Attachment XI Housing Shuttle Form Short Pricing

Consumer Price Index Update Form: Housing
BLS Contact:	<Enter Name>
Contact Phone:	<Enter Phone>
Contact Fax:	<Enter Fax>
Contact Email:	<Enter Email>
Last time contacted:	<Enter Date of Last Time Collected in CI>
Please Return Form By:	<Add Date>
Number of Units:	1
Address:
			(if applicable) Unit:
Tenant Name OR Initials					<Enter Name of Occupant>
Is the occupancy the same, different, or vacant since					<Select One>
When did the person, who has lived in this house the longest, move in?					<Enter Date>
Is this unit occupied by the owner or is it rented?					<Select>
Do you/Does the tenant have a lease or other rental agreement?					<Select Yes or No>
If Yes, How long is the current lease agreement?					<Select>
If 12-months or any other length of time, “In what month and year did the current lease start?”					<Enter Month and Year>
How much rent is the tenant paying for this house now?					<Enter Amount>
What period of time does that rent cover?					<Select>
Is the rent lower because the Landlord receives a subsidy from the government such as Section 8?					<Select Yes or No>
If Yes, how much was the subsidy?					<Enter Amount>
Is the rent lower because someone did work for the landlord?					<Select Yes or No>
If Yes, how much was the work reduction?					<Enter Amount>
			Total Rent:		$-
Does this rent include any optional extra charges?					<Select Yes or No>
If Yes, what are they and how much is each one?					<Enter Text and Amount>
Since , has there been any changes to who pays the Utilities? This includes, water, sewer, electricity, air conditioning, heating, and hot water.					<Select Yes or No>
If the building/structure is a multi-unit, how many units are in the building?					<Enter Number of Units>
If the building/structure is a multi-unit, is there an elevator?					<Select Yes or No>
Additional Information:
Respondent Comments: