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HOUSING REHABILITATION INTAKE FORM
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Primary Applicant First Name:
*
Your answer
Primary Applicant Last Name:
*
Your answer
Social Security #:
*
Your answer
Mobile:
*
Your answer
Email:
*
Your answer
Street Address:
*
Your answer
City:
*
Your answer
State:
Your answer
Zip Code
*
Your answer
Birthdate:
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MM
/
DD
/
YYYY
Gender:
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Female
Male
Other:
Race:
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
American Indian AND White
Asian AND White
Black or African American AND White
American Indian AND Black
Other Multiple Race
Ethnicity:
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Hispanic
Non-Hispanic
Educational Attainment:
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Less than HS Diploma
High School Diploma or Equivalent
Some Post-Secondary Education
Certification from a Vocational or Technical Training Program
Associate's Degree
Bachelor's Degree
Master's or Other Graduate Degree
Employment Status:
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Self-Employed
Work Full Time for Employer
Work Part Time for Employer
Homemaker
Full-Time Student
Permanently Unable to Work
Unemployed and Seeking Work
Unemployed and Not Seeking Work
Retired
Other
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