Community Needs Survey

Tooh Haltsooi Council of Naataanii Chapter is in the process of doing and assessment of the community needs. Please understand that this is NOT an application! The intent of this form is to gather information about the needs of the Tooh Haltsooi community.

Name of Person Completing Form: *

Current Needs? *

Do you have a homesite lease? *

Yes

No

Are you a registered voter? *

Yes

No

No, but I want to register

List Names and Ages of Household Members

	Name	Age
-	Name	Age
-	Name	Age
-	Name	Age
-	Name	Age
-	Name	Age
-	Name	Age

List additional household members and age here:

Which of the following applies to you or someone in the house hold? *

Household with minor children

Age 65 or older

Disabled

None

GPS Coordinate's: *

Mailing Address:

City *

State *

Zip Code *

Phone Number *

Email Address

What are your housing needs? *

Do you need housing?

Does your current home need repair?

Other please explain: Other please explain:

Do you currently have electricity connected to your home? *

Yes

No

Other: Other:

Do you currently have water connected to your home? *

Yes

No

Other: Other:

Do you currently need a bathroom addition or upgrade? *

Yes, I need a bathroom addition

Yes, I need upgrades for bathroom

No

If yes please explain current bathroom needs or conditions If yes please explain current bathroom needs or conditions

Do you currently have a septic tank connected to your home? *

Yes

Yes, needs servicing

No

Questions or Comments: