Full Name

ATTACHMENT A: Survey Questions List every member in the household? Date of Birth Place of Birth

Maiden Name

Physical Address

Box Number

Email Address

1. How many people are living or staying in this house, apartment or mobile home today? Count the total number of persons who usually live here, whether they are members of the same or different families. For example, a housing unit with three families residing in it is counted as one household, NOT three. INCLUDE in this number: Foster children, roomers, or housemates People staying here today who have no other permanent place to stay People living here most of the time while working, even if they have another place to Children in boarding schools below the college level DO NOT INCLUDE in this number: College students living away while attending college People currently in a correctional facility, nursing home, or mental hospital Persons in the Armed Forces who live somewhere else People who live or stay at another place most of the time Total number of persons

2a. What is the race of EACH person indicated above? Please tell us if each household member identifies themselves as American Indian or Alaska Native, that is, AIAN either alone or in combination with other races? Other races include: White; Black, African American or Negro; Asian Indian; Chinese; Filipino; Japanese; Korean; Vietnamese; Other Asian; Native Hawaiian; Guamanian or Chamorro; Samoan; other Pacific Islander; or some other race. Persons in AIAN Alone AIAN in combination NOT AIAN other race Household with other races only Check ONE response for each person in household. Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 6 Person 7

2b. How many of the people living in your household are enrolled members of Native Village of Eyak? Number of enrolled members of this tribe 3. Does the head of household and/or their spouse identify themselves as an AIAN person either alone or in combination with other races? The head of household is the person in whose name this house or apartment is owned, being bought, or rented. Check YES if EITHER the head of household or his/her spouse is AIAN either alone or in combination with other races. Other races include: White; Black, African American or Negro; Asian Indian; Chinese; Filipino; Japanese; Korean; Vietnamese; Other Asian; Native Hawaiian; Guamanian or Chamorro; Samoan; other Pacific Islander; or some other race. YES, AIAN alone YES, AIAN in combination with other races

4. How many rooms do you have in THIS house, apartment, or mobile home? In addition to bedrooms,
count all whole rooms used for living purposes such as living rooms, dining rooms, kitchens, recreation rooms, rooms in a finished basement, enclosed porches that can be used year-round, lodgers rooms and any other finished rooms. DO NOT count bathrooms, unenclosed porches, balconies, foyers, halls or half-rooms. Total Number of Rooms_______

5. Do you have COMPLETE plumbing facilities in THIS house, apartment, or mobile home; that is,

a) hot and cold piped water, b) a flush toilet, and c) a bathtub or shower?
_____ YES, have all three facilities NO

6. Do you have COMPLETE kitchen facilities in THIS house, apartment, or mobile home; that is a) a
sink with piped water, b) a range or stove, and c) a refrigerator? _____ YES, have all three facilities NO

7. What are the ANNUAL costs of utilities and fuels for THIS house, apartment, or mobile home?
If you have lived here less than one year, estimate the annual cost.

a. Electricity
$ Annual Cost Dollars

OR Included in rent or in condominium fee No charge or electricity not used

b. Gas
$ OR Included in rent or in condominium fee No charge or gas not used Annual Cost Dollars

c. Water and sewer

$ OR Included in rent or in condominium fee No charge Annual Cost Dollars

d. Oil, coal, kerosene, wood, etc.

$ OR Included in rent or in condominium fee No charge or these fuels not used Answer question 8 only if you pay rent for THIS house, apartment or mobile home. All others skip to question 9a. 8. What is the monthly rent? $ Monthly Amount in Dollars Annual Cost Dollars

Answer questions 9a to 9d if you or someone in this household owns or is buying THIS house, apartment or mobile home. Otherwise skip to question 15. 9a. Do you have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property? YES, mortgage, deed of trust or similar debt YES, contract to purchase NO Skip to question 10a

9b. How much is your regular monthly mortgage payment on THIS property? Include payment only on first mortgage or contract to purchase. $ Monthly Amount OR No regular payment required Skip to question 10a

9c. Does your regular monthly mortgage payment include payment for real estate taxes on THIS property? YES, taxes included in mortgage payment NO, taxes paid separately or taxes not required

9d. Does your regular monthly mortgage payment include payment for fire, hazard, or flood insurance on THIS property? YES, insurance included in mortgage payment NO, insurance paid separately or no insurance 10a. Do you have a second mortgage or a home equity loan on THIS property? Mark all that apply. YES, a second mortgage YES, a home equity loan NO Skip to question 11 10b. How much is your regular monthly mortgage payment on all second or junior mortgages and all home equity loans on THIS property? $ Monthly Amount Dollars OR No regular payment required

11. What were the real estate taxes on THIS property last year?
$ Monthly Amount Dollars OR No regular payment required

12. What was the annual payment for fire, hazard, and flood insurance on THIS property?
Annual Amount Dollars OR No regular payment required

Answer question 13 only if this is a condominium.

13. What is the monthly condominium fee?

$ Monthly Amount Dollars

Answer questions 14a and 14b only if this is a mobile home. 14a. Do you have an installment loan or contract on THIS mobile home? YES ____NO Skip to question 15

14b. What was the total cost for installment loan payments, personal property taxes, site rent, registration fees, and license fees for THIS mobile home and its site last year? Exclude real estate taxes. $_________Yearly Amount Dollars ASK EVERYONE QUESTION 15
Family of 1: below 16,300 [__] above 16,300 but below 27,150 [__] above 27,150 but below 43,400 [__]above 43,000 Family of 2: below 18,600 [__] above 18,600 but below 31,000 [__] above 31,000 but below 49,600 [__] above 49,600 Family of 3: below 20,950 [__] above 20,900 but below 34,900 [__] above 34,900 but below 55,800 [__] above 55,800 Family of 4: below 23,250 [__] above 23,250 but below 38,750 [__] above 38,500 but below 62,000 [__] above 62,000 Family of 5: below 25,150 [__] above 25,150 but below 41,850 [__] above 41,850 but below 67,000 [__] above 67,000 Family of 6: below 27,000 [__] above 27,000 but below 44,950 [__] above 44,950 but below 71,950 [__] above 71,950 Family of 7: below 28,850 [__] above 28,850 but below 48,050 [__] above 48.050 but below 76,900 [__] above 76,900

16. What water leak incidents have occurred within the past year?
a. b. c. d. e. f. Windows Leaked? Plumbing Leaks? Roof Leaks? Flooding? Basement Flooding? Sewage Backups? [ ]Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ]Yes [ ] No [ ] Yes [ ] No

17. Are all the bathrooms, shower rooms, and dryers vented to the outside?
[ ] Yes [ ] No

18. Does the home or has the home ever contained visible mold growth?
[ ] Yes [ ] No

19. Has an Indoor Air Quality (IAQ) or mold assessment been performed in the past year?
[ ] Yes [ ] No

20. Have you noticed any musty odors in the home?

[ ] Yes [ ] No

21. What type of heating system is in your home? ______________________________ 22. What type of fuel do you use to heat your home?
[ ] Oil [ ] Gas [ ] Wood [ ] Electric

23. What are the transportation problems in Cordova?

Rank from highest to lowest priority. 1 being highest 5 being lowest. [ ] Lack of Enforcement [ ] Lack of Traffic Signs [ ] Lack of Driver Education [ ] Road Surface Conditions

[ ] Lack of Sidewalk/non-motorized pathways [ ] Other Safety Issue: Please explain

24. Do you own a running vehicle? 25. How many running vehicles do you own? 26. Do you own a boat? 27. Do you own an ATV? 28. Do you own a snow machine? 29. What other modes of transportation do you use in Cordova? 30. How often do you use alternative modes of transportation? 31. How far do you drive to/from work each day? 32. Have you been in any transportation accidents in or around Cordova?
If so, where did the accident occur? __________________________________________________

33. Do you have health insurance?

[ ] Yes [ ] No

34. What type of health insurance do you have?

[ ] Private [ ] Employer [ ] Spouse Employer [ ] Medicaid [ ] Medicare

35. What type of assistance would be most beneficial for your household?
_____________________________________________________