Att_B_OS2000.pdf

Office of the Secretary (OS) Form 2000

OMB Control Number 1084-0033 Expires mm-dd-yyyy

PRIVATE RENTAL SURVEY

HOUSES – APARTMENTS – MOBILE HOMES

Realty Company Name:

Owner/Agent Name:

Owner/Agent Phone:

Owner/Agent Address or Email:

Owner/Agent City: State: Zip Code:

Owner: Agent: Tenant:

Street Address of Rental Unit:

Unit City: State: Zip Code:

Survey Community and State:

Comp I.D. Number:

Community Code:

Contractor’s Representative: Date Collected:

HOUSING DATA (FILL IN APPROPRIATE BLANKS AND CHECK BEST CHOICE)

1. Year Constructed

2. Gross Finished Floor Space of this Housing Unit (square feet)

Basement

First Floor

Other Floors

3. Gross Unfinished Basement Space (square feet)

4. Number of Bedrooms

5. Number of Bathrooms (sink/toilet/bathtub = 1.0; sink/toilet/shower = 0.75)

6. Number of Rooms (excludes bathrooms)

7. Exterior Condition

Excellent Good Fair Poor

8. Interior Condition Excellent Good Fair Poor

9. Primary Heating Energy

Natural Gas Liquid Propane Gas Fuel Oil Electricity – resistance heat Electricity – heat pump Coal Wood Solar None

10. Central Cooling System

None

Refrigerated Air

Evaporative Air

Both Refrigerated & Evaporative

11. Window Cooling Units

No. of Refrigerated Air Units

No. of Evaporative Air Units

12. Garage/Carport

None

Garage – Single Car

Garage – Double Car

Carport

13. Rent Class

House Plexed

Apartment

Mobile Home

14. Appliances Provided by Landlord (enter # included)

Refrigerator Range Dishwasher Washer Dryer Freezer Microwave Oven Trash Compactor

15. Services Paid for by Landlord (included)

Water (incl. well) Yes No Sewer (incl. septic) Yes No Garbage Yes No Lawn Care Yes No Cable TV Yes No Satellite Dish Yes No Electricity Yes No Heating Fuel Yes No Firewood Yes No Snow Removal Yes No

16. Furnishings Provided by Landlord (enter # of furnished rooms)

17. Fireplace

Yes, Working Fireplace Available

No Fireplace or Not Working

18. Free Standing Stove (a stove that is not inside of, attached to, in front of or vented through a fireplace)

Yes No

19. Monthly Contract Rent (round to nearest dollar)

OS-2000

LWalters Typewritten Text

ATTACHMENT B

Office of the Secretary (OS) Form 2000

OMB Control Number 1084-0033 Expires mm-dd-yyyy

PRIVATE RENTAL SURVEY

HOUSES – APARTMENTS – MOBILE HOMES

Paperwork Reduction Act Statement: This information is being used to determine private sector rental rates for houses, apartments and mobile homes, and subsequently to establish rental rates for occupants of government-furnished quarters.

Response to this request is voluntary. No action may be taken against you for refusing to supply the information requested. An agency may not conduct or sponsor a collection of information unless it displays a current valid Office of Management and Budget (OMB) control number.

Estimated Burden Statement: Public reporting burden for this form is estimated to average 6 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate, or any other aspect of this form, to the U.S. Department of the Interior, Office of the Secretary, Office of Acquisition and Property Management, 1849 C Street NW, MS 4262, Washington, DC 20240.

Privacy Act Statement: Your participation is voluntary. If you do participate, you do not have to give us personal information in order to complete this form. The data obtained from you will be treated anonymously, and will be used only for statistical purposes

– to measure private rental rates in your community and region. However, we reserve the right to contact you to clarify this information or to verify our contractor’s performance. We will not disclose this information; it is published only in aggregate form.

We do not give, sell or transfer any personal information to a third party. It will not be shared with other property managers or rental companies. Direct comments regarding the Privacy Act, or any other aspect of this form, to the U.S. Department of the Interior, Office of the Secretary, Office of Acquisition and Property Management, 1849 C Street NW, MS 4262, Washington, DC 20240.

OS-2000