U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-5571B (06-06)
Condition Inspection Report
Lease / HU Number:
Date of Inspection:
Date of Occupancy:
Local Housing Authority:
Inspection Type:
Member/Tenant Name:
Members Pay Grade:
Members Unit:
Address of Property:
Age of Unit:
Total Bedrooms:
Description:
Total Baths:
Detached, One-Story House
✔
Sq. Ft.:
Semi-detached, One-Story House
Attached, One-Story House
Detached, Two-Story House
Attached, Two-Story House
Apartment, Two or More Stories
Semi-detached, Two-Story House Condition of Leased Premises 1. The general condition and state of repair of the premises listed above should be noted as follows: New Good Fair Poor N/A
= = = = =
Not previously occupied Of high quality, with little or no wear (indicate any marks, etc.) Moderately good quality (indicate discrepancies in remarks) Inadequate, inferior Not applicable
2. Use “Remarks” to list all exceptions, details and identify decorative work to reflect a true description of the property (e.g. patch on the wall, stains in the carpet, scratches on Formica, stained glass windows). 3. Deficiencies noted on the Condition Inspection report are for the protection of the U.S. Government, and the occupant. These discrepancies are considered to be pre-existing and in no way render the premises unsuitable for occupancy. 4. This inspection report consists of _______ pages, including this page, and represents an accurate description of the property herein described.
Certificate of Inspection Acceptance _______________________________ Print Name
_______________________________ Signature of Lessor
___________ Date
_______________________________ Print Name
_______________________________ Signature of Government Rep.
___________ Date
_______________________________ Print Name
_______________________________ Signature of Occupant (If Present)
___________ Date
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1. Floor Covering 2. Baseboard
3. Walls
___ Wood ___ Carpet
Color: __________ Age: ____ ___ Tile
Finish:
___ Paint ___ Stain ___ Other
___ Sheetrock
5. Trim
___Vinyl
___ Brick
N/A
Poor
Fair
___ Other
Yr: ____ Months: ____
___ Wood
Finish: ___ Paint 4. Ceiling
___ Tile ___Vinyl
Good
Check the space or include quantities as applicable. Note details, discrepancies and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
Kitchen
___ Other
___ Cement ___ Paneling
___ Stucco ___ Plaster ___ Wallpaper
___ Paint ___ Stucco ___ Plaster ___ Blown ___Hanging ___ Sculptured ___Open Beam ___ Acoustic Tile ___ Other ___ Chair Rail
___ Crown
___ Wood
___ Other
___ ¾ Round
___ Thermal ___ Double Hung
___ Casement ___ Picture
___ Bay
___ Storm
___ Single Pane
___ Other
___ Security Bars 6. Windows
Lock: ___ Working
___ Not Working
Screen: ___ Aluminum
___ Nylon
Blinds:
___ Vertical
___ Roll-up ___ Venetian
___ Mini
___ Other
___ Other
Note: USCG is not responsible for drapes or curtains left by lessor.
7. Doors
___ Wood
___ Hollow
___ Louver
___ Solid
___ Sliding Glass
___ Metal ___ Other
Door Stop Type: Threshold: ___ Metal ___ Wood ___ Marble ___ Other 8. Pantry 9. Light Fixtures 10. Cover Plates
Number of Shelves: Shelf Type: ___ Wood ___ Incandescent
___ Metal
___ Florescent
___ Wall Mount
___ Track
___ Metal
___ Plastic
___ Other ___ Ceiling Mount
___ Recessed ___Other ___ Other
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11. Heat/Air Vent
___ Floor
___Ceiling
N/A
Poor
Fair
Good
New
Kitchen (continued) ___Wall ___Radiator
___ Baseboard ___ Single ___ Double ___ Porcelain ___ Fiberglass
12. Sink
___ Stainless Steel
___ Sprayer
___ Strainer Plug
___ Other
___ Rubber Plug
Garbage Disposal: ___ Working
___ Not Working
___ Drain Plug ___ Unclogging Tool ___ Electric 13. Stove 14. Broiler Pan
15. Refrigerator
___ Gas
Make: _______________ Age: _____ # of Burners: ____ ___ Enamel ___ Aluminum ___ Stainless Steel ___ Other ___ Standard
___ Side by Side
___ Ice Maker
___ Water/Ice Dispenser
Make: ___________ 16. Microwave
18. Trash Compactor
___ Frost Free
Age: ______
___ Built In ___ Portable Make:________________ Model: ____________ Age: _______ Watts: ________ ___ Built In
17. Dishwasher
