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2. First Name*
3. Last Name*
5. Address*
7. Second Address
9. City*
10. State*
11. Zip Code*
13. Email*

17. Select the priority of importance for each eligible activity.

19. Assistance for Homebuyers: Providing down Payment Assistance*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
20. Assistance for Homeowners: Housing Repair, Reconstruction, and Lead Abatement*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
22. Assistance for Renters: Creating and Rehabilitating Affordable Rental Units*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
23. Economic Development Needs: Job Creation/Retention, Employment Training, and Business Lending*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
25. Fair Housing Needs: Promoting Fair Housing Through Education and Training*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
26. Improvement of Neighborhood Facilities: Constructing Community Centers, Libraries, and Parks*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
28. Other: Mental Health Services, Senior Housing, Housing for Persons with Disabilities, Energy-Efficiency Improvements, Demolition of Blighted Structures, Workforce Development Programs, Services for Special Needs, Storm Sewer Projects*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
30. Should the Housing and Community Development Department with the City of Beaumont address any other community need not listed above? If so, please list those needs below

34. Select the priority of importance for each neighborhood feature.

36. Child Care Services: Day Care*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
37. Community Spaces: Multi-Service Center*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
39. Employment Opportunities*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
40. High-Quality Schools*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
42. Medical Services: Doctor, Clinic, Pharmacy*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
43. Public Transportation*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
45. Recreational Facilities: Parks*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
46. Retail Services: Grocery Store, Shopping Mall, Restaurant*

    1. High Priority
    2. Medium Priority
    3. Low Priority
    4. Not a Priority
48. Are there other features that would help improve your neighborhood? If so, please list those features below:
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50. 1. Receive an email copy of this form.
51. Email address

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