Government Housing Inventory
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Add Record
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Delete Record
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Change Record
Q1 Agency__________________Installation______________________________________
Quarters I.D. No.__________________
L1
L2
L3
L4
L5
L6
L7
S1
S2
S3
S4
S5
S6
S7
LOCATION
Quarter Name (e.g. unique name, address, meaningful identifier)_______________________________
Survey Region________ (AK, AN, AS, CB, CL, CU, GU, HI, IM, MS, NE, NM, NC, PL, OW, SE)
Nearest Established Community (NEC) and State_____________________________________________
One-way Miles between housing unit and nearest established community (round to nearest mile):
Paved Road ________ Unpaved/Improved Road ________ Unimproved Road ________
Water/Special _________ Air ________
Mgmt Unit/Prop System Mgmt ID____________________
Facility Mgmt No/Prop Equip ID__________________
† Justification of Housing Unit is Approved
Rent Class:
† Apartment
† Boat
† Cabin
† Dormitory
† House
† Plex
† Mobile Home
† Trailer Pad/Space (for a Tenant RV)
† Travel Trailer (Govt-owned RV)
Date Built (mm / dd / yyyy)
STRUCTURE
S11 Rooms________
No. Used________
S12 Bedrooms_________
No. Used________
S13 Bathrooms___.___ ___
No. Used ___.___ ___
S14 Dorm Rooms________
S15 † One-Car Garage (No._______)
S16 † Two-Car Garage (No._______)
S17 † Carport (No.______)
_______/_______/____________
Interior Condition:
† Excellent † Poor
† Good
† Obsolete
† Fair
† Not Applicable
Exterior Condition:
† Excellent † Poor
† Good
† Obsolete
† Fair
† Not Applicable
Insulation:
† Adequate † None
† Minimum
S18 Current Use:
† QMIS
† Office
† Training
† Conference
† Shop
† Storage
† Excess
† Destroy
† Other
S19 Carbon Monoxide Detectors
No.___________
Gross Finished Floor Space (sq. ft.):
Finished Basement ____ , ____ ____ ____
First Floor ____ , ____ ____ ____
Other Floor(s) ____ , ____ ____ ____
Official Business Use Space (sq. ft.):
S20 Smoke Detectors
No.___________
S21 † Handicap Accessible
S22 † Seasonal Use Only
S23 † Fire Sprinklers
Finished Basement ____ , ____ ____
First Floor ____ , ____ ____
Other Floor(s) ____ , ____ ____
S8 Unused Finished Space (sq. ft.):
Finished Basement ____ , ____ ____
First Floor ____ , ____ ____
Other Floor(s) ____ , ____ ____
S9 Unfinished Basement ____ , ____ ____
S10 Planned Tenants (if > 1) _________
Form DI 1875, page 1 of 3
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S24 Lead Based Paint (LBP):
† No LBP Hazard (built in 1978 or after)
† Inspected/No Hazard - LBP does not exist*
or did exist and was mitigated*
† Inspected/Hazard - LBP does exist*
† Not Inspected - LBP existence is unknown*
*All known LBP information must be given
to each tenant, with a LPB brochure,
per EPA regulations 42 USC 4852d
Revised 12/2008
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
AMENITIES / ADJUSTMENTS
Check if Amenity is OK or Exists:
† Adequate Water Service
† Adequate Electric Service
† Adequate Fuel for Heating/Cooking
† Adequate Police Protection
† Adequate Fire Protection
† Adequate Sanitation
† No Significant Noise or Odors
† Sidewalks
† Street Lights
† Paved Streets
† Phone - Land Line or Cellular Available in Unit
† No Phone; No Land Line or Cellular Available in Unit
† Phone Nearby; Land Line or Cellular Available within
100 yards of Unit
† Loss of Privacy
________%
Describe:_____________________________________
† Excessive Size
________%
† Inadequate Size
________%
† Excessive Heating/Cooling
-$ ________
† Additional Charges
+$ ________
Describe:_____________________________________
† Additional Deductions
-$ ________
Number:
_______
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P19 Fireplace Insert
P20 Firewood (no. of cords per year)
P21 Free-Standing Stove
† Primary Heating † Primary Cooking
_______
_______
_______
_______
in Rent Provides Metered Usage/mo.
