Att_C_OS2001.pdf

Office of the Secretary (OS) Form 2001

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

PRIVATE RENTAL SURVEY

TRAILER SPACES

TRAILER PARK SITE DATA (FILL IN APPROPRIATE BLANKS AND CHECK BEST CHOICE)

1. Total Square Feet (Single-wide sites only)

2. Monthly Contract Rent, single-wide (Round to the nearest dollar)

3. Year Trailer Park Constructed

4. Trailer Pad Construction

Hard Surface (cement, asphalt, etc.)

Natural Surface (dirt, gravel, etc.)

5. Services Paid for by Landlord

Water (including wells) Yes No Sewer (including 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 Snow Removal Yes No

Paperwork Reduction Act Statement: This information is being used to determine private sector rental rates for trailer spaces, and will be used 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, and a person is not required to respond to, 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 4 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-2001

Trailer Park Name:

Owner/Agent Name:

Owner/Agent Phone:

Owner/Agent Address or Email:

Owner/Agent City: State: Zip Code:

Owner: Agent: Tenant:

Street Address of Trailer Pad:

Pad City: State: Zip Code:

Survey Community and State:

Comp I.D. Number:

Community Code:

Contractor’s Representative: Date Collected:

LWalters Typewritten Text

LWalters Typewritten Text

ATTACHMENT C

Slide Number 1