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Resident Intake Form
Name/Nombre
First Name/Nombre
Last Name//Apellido
Address/Dirección
Street Address/Dirección
Street Address Line 2
City/Ciudad
State/Estado
Zip Code/Código Postal
Phone Number/Número de Teléfono
Please enter a valid phone number/Por favor ingrese un número de teléfono válido
Email/Correo Electrónico
example@example.com
Ethnicity/Etnicidad
Please Select
Hispanic
Non Hispanic
Race/Rās
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian and Other Pacific Islander
White
Other
Number of Household Members/Numero de miembros del hogar
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Please check all that applies/Por favor marque todos los que apliquen
Child Care Assistance
Energy Assistance (LIHEAP)
General Public Assistance
Refugee Cash Assistance
Medicaid
RIworks
SNAP(Food Stamps)
SSI or SSDI
Temporary Disability
Unemployment
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Annual Household Income/Ingreso Anual del Hogar
43,740-59,160
59,160-74,580
74,580-90,000
90,000-105,420
105,420-120,840
120,840-136,260
136,260-151,680
151,680-167,100
167,100-182,520
Submit
Should be Empty: