Visions Five Group
Mutual Self-Help Rural Housing Survey
http://www.oocities.org/visionsfive/selfhelpquest.html
A Mutual Self-Help Housing Program is being considered for rural Davidson County. You could own your own custom built home by participating in this program. The first step for participation in this program is to complete and file this questionnaire.

1. Name:____________________________________________________________

2. Permanent Address

Street:_______________________________________________________________

Rt./P.O. Box Number: __________________________________________________

City/State/Zip: ________________________________________________________

Telephone: ____________________

E-mail (if any) __________________

3. What age group are you in? 62 or Over ___ 50-61 ___ 35-49 ___ 25-35___ 18-25 ___

4. Number of persons in your household ___________

Number of Adults __________ Males __________ Females _________

Number of Children ________ Males __________ Females _________

5. Are any members of your household handicapped or impaired and in need of specially designed housing arrangements?

Yes _____ No _____ (If "Yes," please describe)

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

6. What was the total combined annual income for all members of your household in 2000? Include all sources (wages, Social Security, pensions, public assistance, investments, etc.)

$ 5,000 - 10,000 _____ $10,000 - 15,000 _____ $15,000 - 20,000 _____
$20,000 - 25,000 _____ $25,000 - 30,000 _____ Over $30,000 _____

7. Where do you presently live?:

House _____ Apartment _____ Mobile Home _____ Room _____ Other _____

8. Do you Own _____ Rent _____?

9. Describe your present housing condition:
Adequate ______ Delapidated _____ Over Crowded ______ Other_____

10. Are you interested in home ownership? Yes _____ No ______

Have you ever tried to buy a house? Yes _____ No ______

Have you owned a house in the last 3 years? Yes _____ No ______

11. Would you be willing to help build your house to help reduce your cost?

Yes _____ No ______

12. Would you be willing to join a group of families building their houses together?

Yes _____ No ______

13. What is your monthly rent or mortgage payment? __________

14 If this program is started, would you like to be notified?

Yes _____ No ______

15. What is the biggest housing problem in your town/county?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Signature of applicant______________________________Date_______________,2004

Print this form, complete, and return to:

Bishop A. E. Harris
Abundant Living Community Outreach

and Non-Profit Housing Corp.
2597 White's Creek Pike
Nashville TN 37207
615 226 1717 ext 3
bishopaeharris@comcast.net

or

Carl Wright, CEO
Visions Five Group
1908 21st Ave N
Nashville TN 37212
615 383 3042
visionsfive@yahoo.com

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"Together We Can"