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Form 1

Lease

Renew lease?

Do you have difficulty seeing, even if wearing glasses?No – no difficultyYes – some difficultyYes – a lot of difficultyCannot do at all

Do you use a Vision Aid?

YesNo

Do you have difficulty hearing, even if using a hearing aid?

Do you have difficulty walking or climbing steps?No – no difficultyYes – some difficultyYes – a lot of difficultyCannot do at all

390ccfc82f5d3bde13c10e2aa13bef2ac41c62c1

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