Corps of Engineers Civil Works Questionnaires Generic Clearance

RESIDENTIAL CONTENTS SURVEY

(Personal Interview or Mail Survey)

OMB 0710-0001

Expires: 30 September 2012

The public report burden for this information collection is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this data collection, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, and the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503, Attn.: Desk Officer for U.S. Army Corps of Engineers. Respondents should be aware that notwithstanding any other provision of law, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Please DO NOT RETURN your completed form to either of these offices.

RESIDENTIAL CONTENTS SURVEY

INVENTORY INSTRUCTIONS:

Most pages of this questionnaire are designed for you to do a thorough inventory of the contents of your home. Contents are items within your home or garage which are not permanently attached to the building.

The simplest way for you to complete this inventory is to walk through the room to which each page applies. For each type of item listed on a page:

1	AND EITHER		2	OR	3
Indicate how many pieces of each item there are in the room(s) to which the page applies.		Indicate the total current cash value for each item. Current cash value is the current cost of replacing an item, minus whatever value the item has lost from deterioration.			Indicate total replacement costs, if you were to purchase the item now.	Indicate the approximate average age of each item.

The information you provide does not have to be absolutely precise. If in doubt, make your best guess. Be sure to fill out each page which lists items found in your house. Most types of items will be listed on only one page. If an item you own is listed on a room page different from the room where the item is found in your house, put the value and age for the item on that page.

After you complete the inventory sheets, please answer the final background questions and mail back our questionnaire. DON'T FORGET TO TEAR OUT THE YELLOW COPIES TO KEEP WITH YOUR INSURANCE RECORDS.

Your participation in this survey is voluntary and you may refuse to give any or all of the requested information.

LIVING ROOM For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Unattached Bookcases				Years
	Books				Years
	Couches/Sofas				Years
	Chairs				Years
	Tables				Years
	Lamps				Years
	Curtains/Drapes				Years
	Unattached Carpets/Rugs				Years
	Television Sets				Years
	Stereo Equipment				Years
	VCR Equipment				Years
	Video Tapes				Years
	Records/CDS/Cassettes				Years
	Pictures				Years
	Television Sets				Years
	Antiques				Years
	Pianos				Years
	Window Air Conditioner				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

DINING ROOM For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Unattached Buffet/Bar				Years
	Chairs				Years
	Tables				Years
	Unattached China Cabinets				Years
	China				Years
	Glassware				Years
	Silverware				Years
	Curtains/Blinds/Drapes				Years
	Linens				Years
	Unattached Carpets/Rugs				Years
	Pictures				Years
	Tables				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

KITCHEN AND PANTRY For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Fresh Food				Years
	Canned Food				Years
	Frozen Food				Years
	Liquor				Years
	Freezers				Years
	Refrigerators				Years
	Range/Stove				Years
	Microwave Ovens				Years
	Portable Dishwashers				Years
	Portable Trash compactor				Years
	Chairs				Years
	Tables				Years
	Dishes & Crockery				Years
	China				Years
	Glassware & Crystal				Years
	Silverware				Years
	Knives/Other Utensils				Years
	Pans & Cooking Ware				Years
	Appliances (Mixer, etc)				Years
	Desks/File Cabinets				Years
	Lamps				Years
	Curtains/Drapes				Years
	Other				Years

DEN, OFFICE, LIBRARY OR FAMILY ROOM For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Unattached Bookcases				Years
	Books				Years
	Couches/Sofas				Years
	Chairs				Years
	Tables				Years
	Desks/File Cabinets				Years
	Lamps				Years
	Curtains/Drapes				Years
	Unattached Carpets/Rugs				Years
	Unattached Bar				Years
	Television Sets				Years
	Videotapes/VCR Equipment				Years
	Stereo Equipment				Years
	Records/CDS/Cassettes				Years
	Computer Hardware				Years
	Computer Software				Years
	Pictures				Years
	Sewing Machine				Years
	Typewriters				Years
	Window Air Conditioner				Years
	Other				Years
	Other				Years

LAUNDRY, BASEMENT, AND GARAGE ITEMS For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Chairs				Years
	Tables				Years
	Clothes Dryer				Years
	Clothes Washer				Years
	Ironing Equipment				Years
	Freezer				Years
	Refrigerator				Years
	Luggage				Years
	Hand Tools				Years
	Power Tools				Years
	Lawn & Garden Tools				Years
	Work Bench				Years
	Barbecue Equipment				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