___ Drip Pan ___ Grill
___ Portable
Make:___________ Model:_________ Age: ________ ___ Built In
___ Portable
Make: __________ Model: _________ Age: ________ ___ Wood ___ Laminate ___ Pressed Wood ___ Metal ___ Stained ___ Drawers ___ Other
19. Cabinets Counter Top:
___ Formica
___ Corian
___Tile
___ Butcher Block ___ Other Item Number
Remarks
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Bathrooms
____ Full
____ Half
N/A
Size:
Poor
____ Downstairs
Fair
____ Upstairs
New
Location:
Good
Bathroom # ____
Make as many copies of this section as needed to complete the Condition Inspection Report. Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
___ Wood 1. Floor Covering
___ Tile ___Vinyl ___Other
Color: _________
Age: ___________
Year: _____
Months: ________
___ Wood 2. Baseboard
___ Carpet
___ Tile
Finish: ___ Paint
___ Vinyl
___ Stain
___ Other
___ Other
__ Sheetrock ___ Brick __ Cement __Paneling __Other 3. Walls
Finish: ___ Paint
___ Stain ___Stucco ___ Plaster
___ Other ___ Paint ___ Stucco ___ Plaster ___ Blown ___Hanging 4. Ceiling
___ Sculptured ___ Acoustic Tile ___Open Beam ___ Other
5. Trim
6. Windows
___ Chair Rail
___ Crown
___ Wood
___ Other
___ Thermal
___ Double Hung
___ Casement
___ Picture
___ Bay
___ Single Pane
___ Storm
___ Other
___ Security Bars
Lock: ___ Working Screen: ____ Aluminum Blinds: ___ Vertical ___ Mini
___ ¾ Round
___ Not Working ___ Nylon ___ Other
___ Roll-up
___ Venetian
___ Other
Note: USCG is not responsible for drapes or curtains left by lessor
7. Doors
___ Wood
___ Hollow ___ Louver
___ Metal
___ Solid
___ Sliding Glass
___ Other
Door Stop Type: Threshold: ___Metal ___ Wood ___ Marble ___ Other Page _____ of ______ U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5571B (06-06)
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Bathroom (continued)
____Half
N/A
____Full
Poor
Size:
Fair
____Upstairs ____Downstairs
Good
Location:
New
Bathroom # _____
Make as many copies of this section as needed to complete the Condition Inspection Report. Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
8. Closets
9. Light Fixtures
10. Cover Plates
Number of Closets: ___
Number of Rods: ___
Shelves: ___ Wood
___ Metal
___ Incandescent
___ Florescent
___ Ceiling Mount
___ Wall Mount
___ Track
___ Recessed
___ Other ___ Other
___ Metal
___ Plastic
___ Other
___ Floor
___ Ceiling
___ Wall
___ Radiator
___ Baseboard
12. Toilet/ Commode
___ Standard
___ Other Color: _______________
13. Tub
___ Fiberglass ___ Porcelain ___Whirlpool ___ Tile ___ Other Color: ____________________________
11. Heat/Air Vent
14. Shower Stall
___ Fiberglass ___ Plastic
___ Tile
___ Other
Color: _____________
15. Shower Curtain Rod
___ Wood
16. Shower Door
___ Plexiglas
___ Glass
___ Other
___ Metal
___ Plastic
___ Wood
___ Ceramic
___ Ring
___ Other
___ Single
___ Pedestal
___ Porcelain
___ Fiberglass
___ Stainless Steel ___ Other
17. Towel Bar
18. Sink
___ Metal
___ Plastic
___ Other
Color: _____________________ ___ Wood ___ Laminate ___ Pressed Wood ___ Metal 19. Vanity Cabinet
___ Stained ___ Drawers ___ Corian ___ Fiberglass ___ Other Counter Top: ___ Formica ___Tile __One Piece Molded ___ Other Page _____ of ______
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Bathroom (continued)
____Half
N/A
____Full
Poor
Size:
Fair
____Upstairs ____Downstairs New
Location:
Good
Bathroom # _____
Make as many copies of this section as needed to complete the Condition Inspection Report. Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
20. Medicine Cabinet
___ Wood
21. Mirror
___Wall Mounted
22. Exhaust Fan
___ Working
___ Not Working
___ Plastic
___ Metal
___ Ceramic
___ Other
___ Plastic
___ Metal
___ Ceramic
___ Other
___ Plastic
___ Metal
___ Ceramic
___ Other
___ Wall Mounted
___ Vanity Mounted
23. Soap Dish 24. Tooth Brush Holder
25. Toilet Paper Holder
___ Mirrored
___ Recessed
___ Plastic
___ Wall Mounted
___ Metal ___ Other
___ Other
Item Number
___ Wood
___ Wood
___ Wood ___ Other
Remarks
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Interior Room
Make as many copies of this section as needed to complete the Condition Inspection Report.
