Head of Household Demographic Information
Instructions: This form is to be completed by the head of household only after occupancy has been approved. 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 is to be completed by the owner/agent.
Property Name:      	Unit #:      
Head of Household Information This section is to be completed by the head of household.
Name:      
Date of Birth (MM/DD/YYYY):      /     /     
Table 1: Head of Household Demographic Information
Item/Question	Response	
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
 Native Hawaiian/Other Pacific Islander
 Native Hawaiian	 Guamanian or Chamorro
 Samoan	 Other Pacific Islander
 Asian
 Chinese	 Asian Indian	 Filipino	 Japanese
 Korean	 Vietnamese	 Other Asian
 White
 Black/African American
 I choose not to respond	
Age of household members	      Adults (including head of household) residing in unit
      Children under age 18 residing in unit	
Is any member mobility impaired?	 Yes
 No
 I choose not to respond	
Is any member a person with a disability other than mobility impairment?	 Yes
 No
 I choose not to respond	
Main source of household income (check only one)	 Salary/wages	 Alimony/child support
 Self-employment	 Unemployment/disability
 Social Security	 Public assistance
 Retirement/pension/annuity	 No income
 Interest/dividends/rental income