BEDROOMS For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Beds				Years
	Box Springs/Mattresses				Years
	Bedding/Bedspreads				Years
	Chest of Drawers				Years
	Dressing Tables				Years
	Night Tables				Years
	Other Tables				Years
	Lamps				Years
	Chairs				Years
	Curtains/Drapes				Years
	Unattached Rugs				Years
	Pictures				Years
	Trunks (Hope Chests)				Years
	Television Sets				Years
	Window Air Conditioner				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

MEN’S CLOTHING For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Ties/Neckwear				Years
	Coats and Jackets				Years
	Raincoats				Years
	Pants				Years
	Shirts				Years
	Suits				Years
	Sweaters				Years
	Underwear				Years
	Robes				Years
	Socks				Years
	Shoes and Boots				Years
	Jewelry				Years
	Belts				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

WOMEN’S CLOTHING For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Coats and Jackets				Years
	Raincoats				Years
	Dresses				Years
	Pants & Slacks				Years
	Skirts				Years
	Blouses & Shirts				Years
	Suits				Years
	Sweaters				Years
	Robes				Years
	Underwear				Years
	Socks/Stockings				Years
	Shoes and Boots				Years
	Handbags/Purses				Years
	Hats				Years
	Jewelry				Years
	Scarves				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

CHILDREN’S CLOTHING For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Coats and Jackets				Years
	Raincoats				Years
	Dresses				Years
	Pants				Years
	Skirts				Years
	Blouses/Shirts				Years
	Suits				Years
	Sweaters				Years
	Sportswear				Years
	Underwear				Years
	Socks/Stockings				Years
	Shoes and Boots				Years
	Jewelry				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

SPORTS, RECREATION, AND HOBBY ITEMS KEPT IN RESIDENCE For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	Billiard Table				Years
	Camping Equipment				Years
	Fishing Tackle				Years
	Games				Years
	Golf Equipment				Years
	Skiing Equipment				Years
	Guns/Hunting Equipment				Years
	Musical Instruments				Years
	Photography Equipment				Years
	Sewing Machine				Years
	Tennis Equipment				Years
	Bicycles				Years
	Exercise Equipment				Years
	Toys				Years
	Collections (Coins, etc)				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years
	Other				Years

BATHROOM ITEMS, MEDICAL APPLIANCES, AND MISCELLANEOUS ITEMS For ALL such items, please give: (1) the total number of pieces, AND EITHER (2) the total current cash value, OR (3) the total replacement cost, and average age.
(1)		(2)	(3)
Total No. of Pieces		Total Current Cash Value	Total Replacement Costs	Average Age
	BATHROOM ITEMS
	Medication				Years
	Hygiene Items				Years
	Towels				Years
	Bathroom Appliances				Years
	Cosmetics/Perfumes				Years
	Other				Years
	MEDICAL APPLIANCES
	Wheelchairs				Years
	Walkers				Years
	Other				Years
	MISCELLANEOUS ITEMS
	Art Work				Years
	Indoor Plants				Years
	Telephones				Years
	Curtains/Drapes/Blinds				Years
	Luggage				Years
	Briefcases				Years

BACKGROUND QUESTIONS

Please fill in the following background questions circling the appropriate number and filling in the blanks.

Q1. From the list below, please circle the number in front of the type of building that most closely matches your residence.

(CIRCLE ONE NUMBER)

1. SINGLE FAMILY

2. LOW-RISE MULTIPLE FAMILY

(3 STORIES OR LESS)

3. MID- AND HIGH-RISE MULTIPLE

FAMILY (4 OR MORE STORIES)

4. TOWNHOUSE, END UNIT

5. TOWNHOUSE, INSIDE UNIT

6. DUPLEX

7. MOBILE HOME

Q2. From the list below, please circle the number of the building style that most closely matches the style of this residence.

(CIRCLE ONE NUMBER)

1. ONE STORY

2. TWO STORY

3. THREE STORIES

4. SPLIT LEVEL

5. 1 STORY (WITH THE  FINISHED)

6. 1 STORY (UNFINISHED )

7. 2 STORY (WITH THE  FINISHED)

8. 2 STORY (UNFINISHED )

9. 3 STORY (WITH THE  FINISHED)

10. 3 STORY (UNFINISHED )

11. BI-LEVEL (2 STORY WITH 1ST FINISHED)

12. OTHER (Please Explain):

____________________________________________________________________

Q3. From the list below, please circle the number of the heating and/or cooling system that most closely matches the system installed in this home.

