Brookland Lakeview
First Name
Last Name
Email
Address
City
State(Optional)
Zip`
County
Ethnicity and Race
Race American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderTwo or moreWhiteOther
Total number of persons living in household (optional)
Number of Elderly in household – 62 years & older (optional)
Number of Disabled persons in household (optional)
Female Head of household (optional)
Number of Children under 7 years of age (optional)
Number of Children between 7-17 years of age (optional)
Household Size 1 Person2 Persons3 Persons4 Persons5 Persons6 Persons7 Persons8 Persons
Does your house have a working stove? YesNo
Does your house have a working water? YesNo
Does your house have connection to public water? YesNo
Does your house have hot water? YesNo
Do you own or rent? YesNo
Age of House:
All information is strictly confidential. Applicants should be aware that additional questions may be asked.
