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ALL HOUSEHOLD MEMBERS BIRTH DATES OF CHILDREN NAMES OF ALL HOUSEHOLD FIRST MIDDLE INITIAL LAST CHECK IF A FOSTER CHILD THE LEGAL RESPONSIBILITY OF A WELFARE AGENCY OR COURT I F ALL CHILDREN L ISTED BELOW ARE FOSTER CHILDREN SKIP TO P ART 4 TO SIGN THIS FORM. CHECK IF NO INCOME PART 2. BENEFITS IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVED FOOD STAMPS OR STATE TANF CASH ASSISTANCE PROVIDE THE NAME AND CASE NUMBER FOR THE PERSON WHO RECEIVES BENEFITS. IF NO ONE RECEIVES THESE BENEFITS SKIP TO PART...
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