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Get VT Under 5000 Dollar Asset Certification Form 2017-2024

A household contains both joint and separate assets, use separate forms and list the joint asset on both forms with the statement (Joint) next to the applicable asset. Household Name: Unit No. Development Name: City: Complete the following: 1. Choose one: I/we do not have any assets at this time. (if this box is checked, draw a line through the asset information below, place a zero in #3, sign and date) OR My/our assets include: (Please complete fully. Put a zero in any columns that do not.

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