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Get United Way Low Income Self-Sufficiency Plan (LSP) 2013

Ing Evening TDD/Other number: 5. Reasons for Energy Assistance Low-income household Job Loss Medical hardship Other (explain): SECTION 2: Please fill out the attached Household Income Worksheet Page 1 of 4 Continued on Page 2 SECTION 3: HOUSEHOLD INFORMATION Total number of members, including the applicant, in the household: Name (full name) Social Security Number Date of Birth (If more space is needed please attach separate sheet) DOCUMENTS REQUIRED FOR THE HOUSEHOLD Identity verifi.

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