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EFSP Phase 39/40/ARPA-R/41 Clearinghouse Form
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Date Submitted:LRO #:
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Funding Phase (39, 40 ARPA-R or 41):
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Jurisdiction:
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Applicant Information
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Applicant DOB:Agency Name:
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Applicant Last Name:
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Applicant First Name: LRO Contact Name:
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Address (including city & zip code): LRO Contact Phone:
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Spouse/Roommate Information:LRO Contact E-mail:
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Spouse/Roommate DOB:
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Spouse/Roommate Last Name:
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Spouse/Roommate First Name:
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Additional Household Member DOB:
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Additional Household Member Last Name:
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Additional Household Member First Name:
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Assistance Information:
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Please Check the appropriate box, and supply additional information where needed.Remind LROs that no late fees or deposits can be paid with EFSP funds.
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Rent:One month amount rent: Amount to be paid by LRO: $
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Mortgage:One month amount mortgage: $Amount to be paid by LRO: $
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Temporary Lodging:$ per night/Number of nights: Amount to be paid by LRO: $
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Gas:One month amount gas: $Amount to be paid by LRO: $
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Electricity:One month amount electricity: $ Amount to be paid by LRO: $
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Water:One month amount water: $ Amount to be paid by LRO: $
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Vendor for payment made:
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