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* 1. What is the name of the Street that you live on?

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* 2. What ZIP Code do you live in?

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* 3. What is your gender?

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* 4. What is your race? Please choose all that apply.

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* 5. What is your Ethnicity?

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* 6. What is your age group?

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* 7. How many people are living in your household?

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* 8. Check the appropriate box which reflects your approximate total yearly household income:

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* 9. What is your living situation?

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* 10. Does the housing supply need any of the following: Please check all that apply:

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* 11. Are there any other housing issues in the Borough of Chambersburg? Please list:

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