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Date
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Date
First Name
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Last Name
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Address
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Street Number, Street Name, Apt # (If Applicable)
City
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State
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Zip Code
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Phone Number
*
Email Address
Do you own or rent?
*
Own
Rent
Who is your landlord? (If applicable)
How many apartments in building? (If applicable)
How many live at this address?
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What is the best time to send a crew?
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The information below is for tracking purposes only. It is not used as a determinant for your eligibility in this program.
Ethnicity of head of household?
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White
Black/African American
Black/African American & White
Asian
Asian & White
American Indian/Alaskan Native
American Indian/Alaskan Native & White
American Indian/Alaskan Native & Black/African American
Other
Is head of household Hispanic?
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No
Is head of household female?
Yes
No
Is above information correct to the best of your knowledge?
*
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