RESIDENTIAL DATA SHEET (FRM15-A)
North Carolina Department of Transportation
relocation assistance
WBS Element / TIP/Parcel / County
Displ. No. / F.A. No. / Email
Claim Of: / Home Phone / Mobile Phone / Bus. Phone
Displacee:
Address: / ZC
Residential Household Data
Name / Age / Sex / Rel. / Employer or school / Gross Income
Owner / Tenant / Yes / No / total income from all sources
1. / is tax identification form signed? / 14. / Tenant: 30% of month gross household income?
2. / Has displacee received Relocation Brochure? / 15. / Rent / Monthly Rent (Average last 3 mos.)
3. / Does displacee desire help finding housing? / Subsidized? / No / Yes / Amount
4. / Will displacee need public transportation? / Utilities in rent? / No / Yes / Amt.
5. / Is public transportation available now? / Rent verified how?
6. / Afro-Am. / Am. Indian / Spanish Surname / 16. / Utilities / Heating
Oriental / Caucasian / All others / A.C. / Central / # Units
7. / Owner-occupant / 0-89 days / 90-179 / 180+ / Water Heating:
8. / Tenant-occupant / 0-89 days / 90 days+ / Cooking:
9. / Length of occupancy: (Yrs.) / (Mos.) / Water System: / Public / Private / Well & Pump
How verified? / Sewer System: / Public / Private / Septic Tank
10. / Present Dwelling / Frame / Brick / Other / 17. / Mobile Home Occupant / Size MH:
Condition: / Excellent / Good / Fair / Poor / Yr. Built / Titled Owner:
Type: / Single Family / Duplex / Multi-Family / Rents: / Site / Home / Owns: / Site / Home
Garage/CP / Age / Can MH be moved? / Yes / No / If not, why not?
Total SF Area / DSS: / Yes / No
Site Improvements: / List of MH attachments to move / Porches / Decks
11. / Rooms: / Total / BR / Baths / Central Heat/AC / Room Attach. / Screen porch
Basement / Storage / Rooms Used / 18. / Relocation Preference: / Purchase / Rent
12. / Mortgage? / No / Yes / Terms (Yrs.) / Build / Retain & Move / Undecided
Int. Rate / % / Balance Due / House / Apartment / M.H. / Public Housing
Held by: / COMMENTS:
Is Property owned by others? / No / Yes
Who?
13. / Fixed Rate / Actual
Bids Obtained: / 1. / 2.
NOTE: IF MH, obtain copy of title.
I HEREBY CERTIFY THAT ALL PERSONS LISTED ABOVE ARE EITHER A CITIZEN OR NATIONAL OF THE UNITED STATES OR AN ALIEN WHO IS LAWFULLY PRESENT IN THE UNITED STATES / Displacee / Head of Household / date:
FRM15-A
Revised 6-13-14