N/A
Poor
____ Downstairs
Fair
____ Upstairs
Good
Location:
________________________ New
Type of Room:
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
1. Floor Covering
___ Wood
___ Carpet
___ Vinyl
___ Other
___ Tile
Color:__________ Age: _____ Yr.: ____ Months: _____ 2. Baseboard
3. Walls
4. Ceiling
5. Trim
___ Wood
___ Tile
Finish: ___ Paint
___ Stain
___ Sheetrock ___ Brick
___ Other
___ Other
___ Cement ___Paneling
Finish: ___ Paint ___ Stucco ___ Plaster ___ Wallpaper ___ Paint
___ Stucco
___ Plaster
___ Blown
___ Hanging
___ Sculptured
___ Open Beam
___ Acoustic Tile
___ Other
___ Chair Rail
___ Crown
___ ¾ Round
___ Wood
___ Other
___ Thermal
___ Double Hung
___ Casement
___ Picture
___ Bay
___ Single Pane
___ Storm
___ Security Bars
___ Other
Lock: ___ Working
6. Windows
___ Vinyl
___ Not Working
Screens:
___ Aluminum
___ Nylon
Blinds:
___ Vertical
___ Roll up
___ Venetian
___ Mini
___Other
___ Other Note: USCG is not responsible for drapes or curtains left by lessor.
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Interior Room (continued)
N/A
Poor
____Downstairs
Fair
____Upstairs
Good
Location:
________________________ New
Type of Room:
Make as many copies of this section as needed to complete the Condition Inspection Report. Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
7. Doors
___ Wood
___ Hollow
___ Louver
___ Solid
___ Sliding Glass
___ Metal ___ Other
Door Stop Type: Threshold:
___ Metal
___ Wood
___ Marble ___ Other 8. Closets
9. Light Fixtures
Number of Closets: ____ Number of Shelves: ___ ___ Rod
___ Wood
___ Metal
___ Other
___ Incandescent
___ Florescent
___ Ceiling Mount
___ Wall Mount
___ Track
___ Recessed
___ Metal
___ Plastic
___ Other
___ Floor
___ Ceiling
___ Wall
___ Radiator
___ Baseboard
___ Other 10. Cover Plates 11. Heat/Air Vent Item Number
Remarks
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Hall Location:
____Upstairs
____Downstairs
1. Floor Covering
___ Wood
___ Carpet
___ Vinyl
___ Other
N/A
Poor
Fair
Good
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
Make as many copies of this section as needed to complete the Condition Inspection Report.
