1.1.4 ATTACHMENT 13 - Direct Lease Inspection Report.pdf
PDF 53 KB Posted
- Attached to
- DIRECT LEASE PROGRAM - State of Kentucky
- Solicitation number
- 70FBR426Q00000002
About this file
This is a Direct Lease Housing Unit Inspection Report from the Federal Emergency Management Agency (FEMA), Department of Homeland Security, used for documenting the condition of a housing unit during move-in or move-out processes. The form comprehensively catalogs the status of various furnishings and unit components across different areas including kitchen and dining, living room, bedrooms, bathroom, and exterior, with columns to mark the condition as new (N), damaged (D), good (G), missing (M), or poor (P).
The document includes privacy act statements and paperwork burden disclosure notices, explaining that the information is collected under the Robert T. Stafford Disaster Relief and Emergency Assistance Act for obtaining landowner consent and facilitating disaster-related temporary housing assistance. The inspection report is designed to meticulously record the state of appliances (such as refrigerator, range, A/C), furnishings (beds, curtains, light fixtures), and structural elements (floor coverings, wall panels, doors, windows) to track any changes or damages between occupancies.
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Text version
RFO MOVE OUT
DATE
Site RFO
Move In HOUSE Move Out
MODEL SERIAL #
N/A N/A
N/A N/A
N/A N/A
Property Name:
Unit #: Floor #:
YES
CONDITION OF FURNISHINGS, INTERIOR &
EXTERIOR:
N=NEW D= DAMAGED
G=GOOD M=MISSING
P=POOR
Is this Unit UFAS or ADA? Please check one of the following boxes.
# of Bathrooms
Property Phone Number:
N/A
UNIT INFORMATION NOTES:
***OBTAIN AND ATTACH COPY OF PROPERTY TENANT RULES ***
NO
Property Address:
# of Bedrooms:
OTHER:
Refrigerator
A/C N/A
Water Heater N/A
Furnace
Range
Microwave
DIRECT LEASE HOUSING UNIT INSPECTION REPORT
DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
MHU
TYPE OF INSPECTION: CIRCLE ONE
Public reporting burden for this form is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering, and maintaining the needed data, and completing, reviewing, and submitting the form.
This collection of information is mandatory. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0030). Please do not send your completed form to the above address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part 206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of obtaining necessary landowner consent to inspect ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended.
This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster-related temporary housing assistance.
MOVE IN
CHECK ONETYPE OF FACILITY: CHECK ONE BOX BELOW
PAPERWORK BURDEN DISCLOSURE NOTICE
APARTMENT
APPLIANCES: MANUFACTURER
FURNISHINGS: RFO MOVE IN MOVE OUT FURNISHINGS: RFO MOVE IN MOVE OUT
Kitchen & Dining
Dinette Table Arm Chair Dinette Chairs (6 for 3 BR) End Table
Range Hood & Vent Fan Coffee Table
Refrigerator Wall Coverings Wall Coverings
Light fixtures
Cabinets Hall Sink Furnace Light Fixtures Smoke Detector
Fire Extinguisher Light Fixtures
Living Room Mirror A/C Cabinets Storage
Couch Wall Coverings
FURNISHINGS: RFO MOVE IN MOVE OUT
FURNISHINGS: RFO MOVE IN MOVE OUT
Double Bed, Complete
Mirror Commode
Curtains & Rods/Blinds Tub/Shower
Light Fixtures Lavatory
Second Bedroom Cosmetic Cabinet
Double Bed, Complete Mirror
Mirror Wall Coverings
Cabinet Storage Light Fixtures
Curtains & Rods/Blinds
Light Fixtures Water Heater Third Bedroom Doors
Double Bed, Complete 2 Key Per Door
Mirror Windows
Cabinet Storage Screens
Curtains & Rods/Blinds
Light Fixtures
Interior Condition
Floor Covering
Wall Panels
Ceiling Panels
Condition
DIMOVEOUTT LEASE HOUSING UNIT INSPECTION REPORT
Condition
First Bedroom Condition
Bathroom
Living Room (continued) Condition
Exterior Condition
Other
OCCUPANT MOVE IN/MOVE OUT:
OCCUPANT SIGNATURE (Move in or out): DATE:
FEMA REPRESENTATIVE SIGNATURE: DATE:
COMMENTS (If more space is needed, continue on reverse):
INSPECTOR SIGNATURE: DATE:
DIRECT LEASE HOUSING UNIT INSPECTION REPORT
READY FOR OCCUPANCY:
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