| Household Information |
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| Is everyone living in your household a US citizen or legal alien? |
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| Does everyone share food? |
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| Is anyone in your household disabled or blind? |
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| Housing |
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| If you own a mobile home and also rent your space, please choose "Own your own home". |
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| Utilities |
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| Do you pay for phone service? |
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| Monthly water and sewer utility bill: |
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| Monthly garbage disposal bill: |
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| Monthly electricity utility bill: |
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