___ Tile
Color:__________ Age: ____ Yr.: _____ Months: _____ 2. Baseboard
3. Walls
4. Ceiling
5. Trim
6. Doors
___ Wood
___ Tile
Finish: ___ Paint
___ Vinyl
___ Stain
___ Sheetrock ___ Brick
___ Other
___ Other
___ Cement ___Paneling
Finish: ___ Paint ___ Stucco ___ Plaster ___ Wallpaper ___ Paint
___ Stucco
___ Plaster
___ Blown
___ Hanging
___ Sculptured
___ Open Beam
___ Acoustic Tile
___ Other
___ Chair Rail
___ Crown
___ ¾ Round
___ Wood
___ Other
___ Wood
___ Hollow
___ Louver ___ Sliding Glass
___ Metal
___ Solid
___ Other
Door Stop Type: Threshold: ___ Metal ___ Wood ___ Marble ___ Other
7. Closet
8. Light Fixtures
Number of Closets: ____ ___ Rods
___ Wood
___ Metal
___ Other
___ Incandescent
___ Florescent
___ Ceiling Mount
___ Wall Mount
___ Track
___ Recessed
___ Other 9. Cover Plates
___ Metal
___ Plastic
___ Other
10. Heat/Air Vents
___ Floor
___ Ceiling
___ Wall
___ Radiator
___ Baseboard
11. Smoke Detector
___ Working
___ Not Working
___ Other Location ___ Hardwired ___ Battery ___Other Page _____ of ______
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Hall (continued) Location:
____Upstairs
____Downstairs
12. Thermostat
___ Mercury
13. Stairs
___ Wood
___Carpet ___ Non-Skid Strips ___Other
14. Bannister/ Handrails
___ Wood
___ Metal
___ Other
Finish:
___ Paint
___ Stain
15. Windows
___ Digital
___ Rheostat
N/A
Poor
Fair
___ Other
___ Other
___ Thermal
___ Double Hung
___ Casement
___ Picture
___ Bay
___ Single Pane
___ Storm
___ Security Bars
___ Other
Lock: ___ Working
___ Not Working
Screen:
___ Nylon
___ Aluminum
Good
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
Make as many copies of this section as needed to complete the Condition Inspection Report.
___ Other
Blinds: ___ Vertical ___ Roll-up ___Venetian ___ Mini
___ Other
Note: USCG is not responsible for drapes or curtains left by lessor
Item Number
Remarks
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1. Floor 2. Baseboard
3. Walls
5. Windows
N/A
Poor
Fair
__ Ground __ Cement ___Gravel ___ Asphalt __ Other ___ Wood
___ Tile
___ Vinyl
___ Other
Finish:
___ Paint
___ Stain
___ Other
Construction: ___ Sheet Rock ___ Cinder Block Finish: ___ Paint
4. Ceiling
Good
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
Garage/Carport
___ Paint
___ Brick ___ Cement ___ Other
___ Stucco ___ Plaster
___ Other
___ Stucco ___ Plaster ___ Hanging
___ Open Beam
___ Other
___ Thermal
___ Double Hung
___ Casement
___ Picture
___ Bay
___ Single Pane
___ Storm
___ Security Bars
___ Other
Lock: ___ Working
___ Not Working
Screen: ___ Aluminum
___ Nylon
___ Other
Blinds: ___ Vertical ___ Roll-up ___ Venetian ___ Mini
___ Other
Note: USCG is not responsible for drapes or curtains left by lessor.
6. Doors
___ Wood
___ Hollow
___ Louver
___ Solid
___ Sliding Glass
___ Metal ___ Other
Door Stop Type: Threshold: ___Metal ___Wood ___ Marble ___ Other
7. Light Fixtures 8. Cover Plates
___ Incandescent
___ Florescent
___ Ceiling Mount
___ Wall Mount
___ Flood
___ Other
___ Metal
___ Plastic
___ Other
___ Metal 9. Overhead Door
___ Wood
___ Fiberglass
___ Other
___ Electric Door Opener Number of Windows: ______ Number of Remote Controls: ______
10. Deep/Utility Sink
___ Metal
___ Fiberglass
___ Porcelain
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11. Shelving
___ Metal
___ Wood
___ Peg Board
12. Cabinets
___ Metal
___ Wood
___ Other
13. Work Bench
___ Metal
___ Wood
___ Other
14. Heating
Type:
Item Number
N/A
Poor
Fair
Good
New
Garage/Carport (continued)
___ Other
Remarks
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1. Landscaping
___ Grass
___ Gravel
___ Trees
___ Other
N/A
Poor
Fair
Good
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
Exterior
___ Sand ___ Scrub
Maintenance Responsibilities: ___ Landlord __Tennant Exceptions: Age: ____ Type: ___ Asphalt ___ Wood ___ Fiberglass
2. Roof
Chimney:
___ Cedar
___Tin
___ Terra Cotta ___ Other
___ Brick
Gutters: ___ Aluminum
___ Metal
___ Other
___ Vinyl
___ Shingles
Downspouts: ___ Vinyl
