Exhibit A-4 to Subpart E of Part 1944 - Cooperative Housing Survey

BEFORE ATTEMPTING TO ANSWER THESE QUESTIONS, PLEASE READ THE GUIDELINES FOR UNDERSTANDING THE PRINCIPLES OF COOPERATIVE HOUSING. NOW TAKE TIME TO ANSWER THE FOLLOWING QUESTIONS AS HONESTLY AS YOU CAN.

(Circle yes or no)

1. Are you willing to share the responsibilities required of a cooperative member?

yes ____no____

2. If asked, will you serve on the board of directors or on a committee?

yes ____no____

3. Are you willing to help in maintaining the cooperaive property?

yes ____no____

4. Do you now have a better idea of what cooperative housing really is?

yes ____no____

5. Do you want to ask more about the cooperative before deciding whether to join?

yes ____no____

6. If the answer to question 5 is “yes,” will you come to an information meeting to be held in town?

yes ____no____

7. Have you answered the questions truthfully? Did you answer “no” to any of questions 1, 2, or 3? If so, this type of housing is not for you. If you are interested, please go on to complete the second portion of this survey.

1. How many persons in your household?

adults children

2. Approximate annual income from all sources: $______

3. Are you or members of the household handicapped or impaired and in need of specifically designed housing arrangements?

yes ____no____

4. An informal meeting is scheduled for ___ a.m./p.m., on ______, 19__, for the purpose of discussing a proposed __ -unit cooperative planned for this community. At that time a representative of the cooperative will be on hand to answer other questions you may have.

So that we may know how many persons to expect at the meeting, we ask that you give us your name, address, and phone number.

NAME ADDRESS PHONE