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Hello, John!
Household Composition & General Home Information
"I need to know a bit more about the people in your household"
Document Resource Needs
Owner / Tenant
Client's Listing of Damage
How many people are in your household?
- Required
Yes
No
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How many people are in your household?
$
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Is anyone in the household disabled?
- Required
Yes
No
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Is anyone in the household disabled?
$
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Is anyone in the household a veteran?
- Required
Yes
No
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Is anyone in the household a veteran?
$
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How many adults age 18 and over in the household?
- Required
Yes
No
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How many adults age 18 and over in the household?
$
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How many children age 17 and under are in the household?
- Required
Yes
No
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How many children age 17 and under are in the household?
$
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How many adults age 65 and older are in the household?
- Required
Yes
No
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How many adults age 65 and older are in the household?
$
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Is anyone in the household currently pregnant?
- Required
Yes
No
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Is anyone in the household currently pregnant?
$
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Is this your primary residence?
- Required
Yes
No
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Is this your primary residence?
$
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What is your current home ownership status?
- Required
Yes
No
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What is your current home ownership status?
$
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If own, What type of Home?
- Required
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No
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If own, What type of Home?
$
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If own, Type of Construction?
- Required
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No
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If own, Type of Construction?
$
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If own, Type of Foundation?
- Required
Yes
No
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If own, Type of Foundation?
$
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Additional Assistance Needed
No items found.
Document Housing Needs
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Add Alternate Contact
Alternate Contact Information
Remove Contact
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Notes
- Required
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No
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Notes
$
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