Exhibit A-3 to Subpart E of Part 1944 - Rental Housing Survey

(SAMPLE)

A rental housing project is being planned for (name of community.) The project would provide comfortable living at monthly rental rates of (Indicate proposed basic rent by number of bedrooms.) Your opinion on the following will help us to determine whether such a project is practical. This information does not obligate you in any way.

1. What age group are you in? 62 or over [] 50-61 [] 35-49 [] Under 35 []

2. Are you or members of the household handicapped or impaired and in need of specially designed housing arrangements? yes [] no []

3. Number of person(s) in your household: ___.

4. Approximate annual income from all sources including any social security pension, payments made on behalf of minor children, public assistance, etc.: $___.

5. Do you own () or rent () present residence?

6. Do you live in house () apartment () room () mobile home () on a farm () in town ()?

7. Is your present housing modern () not modern, but adequate () inadequate (). If inadequate, in what respect? ___.

8. What amount of monthly rent do you pay with utilities included? $___.

9. Would you pay 30 percent of your monthly income for modern housing for your family? yes () no ()

10. Would you be willing to move in if an apartment were available___, 19__? yes () no ()

11. Do you have a car? No, 1, 2, 3 (circle)

Name Address (including city/town) Telephone Number Location of employment For Elderly and Congregate Housing

12. Number of meals you would like prepared for you per day ___

13. What other services would you like to have available to you?

YesNoa. Housekeeping servicesb. Personal care servicesc. Social and recreational activities servicesd. Linen and laundry servicese. Health and medical related servicesf. Beauty and barber servicesg. Transportation or access servicesh. Other (specify)

14. List any hobbies or organizational membership you have.

Note to Applicant:

This sample survey form is for your use in evaluating the need for new rental units in the community and its market area. You should be prepared to explain the methodology of the survey since FmHA or its successor agency under Public Law 103-354 will be spotchecking the respondents' answers. How the survey is performed can influence the outcome; therefore, it is encumbent upon you to see that the manner in which it is conducted is suitable and acceptable to FmHA or its successor agency under Public Law 103-354. For instance, compensation being paid to someone for survey work should not be dependent upon the number of respondents who would be willing to move into the project. The survey should be based on a random sampling of persons now residing in the market area. Things to avoid are surveying from the telephone book listing or a door-to-door canvass of a certain segment of the community. We want the development of rental units to be based upon actual circumstances prevailing in the market area in order that the housing development will present a secure and economical living arrangement for the persons in need of the housing.