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* 1. How many persons are there in your household?

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* 2. Is this a single-parent head of household?

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* 3. If yes to #2, is the head of the household male or female?

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* 4. Are any household members disabled or handicapped?

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* 5. Please indicate the number of people in your household for each age group provided below.

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* 6. Based upon the size of your household, which of the following most nearly approximates your household's income? (Please check appropriate line)

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* 7. Property Address

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