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Street Number, Street Name, Apt # (If Applicable)
Do you own or rent?
Who is your landlord? (If applicable)
How many apartments in building? (If applicable)
How many live at this address?
What is the best time to send a crew?
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?
-- Select One --
Black/African American & White
Asian & White
American Indian/Alaskan Native
American Indian/Alaskan Native & White
American Indian/Alaskan Native & Black/African American
Is head of household Hispanic?
Is head of household female?
Is above information correct to the best of your knowledge?
If you have additional questions or comments not covered on this form, please call 301-791-2544.
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