Address
*
Street Address
Address Line 2
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State / Province/ Region
Preferred Language
*
-Select- UNASSIGNED Chinese English German Italian Laotian Other Russian Spanish Polish
Marital Status
*
-Select- Civil Union Divorced Married Never Married Other Partner Separated Single Unknown Widowed
Race/Ethnicity
*
-Select- White Other Hispanic & White African American Pacific Islander Hispanic Native American/Alaskan Asian Unknown Race
Veteran Status
*
-Select-
Veteran
Not Veteran
Living Situation
*
-Select- Lives alone Lives with spouse Lives with spouse and children Lives with children Working household member Other Unknown Lives with adult relative Lives with non-relative Lives with primary caregiver
