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Surance Medicaid No Insurance Other: Family Type Single parent/female Single parent/male Two-parent household Day Phone Ethnic Background White Multi-race (any 2 or more) African American Single person Two-adults/no children Other Education Level 0-8 9-12/non-graduates Family/Household Size One member Two members Three members Seven members Four members Five members Six members Eight or more members Mobility (check appropriate item/s) No limitation Ambulatory Scooter Wheelcha.

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  3. Fill out the requested boxes (they will be yellow-colored).
  4. The Signature Wizard will allow you to add your e-signature after you?ve finished imputing info.
  5. Put the relevant date.
  6. Check the whole document to ensure you?ve filled out all the information and no changes are needed.
  7. Hit Done and save the resulting form to the computer.

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