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Monthly Gross Income I certify that the above information is true. I understand that the center will get Federal funds based on the information I give. Signature Date FOR SPONSOR USE ONLY Sponsor Agreement Number Total Household Members including foster children if applicable Total Income Free Reduced Paid Date Determined / / Center Staff DOH-3688 5/11 is reported. I understand that the center will get Federal funds based on the information I giv.

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