___ Aluminum
___ Splash Guards ___ Other 3. Foundation
___ Slab
___ Poured w/Basement
___ Pilings
___ Crawl Space
Walls: ___ Wood
___ Aluminum
___ Shingles ___Stucco 4. Exterior Construction
Awnings:
___ Brick ___Vinyl ___ Other
____Fiberglass
____Metal
____Cloth
____Other
Shutters: ___ Wood
___ Vinyl ___ Metal
___ Functional
5. Door
___ Other
___ Other
___ Decorative
___ Wood
___ Hollow
___ Louver
___ Solid
___ Sliding Glass
___ Metal ___ Other
Screen Door:____ Sliding ___ Hinged ___ Full Screen Threshold: ___ Metal ___ Wood ___ Marble ___Other
6. Storm Door
___ Wood ___ Metal ___ Solid ___ Hollow ___Other
7. Porch/ Deck/Patio
___ Wood
___ Metal ___ Solid ___ Hollow
___ Enclosed ___Open ___ Other Page _____ of ______
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8. Driveway
9. Walkway 10. Outdoor Lighting 11. Water
12. Storage Shed
13. Antenna
___ Cement
___ Asphalt
___ Gravel
___ Brick
___ Ground
___ Other
___ Cement
___ Asphalt
___ Gravel
___ Brick
___ Flagstone
___ Other
___ Flood
___ Carriage
___ Gas ___ Photocell
___ Motion Detector ___ Metal Base/Glass ___ City
N/A
Poor
Fair
Good
New
Exterior (continued)
___Other
___ Individual Well ___ Community Well
___ Well Pump Exterior: ___ Wood
___ Metal
✔ No Electricity: ____ Yes ____
___ Other ___ Paint Number of Outlets: ____
___ External ____ Internal ___ Satellite Dish ___ Cable/Cable Ready Fence Height: ______
14. Fence Gate: 15. Mailbox 16. Doorbell
17. Garbage Can
___ Wood
___ Chain Link
___ Other
___ Wood
___ Chain Link
___ Other
___ Curb
___ Attached
___ Door Slot
___ Wood
___ Metal
___ Plastic
___ Working
___ Cluster ___ Other
___ Not Working
Size: ______
___ Metal
___ Plastic ___ Other
Provided by:
___ Landlord ___ Municipal ___ Member
18. Clothes Line Pole
___ Wood
___ Metal
___ Umbrella
___ Other
19. Sewage System
___ City
___ Septic Tank
20. Outdoor Shower
___ Plastic
If septic tank enter date last pumped: ___ Open Air
___ Enclosed Page _____ of ______
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21. Special Needs
___ Ramp
___ Bath
___ Doors
___Counters
___ Cabinets
___ Other
Item Number
N/A
Poor
Fair
Good
New
Exterior (continued)
___ Rails
Remarks
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Fuel Type: 1. Heating and Cooling
___ Gas
___ Oil
3. Washer
N/A
Poor
Make:________
___ Gas
___ Electric
Make: ________
Capacity: _______(gals)
Provided: ____
Location: ____________________ Age:_______
Provided: ____
Location: ____________________
___Gas
___ Electric
Make:_______________ ___ Wood 5. Fireplace
Fair
___ Hot Water Baseboard ___ Wood/Coal Burning Stove
Make:_______________
4. Dryer
___ Electric
___ Heat Pump ___ Central A/C ___ Forced Hot Air ___ Window A/C Number of Units: ___
2. Hot Water Heater
Good
Check the space or include quantities as applicable. Note details, discrepancies, and exceptions in remarks. If “Other” is checked explain in remarks section with corresponding number of the item.
New
General
___ Gas
Chimney Cleaned by:
Age:_______ ___ Chimney
___ Ventless
___ Landlord
___ Tennant
Date chimney last cleaned:___________________ 6. Attic Access
Location:
7. Sprinkler System
Provided: ___Yes
___ No
Age: ______
Working: ___ Yes ___ No ___ Hard Wired
___ Hard Wired with Battery Backup
___ Battery Location and date last tested: ______________________________________ 8. Smoke Detectors
______________________________________ ______________________________________ ______________________________________ ______________________________________ Page _____ of ______
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N/A
Poor
Fair
Good
New
General (continued)
Location and date last tested: _______________________________________ 9. Carbon Monoxide Detector
_______________________________________ _______________________________________ _______________________________________ _______________________________________
Item Number
Remarks
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Additional Remarks Page This page may be used to supplement any section of the Condition Inspection Report. Item Number
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