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* 1. Looking at the map below, please check the box that corresponds to the area where you live:

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* 2. How many persons are in your household?

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* 3. What is your age and that of any other adults in the household?

  Your Age Other Adult Other Adult Other Adult
18-25 Years
26-35 Years
36-45 Years
46-55 Years
56-65 Years
66 Years +

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