Instructions to owner/landlord/manager: Complete one form for each development or structure you own or manage. 

Name/address of property 

_______________________________________________ 

_______________________________________________ 

Owner's/agent's name __________________ 

Phone ______________ 

Address __________________________________________ 

Q-1 Type of structure (Circle one)
1 Mobile/manufactured home
2 Single-family detached house
3 Duplex, tri-plex, or four-plex
4 Building with 5-9 apartments
5 Building with 10 or more apartments
6 Other, explain _____________________________________ 

Q-2 Building accessibility (Circle all that apply): 
1 One or fewer steps to building entrance
2 Two or more steps to building entrance
3 One-story building
4 Two- or more story building without elevator
5 Two or more story building with elevator 

Q-3 Wheelchair accessibility (Circle all that apply):
1 Building entry door has at least 32 inches clear passage
2 Each apartment entry door has at least 32 inches clear passage
3 Each kitchen door or opening has at least 32 inches clear passage
4 At least one bathroom per unit has a door with at least 32 inches clear 

Q-4 Number of units by bedroom size and rent level: Fill blanks and circle. 

Number of Units Rent Amount Furnished? Utilities included? 

_____	Efficiency unit	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C
_____	1-bedroom	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C
_____	2-bedroom	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C
_____	3-bedroom	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C
_____	4-bedroom	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C
_____	5 or more	Monthly rent $______	Yes	No	Heat	Lights	W/S	A/C

Q-5 How many of the above units were vacant on _______ (date)? 

Number of Units: 

_____ Efficiencies
_____1-bedroom
_____2-bedroom
_____3-bedroom
_____4-bedroom
_____5-bedroom 

C-1. City Rental Housing Cost Survey Results 

Census Tracts (in dollars per Month)* 

Mean Rent by Dwelling Size	City Total	1	2	3	4	5	6	7	8	9	10
Efficiencies	$
1 Bedroom	$
2 Bedroom	$
3 Bedroom	$
4 Bedroom	$
5 Bedroom	$
Mobile Home	$
Census Tract Average	$

* not including utilities 

Unit Responses by Dwelling Size	City Total	1	2	3	4	5	6	7	8	9	10	Vacancies
Efficiencies	$
1 Bedroom	$
2 Bedroom	$
3 Bedroom	$
4 Bedroom	$
5 Bedroom	$
Mobile Home	$
Census Tract Average	$

   
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