ࡱ> uwt Mbjbj x^xx n  SSSSSggg8tg $f`lr#t#t#t#t#t#t#q%(t#QS"""t#SS#""""FSSr#""r#"""@MCghj"^##0 $"(("(S"""""""""t#t#f D""" $""""(""""""""" : CERTIFICATION: Relocation Dwelling  Decent, Safe & Sanitary (DSS)  FORMTEXT   Project Name:  FORMTEXT      Contract No.:  FORMTEXT      Names of Displaced Occupants:  FORMTEXT      Relocation Case No. (if applicable):  FORMTEXT        FORMCHECKBOX 180 Day Owner  FORMCHECKBOX 90 Day OccupantDisplacement (from) Dwelling Address (include unit #)  FORMTEXT       Phone:  FORMTEXT      Acquisition Parcel No. (if applicable)  FORMTEXT        FORMCHECKBOX Owned  FORMCHECKBOX RentedReplacement (to) Dwelling Address (include unit #):  FORMTEXT       Phone:  FORMTEXT        FORMCHECKBOX Owned  FORMCHECKBOX RentedReplacement Dwelling Type:  FORMCHECKBOX Single Family  FORMCHECKBOX Apartment  FORMCHECKBOX Hotel Room/Dorm  FORMCHECKBOX Condo/Co-op  FORMCHECKBOX Mobile Home ID/Tag No.:  FORMTEXT      INSPECTION REPORT Does the replacement dwelling conform with the following standards for Decent, Safe, and Sanitary Housing? FORMTEXT   YES FORMTEXT  NO FORMTEXT  N/A FORMTEXT  DSS Standard/ Criterion FORMTEXT   FORMCHECKBOX  FORMCHECKBOX 1. Conforms to all local housing and occupancy codes? (Is adequate in size with respect to the number of rooms and area of living space to accommodate the displaced person(s). Number of persons occupying each habitable room used for sleeping purposes shall not exceed that permitted by local housing codes.) FORMCHECKBOX  FORMCHECKBOX 2. Structurally sound, weather tight, and in good repair? FORMCHECKBOX  FORMCHECKBOX 3. Contains a heating (HVAC) system able to maintain 70 Fahrenheit in living area? FORMCHECKBOX  FORMCHECKBOX 4. Adequate, safe electrical wiring system? FORMCHECKBOX  FORMCHECKBOX 5. Bathroom facilities: Separate, well lighted & ventilated, sink, bathtub/shower, and toilet? (private, hot/cold water to sink, shower/tub, sewer connection, flush toilet water closet all in working order.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6. 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FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8. Can property accommodate a disabled person, free of barriers? If  No, describe improvements needed to eliminate property barriers to free ingress, egress, or use of property as required to accommodate disabled person(s) prior to occupancy. FORMTEXT      CERTIFICATION  FORMCHECKBOX I CERTIFY, TO THE BEST OF MY KNOWLEDGE, BASED ON VISUAL INSPECTION OF THE PROPERTY, THE REPLACEMENT DWELLING MEETS THE STANDARDS FOR DECENT, SAFE, AND SANITARY HOUSING, BOTH ACCORDING TO LOCAL HOUSING CODES AND IN 49 CFR PART 24 FOR FEDERALLY-ASSISTED PROJECTS.  FORMCHECKBOX I CERTIFY THAT THE DWELLING DOES NOT PRESENTLY CONFORM TO DSS REQUIREMENTS, BUT CAN BE MADE TO CONFORM BY ACCOMPLISHING THE FOLLOWING MODIFICATIONS PRIOR TO PURCHASE AND OCCUPANCY. (Attach pages if necessary.)  FORMTEXT       INSPECTOR/AGENT: Print name:  FORMTEXT       Signature: FORMTEXT   Date: FORMTEXT           TDHCA  Program Services  URA Compliance  SAVEDATE \@ "M/d/yyyy" \* MERGEFORMAT 9/13/2012 DDDDDDDDDDDDDEEEEEFF G GGGGG:G*CJaJ%jhp>*CJUaJmHnHu j9hp>*CJUaJhp>*CJaJjhp>*CJUaJhh"CJhh=H56CJji8hpCJU hpCJjhpCJUhh0MCJhh=H5CJhh=HCJ:GhI0KXKZK|K*L.L0L4L6L:L*CJUhh2gCJhh>*CJ$jh.fh.fCJUmHnHuj;h.fh.fCJUh.fh.fCJjh.fh.fCJUhhCJ h_v1>*CJ!jh.f>*CJUmHnHuj:h.f>*CJU h.f>*CJjh.f>*CJU2L6L8LLBLLLLLLMMMMhh=HCJhc)mHnHujhc)Uhc)jhX8=UhX8=MM 0\ !)x*$gd_v1v+p,p-p.p/R!4567:p_v1/ =!"