List below all people currently residing in the household. This should include:

• Family members
• Persons under 21 in the applicant’s care. This includes foster children.
• Other residents who are not related. Some examples are significant others, roomers, boarders, tenants, and domestic employees.

List all family members not currently residing in the household including noncustodial children, college students away at school, or any family who lives in an assisted living / skilled care facility.

Does the applicant carry firearms or have firearms in the residence? ___ Yes ___ No

If yes, complete the firearms supplement.

Have there been any water-related (including backup of sewers or drains) losses? ___ Yes ___ No

Are underground or above ground storage tanks on the premises? ___ Yes ___ No

Are flammables, chemicals, or fuel stored on the premises? ___ Yes ___ No

Is lead paint in the residence? ___ Yes ___ No

Are chemicals sprayed on the premises? ___ Yes ___ No

List all animals kept at the primary residence.

Is any of the following outdoor equipment on the premises?

Trampolines ___ Yes ___ No

Playground Equipment ___ Yes ___ No

Tree House ___ Yes ___ No

Swimming Pool ___ Yes ___ No

Do activities that regularly involve non-family members take place at the residence? ___ Yes ___ No

Are there bodies of water (such as rivers, creeks, lakes, or ponds) on the premises? ___ Yes ___ No

Are any other features of the applicant’s property unusually appealing yet dangerous for children or adolescents? ___ Yes ___ No