Time in
Time out
Gender
e-mail
Main causes
curiosity
Rental house
House ownership
House Maintenance
Problem with landlord
Problem with tenant
Problem with neighbor
Emergency house
Others
Other
Details of issues
Treat
Age group
0-17
18-29
30-39
40-49
50-59
60-69
70 years or older
marital status
single, never married
Married or domestic partnership
Widowed
Divorced
Saperated
Employment status?
Employed for wages
Self-employed
Out of work and looking for work
Out of work but not currently looking for work
A homemaker
A student
Retired
Unable to work
Other
Which income group does your household fall under?
Less than $20,000
$21,000 – $30,000
$31,000 to $40,000
$41,000 to $50,000
$51,000 to $60,000
Above $60,000
Other
What date is today?
Contact Phone Number
Thank you
Thank you