrooms would be needed in your choice of housing?

0 bedrooms (efficiency)
1-2 bedroom
3-4bedrooms
5 plus bedrooms

What do you believe would be an appropriate monthly cost?

$500-$700/mo.
$701-$900/mo.
$901-$1100/mo.
$1101-1400/mo.
$1401-1600/mo.
More than 1600/mo.

If you are going to purchase a residence within a year, what price range would you look at?

Under $80,000
$80,000 - $120,000
$120,000 - $160,000
$160,000 - $200,000
$200,000 - $240,000
$240,000 +

What is the highest down payment you could make in order to purchase a residence?

No money down
5%
10%
20%
Other (please specify):
Not Applicable

What is your gender?

Male
Female
Other (please specify):

Where do you currently work?

Within [TownName]
Within 2 to 5 miles of [TownName]
Within 10 to 20 miles of [TownName]
Within 21 to 40 miles of [TownName]

What is your age?

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65+
75 or older

Which of the following best represents the highest level of education that you have completed?

Some high school or less
High school graduate
Attended some college
Associates degree
Bachelor’s degree
Post-college graduate

Please add any additional comments or ideas you have for [TownName] regarding housing, or other community development issues:

Which of the following best describes your total household income before taxes last year?

Under $25,000
$25,000 - $49,999
$50,000 - $59,999
$60,000 - $74,999
$75,000- $99,999
$100,000 - $124,999
$125,000 +

Do you have any children under the age of 18?

Yes
No

If yes how many?

Are you currently employed?

Yes, full-time
Yes, part-time (30 hours or less per week)
No, currently unemployed
No, I am retired

YES or NO?

Yes
No

Housing Questionnaire