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: Do you Amount of current monthly rental or mortgage payment: Check utilities paid by you: Heat Yes Amount: Electricity Gas No (check one) Other (specify) Approximate monthly cost of utilities paid by you (excluding phone and cable TV): Two BR RENT or OWN (check one) $ If owned, do you receive monthly rental income from property? Bedroom size requested: ZIP $ Three BR Handicap BR Do you receive rental assistance? (Example: S.
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