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Household Member Details
| Household Member | [Full Name] |
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| Date of Birth | [Date] | Registration Date | [Date] |
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| Gender | [Male] | Marital Status | [Single] |
| Country/Region of Birth | [United States] | Nationality | [American] |
Additional Household Member Details
| Citizen Status | |||||||
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| Veteran Status | |||||||
| Applied for S.S.N. | Migrant Farm Worker | ||||||
| Start Date |
| End Date |
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Residency Details
| Residency Status |
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Race Details
| Black Or African American | White Or Caucasian | ||
|---|---|---|---|
| Native Alaskan Or American Indian | Native Hawaiian Or Pacific Islander | ||
| Asian |