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Get Return To: Official Use Only Initial Certification Annual Certification Income Change Household

TO YOUR OFFICE APPOINTMENT. THIS FORM MUST BE SIGNED BY ALL ADULT MEMBERS. PLEASE TYPE OR PRINT CLEARLY. COMPLETE ALL SECTIONS OF THE FORM, MARK N/A IF IT DOES NOT APPLY TO YOU. Address City, State, Zip P.O. Box if applicable Phone Email address LIST ALL OCCUPANTS OF THE ASSISTED UNIT Legal Name Relation to Head of Household Sex Age Date of Birth Place of Birth Social Security # Full- time Student over age 18? (Yes or No) HEAD a. FOSTER CHILDREN List the complete name of any foste.

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