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L Status: 1 - Never Married 2 - Married 3 - Widowed 4 - Divorced 5 - Separated No. of Dependents for Income Eligibility: Total number of children for whom the patient is the primary care giver: Client/Patient is pregnant at assessment: Y - Yes OR N - No Living Arrangement: Describes the current living arrangement. A - Shelter (Safe Havens, Transitional Living Centers (TLC), Low Demand Facilities, Reception Centers, other Temporary Day, or Evening Facilities) B - Street/Outdoors.

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