Penniman Road Housing Study Interest Survey

Penniman Road Housing Study Interest Survey
The York County Division of Housing and Neighborhood Revitalization is currently involved in a housing study to assess the needs of housing rehabilitation along the Penniman Road corridor, to include but not limited to Charleston Heights, Middletowne Farms, Nelson Circle/Nelson Park, Parkway Estates, Queenswood, Springfield Terrace, Williams Terrace, York Court/York Terrace, Penniman Road and Queens Creek Rd. The information provided below will be used to determine eligibility for a Community Development Block Grant (CDBG) from the State. If funded, the grant money will be used to make improvements identified through this study. If you would like more information about the project, please call Abbitt Woodall or Jan Marshall at 757-890-3885.

Information and updates about this project will be shared on the York County website at yorkcounty.gov/housing.

Information requested from you in this survey is needed to complete this study and to develop the grant application. THIS INFORMATION WILL BE KEPT CONFIDENTIAL. Your assistance in completing this survey is greatly appreciated.
Resident / Property Owner Information:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
Property Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from property address):
Do you:

Own this homeRent this homeHave recorded life rightsHeir property
Occupancy Status:

OccupiedVacant / AbandonedVacant / For SaleVacant / For Rent
How long have you lived at this address?
What is your Monthly Mortgage / Rent?
If you rent this home, please provide the property owner information below:

First NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Owner Phone Number:
Please enter a valid phone number.
Do you receive any Section 8 rental assistance?

YesNo
Household Size
Select the correct option for total number of members living in the household:*

12345678+
Household Income
Total household income is defined as income of all household members (18 or older) that receive any of the following - wages, interest income, investment income, social security, public assistance or other sources. Please select the correct box for total amount of household income.*

$0 - $59,650$59,651 - $68,200$68,201 - $76,700$76,701 - $85,200$85,201 - $92,050$92,051 - $98,850$98,851 - $105,650$105,651 - $112,500$112,501 and greater
Demographics
Race - (Check all that apply within the household)

WhiteBlack or African AmericanBlack or AA & WhiteAsianAsian & WhiteAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska Native & WhiteAmerican Indian or Alaska Native & Black or AAReporting more than one race
Ethnicity: Latino or Hispanic?

YesNo
How many children (17 or younger) reside in the household?
How many elderly persons (62 years or older) reside in the household?
Are there any persons living in the household that are disabled? (Defined as a physical or mental impairment that is not a short term condition)

YesNo
Is this a female-headed household? Defined as a household where an adult female is the primary decision maker and/or sole main income producer and responsible for one or more children 17 or younger.

YesNo
Property Information
What type of home do you reside in?

Single-FamilyMobile HomeDuplexOther
How many bedrooms does your home have?

OneTwoThreeFourFive
How many bathrooms does your home have?

OneTwoThreeFourFive
Are any of the following accessibility features needed?

RampWider doorwaysRaised commode / grab barsSmoke Alarm for hearing impairedWalk-in shower with fold down seat / grab bars
What is your water source?

Public WaterWellSpringCarry / Portable
Please describe any water problems:
Are you on a public sewer?

YesNo
Do you have a septic tank?

YesNo
Does it currently work?

YesNo
Has it been abandoned?

YesNo
Please describe any sewage problems:
Are you experiencing any storm drainage problems?

YesNo
If yes, what type?

Rainfall runoffFloodingStanding WaterPeriodic Flooding of House
Please describe any other drainage problems:
Are any non-cosmetic repairs needed to improve your home?

YesNo
Please describe:
Initial Level of Interest
Would you be interested in participating in a housing rehab program, which would provide repairs to your home at a reduced cost, if funds were made available?*

Very willingModerately willingNot interested
If you are a property owner in the project area, are you interested in having repairs done in exchange for renting the unit to a low- and moderate-income person(s) for 5 years?

YesNo
If you are a landlord in the project area, are you interested in creating homeownership with the current or new renter?

YesNo
Are there any other community needs in the project area not mentioned above?

YesNo
Please describe below:
Please note that additional income documentation will be requested should a Community Development Block Grant from the State be awarded. This survey is to verify initial interest in the program should it go forward.

Certification:
I hereby certify by my signature below, that the information I have provided herein is both truthful and accurate to the best of my knowledge.

(WARNING: IT IS A FEDERAL OFFENSE TO MAKE WILLIFULLY FALSE STATEMENTS OR MISREPRESENTATIONS WHEN PARTICIPATING IN THE CDBG PROGRAM.)
Signature of Resident or Property Owner:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Penniman Road Housing Study Interest Survey

Household Size

Household Income

Demographics

Property Information

Initial Level of Interest