2. HAPGC requests that you complete this survey. This survey is voluntary and will not affect your tenancy, eligibility, or participation in any of HAPGC’s programs. HAPGC may contact you to see if housing improvements or modifications are needed.

   If you have questions about this survey or need help understanding or filling out this form because of a disability, contact:

   504 Coordinator
   The Housing Authority of Prince George's County
   9200 Basil Court, Suite #500
   Largo, MD 20774
   Phone: 301-883-5576
   For deaf or hard of hearing contact 301-883-5576 through Relay Service at 7-1-1
   Email: DHCD-504@co.pg.md.us

   You can submit this survey online or select print at the end. Printed surveys should be returned to your property manager or to the Housing Authority's office at: 9200 Basil Ct., Suite #500, Largo MD 20774.

4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
11. Zip Code*
13. How many bedrooms are in the current unit?*

    1. 1
    2. 2
    3. 3

    1. 4
    2. 5
    3. Other
14. Please specify the number of bedrooms.*
15. Are you currently a resident of public housing?*

    1. Yes
    2. No
17. Are you currently a participant in the Housing Choice Voucher Program?*

    1. Yes
    2. No
18. Are you currently a resident of either Central Gardens II, Regency Lane or other assisted housing?*

    1. Yes
    2. No
20. Do you or a member of your household have a disability?*

    1. Yes
    2. No
22. Check all accommodations that are needed.*

    1. Unit accommodations for persons who are blind or have limited vision (hand rails, no slip carpet, clear pathways) hand
    2. Unit accommodations for person who are Deaf or hard of hearing (flashing doorbell; strobe fire detector)
    3. An extra bedroom for a live-in aid or attendant
    4. A unit all on one level, with no steps
    5. A unit with a bedroom and bathroom on the first floor
    6. A flat or no step entry
    7. Modifications to the bathroom. (Grab bar, raised or lowered toilet seat, shower bench)
    8. A unit accessible to a person using a wheelchair
    9. Accommodations in using HAPGC services (e.g., large print or Braille notices, electronic copies of Notices, interpreters, in-home recertifications, emotional support animal)
    10. Modifications to any common areas, e.g., leasing office, mailbox, laundry room, community rooms, etc.
24. Please explain.*
26. Thank you for helping us to plan for your needs.
    Please note that you can ask for a reasonable accommodation to use HAPGC’s housing or services. This can include auxiliary aids or services, materials in an alternative format, or help in completing paperwork or changes to your housing based on your disability. Contact the 504 Coordinator at (301)883-5576 or email dhcd-504@co.pg.md.us for assistance.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field