†
†
† ________
†
†
† ________
†
†
† ________
†
†
† ________
†
†
† ________
†
†
† ________
†
†
† ________
P22
P23
P24
P25
P26
P27
P28
P29
P30
_______ _______
_______
_______ _______
_______
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_______
_______ _______
_______
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COMMENTS
P31
P32
P33
P34
P35
P36
P37
P38
P39
P40
P41
P42
P43
P44
P45
P46
P47
Describe:_____________________________________
U1
UTILITIES (CONNECTED TO UNIT)
Billed
Gov't
Average
Electricity
Fuel Oil #1
Fuel Oil #2
Natural Gas
Propane
Water
Sewer
PROPERTY/SERVICES (PROVIDED BY GOVERNMENT)
For each item listed, insert the number provided by the Govt
and the fuel used: C=Coal; E=Electricity; F1=Fuel Oil 1;
F2=Fuel Oil 2; G=Natural Gas; P=Propane; W=Wood
Form DI 1875, page 2 of 3
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
P11
P12
P13
P14
P15
P16
P17
P18
Base Radio (electric credit)
Cable TV
Central Cooling (Evaporative)
Central Cooling (Refrigerated)
Central Heating (Electric Resistance)
Central Heating (Forced Air)
Central Heating (Heat Pump)
Central Heating (Hot Water)
Central Heating (Panel)
Central Heating (Solar)
Community Dryer (not coin-op)
Community Freezer
Community Pool
Community Washer (not coin-op)
Dishwasher
Dryer
Engine Heater
Fireplace
† Primary Heating † Primary Cooking
Freezer
Furnished Rooms
Hot Tub
Lawn Care (est. no. mowings per year)
Lawn Mower
Maid Service
Microwave
Premium Channels
Private Pool
Radon Mitigation Fan (electric credit)
Range (credit if not provided)
Refrigerator (credit if not provided)
Remote Control Relay (electric credit)
Satellite TV Service
Sewer Lift (electric credit)
Snow Removal (est. no. removals per year)
Space Heater
Storage Shed
Sump Pump
Trash Compactor (electric credit)
Trash Removal
Washer
Water Heater
Well Pump (electric credit)
Window A/C Evaporative
Window A/C Refrigerated
Fuel:
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______ _______
_______ _______
_______ _______
_______ _______
_______ _______
_______ _______
_______
_______ _______
_______
_______ _______
_______ _______
_______
_______ _______
_______ _______
_______ _______
_______ _______
_______ _______
Revised 12/2008
T1
T4
T5
T6
T7
T8
T9
T10
T11
TENANT
First Name_______________ Last Name ____________________________
Arrival Date (mm/dd/yyyy) _____/_____/________
Type:
† 100-297 Grant
† Other Non-Federal
† 93-638 Tribal
† Permanent Federal
† Commission Corps
† Researcher Non-Federal
† Concessionaire
† Seasonal Federal
† Contractor
† Tribal
† General Public
† Volunteer Non-Student
† Other Federal
† Volunteer Student
† Tenant Pays Federal Rate (Per Contract)
Room No._________
Department__________________________
Grade/Rank________________
Departure Date (mm/dd/yyyy) _____/_____/________
Required Occupant:
† Necessary Service
† Protection
T12 Tax Exempt:
† Condition of Employment
† Convenience of the Government
† Housing on Government Premises
T13 Termination Notice (days) _________
T14 Lease Start Date (mm/dd/yyyy) _____/_____/________
T15 Lease End Date (mm/dd/yyyy) _____/_____/________
Î
Attach additional pg. 3 sheets if more than one Tenant
TENANT APPLIANCES
If electric, propane or natural gas are billed in rent,
inventory above-named tenant's appliances. Fuel used: C=Coal; E=Electric;
F1=Fuel Oil 1; F2=Fuel Oil 2; G=Nat Gas; P=Propane; W=Wood
TA1
Dishwasher
Dryer
Engine Heater
Freezer
Hot Tub
Microwave
Range
Refrigerator
Satellite Dish
Space Heater
Trash Compactor
Washer
Window AC Evap
Window AC Refrig
Number:
_______
_______
_______
_______
_______
_______
_______
_______
_______
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_______
_______
_______
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Fuel:
_______
_______
_______
_______
_______
_______
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INVENTORY COMPLETED BY
Name _______________________________________
Position _____________________________________
Date _________________________________
Form DI 1875, page 3 of 3
Revised 12/2008