ASSISTED LIVING INCOME AND EXPENSE QUESTIONNAIRE
INCOME QUESTIONNAIRE FOR 36 MONTHS NAME AND LOCATION OF PROPERTY FROM ___2006___TO _ __2008___ OWNER AND ADDRESS OF RECORD
RENT SCHEDULES:
Efficiency 1 Bedroom 2 Bedroom # UNITS __________ __________ __________ __________ __________ BATH/UNIT ___________ ___________ ___________ ___________ ___________
2008 RENT/MO.
__________ __________ __________ __________ __________
2007 RENT/MO.
__________ __________ __________ __________ __________
2006 RENT/MO.
__________ __________ __________ __________ __________
Other (List)
PARKING # SPACES
Retail/Commercial: Shops/Stores
Offices Other (List)
# UNITS
__________ __________ __________
LEASABLE
___________ ___________ ___________
RENT/SF
__________ __________ __________
RENT/SF
__________ __________ __________
RENT/SF
__________ __________ __________
ANNUAL INCOME: 1. Total Gross Rents (100% Occupancy) 2. Owner, Janitor, Manager Apartments 3. Other Income 4. Loss Due to Vacancy or Delinquent 5. TOTAL ACTUAL INCOME (Total lines 1-4) EXPENSES: 6. Payroll (except manager, repair) 7. Supplies (janitor, bulbs, etc.) 8. Electricity 9. Water/Sewage 10. Fuel (Type of fuel_________) 11. Management Fees/Wages 12. Administrative Costs (List) 13. Maintenance & Repairs (List) 14. Food Cost 15. Housekeeping 16. Laundry & Linen 17. Nursing 18. Resident Activities 19. Miscellaneous Expenses 20. Fire Insurance & Extended Coverage 21. Reserve for Replacements (List) 22. TOTAL EXPENSES
2008 $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________
2007 ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
2006 ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
MORTGAGE/SALES INFORMATION:
1. Is there a current mortgage on this property? 2. If Yes, please provide the following data: ________________________________ Name of Mortgagee ___________________ Term of Mortgage 3. Please provide: Yes _________ No _________ ___________________ Mortgage Amount ___________________ Date 1st Payment ________________ Interest Rate ________________ Monthly Payment
Date Purchased______________
Consideration______________
I declare, under the penalties of perjury, that the contents of this form and all the accompanying schedules and statements have been examined by me and are true, correct, and complete to the best of my knowledge, information, and belief. __________________________________ Signature __________________________________ Print/Type Name of Signer ______________________ Title of Signer _______________ Phone Number ______________ Date
RP- 6A (Rev. 12/03rs)