(CIRCLE ONE NUMBER)

Heating Only:

1. FORCED AIR 6. CEILING, RADIANT ELECTRIC

2. GRAVITY FURNACE 7. BASEBOARD, ELECTRIC

(HOT AIR, NO FAN) 8. BASEBOARD, HOT WATER

3. FLOOR FURNACE 9. RADIATORS, HOT WATER

(NO HEAT DUCTS) 10. RADIATORS, STEAM

4. WALL FURNACE 11. WARMED AND COOLED AIR

(NO HEAT DUCTS) 12. HEAT PUMP SYSTEM

5. FLOOR, RADIANT HOT WATER

Cooling Only:

13. EVAPORATIVE WATER COOLER (SINGLE OR SHORT DUCTS)

14. REFRIGERATED, WITH CONDENSER AND DUCTS

Q4. From the list below, please circle the number of the type of exterior wall covering that best matches most of

the exterior of this home.

(CIRCLE ONE NUMBER)

1. PLYWOOD 6. MASONRY VENEER

2. HARDBOARD SHEETS 7. COMMON BRICK

3. STUCCO 8. FACE BRICK

4. SIDING 9. STONE

5. SHINGLE 10. CONCRETE BLOCK

Q5. From the list below, please circle the number of the roofing type that most closely matches the roof of this home.

(CIRCLE ONE NUMBER)

1. COMPOSITION SHINGLE 6. CLAY TILE

2. BUILT-UP ROCK 7. GALVANIZED METAL

(EMBEDDED IN ASPHALT 8. SLATE

3. WOOD SHINGLE 9. COMPOSITION ROLL

4. WOOD SHAKE 10. PLASTIC TILE

5. CONCRETE TILE

Q6. How many bathrooms OF THE FOLLOWING TYPES are there in this home?

There are: _____ FULL BATHS (SINK, TOILET, AND TUB, WITH OR WITHOUT SHOWER)

There are: _____ 3/4 BATHS (SINK, TOILET, AND SHOWER)

There are: _____ BATHS (SINK, AND TOILET)

Q7. Please give the total square feet of finished floor area for floor area for all rooms in this home, not including the basement.

(GIVE YOUR VERY BEST ESTIMATE)

AREA NOT INCLUDING BASEMENT: ______ SQUARE FEET

Q8. Please give the total square feet of floor area for the basement in this home.

(GIVE YOUR BEST ESTIMATE)

TOTAL BASEMENT AREA: ________ SQUARE FEET

FINISHED BASEMENT AREA: ________ SQUARE FEET

Q9. Please circle all of the home features listed below that apply to this home:

(CIRCLE ALL THAT APPLY)

1. ATTACHED GARAGE 5. UNFINISHED BASEMENT AREA

2. DETACHED GARAGE 6. FINISHED BASEMENT AREA

3. BUILT-IN GARAGE 7. OPEN SLAB PORCH

4. CARPORT 8. FIREPLACE

Q10. What year was your home built? _______

Q11. How many years have you lived at this address? _____ years

Q12. How many people live at this residence? ______ people

Q13. Do you own this home? (CIRCLE)

1. YES 2. NO

Q14. If you own this home, how much would it be worth if it were to be sold in the real estate market today?

(YOUR BEST GUESS)

$________________

Q15. What is your zip code? _________

Q16. What is the marital status of the principal wage earner of this household?

(CIRCLE ONE NUMBER)

1. SINGLE

2. MARRIED

3. WIDOWED

4. DIVORCED OR SEPARATED

5. OTHER

Q17. What was the age of the principal wage earner of this household on his/her last birthday?

________ YEARS OLD

Q18. Please indicate which group represents your total pre-tax household income for last year? Please circle one box.

Less than $10,000	$50,000-$74,999
$10,000-$14,999	$75,000-$99,999
$15,000-$24,999	$100,000-$149,999
$25,000-$34,999	$150,000-$199,999
$35,000-$49,999	$200,000 or more

THANK YOU FOR YOUR COOPERATION

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