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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