Instructions: This form is to be completed by the head of household and additional household members only after occupancy has been approved. Head of household, please complete page 1. Make copies as needed, and complete a separate page 2 for each additional household member. 

Your approval for occupancy will not be affected if you choose not to respond. The owner will submit this information to Minnesota Housing for assessment of households being served by its financing programs. Your cooperation is much appreciated.

Housing Information (this section to be completed by owner/agent)	
Property Name	     	
Minnesota Housing D#	     	
Building Address 	     	
Unit #	     	

Head of Household Information	
Name	     	
Date of birth (month/day/year)	     /     /     	
Ethnicity	 Hispanic or Latino
 Not Hispanic or Latino
 I choose not to respond	
Gender	 Female
 Male
 I choose not to respond	
Race 
(check all that apply)	 American Indian/Alaska Native
 Asian                 
 Black/African American		 Native Hawaiian/
      Other Pacific Islander 
 White			
 I choose not to respond	
Are you mobility impaired and requiring features of an accessible unit?	 Yes   
 No  
 I choose not to respond	
Do you have a disability other than mobility impairment?	 Yes  
 No  
 I choose not to respond	
Main source of household income (check only one)	 Salary/wages 
 Self-employment
 Social Security
 Retirement /pension/annuity
 Alimony/child support	 Interest/dividends/rental income
 Unemployment/disability 
 Public assistance
 No income	

Instructions:  Complete a separate page 2 for each household member that is not the Head of Household.  Parents or guardians, please complete the form for your minor child(ren).

Your approval for occupancy will not be affected if you choose not to respond. The owner will submit this information to Minnesota Housing for assessment of households being served by its financing programs. Your cooperation is much appreciated.

Housing Information (this section to be completed by owner/agent)	
Property Name	     	
Building Address:	     	
Unit #	     	

Household Member Information	
Name	     	
Date of birth (month/day/year)	     /     /     	
Ethnicity	 Hispanic or Latino
 Not Hispanic or Latino
 I choose not to respond	
Gender	 Female
 Male
 I choose not to respond	
Race
 (check all that apply)	 American Indian/Alaska Native
 Asian                 
 Black/African American		 Native Hawaiian/
      Other Pacific Islander 
 White			
 I choose not to respond	
Are you mobility impaired and requiring features of an accessible unit?	 Yes   
 No  
 I choose not to respond	
Do you have a disability other than mobility impairment?	 Yes  
 No  
 I choose not to respond