#$% DText17BCERTIFICATION: Relocation Dwelling  Decent, Safe & Sanitary (DSS)D Project Name:DContract No.: $$If!vh55#v#v:V l t0655/ ythDText5Names of Displaced Occupants:DText6$Relocation Case No. (if applicable):De 180 Day OwnerDe90 Day Occupant$$If!vh55#v#v:V l t0655/ ythDText85Displacement (from) Dwelling Address (include unit #)~DText9PhoneDText10&Acquisition Parcel No. (if applicable)rDeOwnedtDeRented$$If!vh55#v#v:V l t0655/ ytWDText73Replacement (to) Dwelling Address (include unit #):vDPhone:rDeOwnedtDeRentedDeCheck6(Replacement Dwelling Type: Single FamilyDe$Replacement Dwelling Type: ApartmentDe*Replacement Dwelling Type: Hotel Room/DormDe&Replacement Dwelling Type: Condo/Co-opDe&Replacement Dwelling Type: Mobile HomeDText12 ID/Tag No.:$$If!vh55#v#v:V l t0655/ ytWpDText18}INSPECTION REPORT Does the replacement dwelling conform with the following standards for Decent, Safe, and Sanitary Housing?DText19Yes (column heading)DText20NO (column heading)DText21%N/A - Not applicable (column heading)DText22(DSS Standard/ Criterion (column heading)$$If!vh55v5v5:##v#vv#v:#:V l4 t0655v5:#ythDCheck5space to accommodate the displaced person(s). Number of persons occupying each habitable room used for sleeping purposes shall not exceed that permitted by local housing codes.)Yes. 1. Conforms to all local housing and occupancy codes? (Is adequate in size with respect to the number of rooms and area of livingDspace to accommodate the displaced person(s). Number of persons occupying each habitable room used for sleeping purposes shall not exceed that permitted by local housing codes.)No. 1. Conforms to all local housing and occupancy codes? (Is adequate in size with respect to the number of rooms and area of living$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0De?Yes. 2. Structurally sound, weather tight, and in good repair?De>No. 2. Structurally sound, weather tight, and in good repair?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0DeYYes. 3. Contains a heating (HVAC) system able to maintain 70 Fahrenheit in living area?DeXNo. 3. Contains a heating (HVAC) system able to maintain 70 Fahrenheit in living area?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0De1Yes. 4. Adequate, safe electrical wiring system?De0No. 4. Adequate, safe electrical wiring system?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0Dr(private, hot/cold water to sink, shower/tub, sewer connection, flush toilet water closet  all in working order.)dYes. 5. Bathroom facilities: Separate, well lighted & ventilated, sink, bathtub/shower, and toilet?Dr(private, hot/cold water to sink, shower/tub, sewer connection, flush toilet water closet  all in working order.)cNo. 5. Bathroom facilities: Separate, well lighted & ventilated, sink, bathtub/shower, and toilet?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0D}(hot/cold water to sink, connected to sewer, range/ stove and refrigerator space & utility connections, all in working order)5Yes. 6. Kitchen facilities conform to DSS standards?D}(hot/cold water to sink, connected to sewer, range/ stove and refrigerator space & utility connections, all in working order)4No. 6. Kitchen facilities conform to DSS standards?DeCheck3@Not applicable. 6. Kitchen facilities conform to DSS standards?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0DeVYes. 7. Has adequate unobstructed access/ egress to safe, open space at ground level?DeUNo. 7. Has adequate unobstructed access/ egress to safe, open space at ground level?$$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0DeFYes. 8. Can property accommodate a disabled person, free of barriers?DeENo. 8. Can property accommodate a disabled person, free of barriers?DeCheck4QNot applicable. 8. Can property accommodate a disabled person, free of barriers?DText12accommodate disabled person(s) prior to occupancy.If  No, describe improvements needed to eliminate property barriers to free ingress, egress, or use of property as required to $$If!vh55v5v5:##v#vv#v:#:V l t0655v5:#ytK0|DCheck1FOR DECENT, SAFE, AND SANITARY HOUSING, BOTH ACCORDING TO LOCAL HOUSING CODES AND IN 49 CFR PART 24 FOR FEDERALLY-ASSISTED PROJECTS.I CERTIFY, TO THE BEST OF MY KNOWLEDGE, BASED ON VISUAL INSPECTION OF THE PROPERTY, THE REPLACEMENT DWELLING MEETS THE STANDARDS~DeCheck2I CERTIFY THAT THE DWELLING DOES NOT PRESENTLY CONFORM TO DSS REQUIREMENTS, BUT CAN BE MADE TO CONFORM BY ACCOMPLISHING THE FOLLOWING DText2LMODIFICATIONS PRIOR TO PURCHASE AND OCCUPANCY. 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