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(MM/DD/YYYY) Property Name: Address: PART I - DEVELOPMENT DATA County: Unit Number: BIN #: Bedrooms: PART II. HOUSEHOLD COMPOSITION Vacant Unit HH Mbr # Last Name First Name Middle Initial Relationship to Head of Household Date of Birth Race Ethnicity Disabled? Last 4 Digits of Social Security No. F/T Student (MM/DD/YYYY) (Y or N) 1 2 3 4 5 6 7 PART III. G.

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