Fill in the form below. Change any entries to match your property. Do not include non-residential parts of your property, such as fields, forest, or open water, in characterizing your house.

1. Age of house in years?

2. Brick exterior?

3. Number of Objects on the lot?

Objects are things such as:

Tool Sheds
Free Standing Garages
Masonry Walls or retaining walls

Railroad Ties
Dog Houses

Junk Piles
Wood Piles
Other things* Piles must have an area of approx. 5 ft. by 5 ft to be counted as an object

4. Indicate the number of Pets that are always or occasionally outside your home (near house, not in pastures or other areas away from house)

    Dogs                      Cats                Horses              Other

5. Is your house regularly treated with pesticides?

6. Number of residents?

7. Length of House(ft.)

Width of House(ft.)

8. Length of Lot(ft.) * or Lot size in acres (if you don't know length and width)

Width of Lot(ft.)

9. Number of Hardwood trees on lot?

10. Number of Pine trees on lot?

The information below is not necessary for calculating the index, but will help us organize and understand the responses of homeowners. If you feel comfortable please provide us with the following:

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