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Your Name
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Your Email Address or Phone Number
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Whichever is the easiest way to reach you
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Which of the following best describes what step you are at in applying for benefits? (Employers and health professionals please select other.)
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Thinking about applying
Started my application
Submitted my application and waiting on my status
Applied and approved for benefits
Applied and denied for benefits
Do not know much about the program
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Your zip code
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What is the highest level of education you completed? (optional)
Grade School
High School or GED
Some College
Associate's or Bachelor's Degree
Graduate or Professional Degree
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