Head of Household

Head of household (your name)(*)
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How many people are in your household?(*)
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Household Name 1
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Gender
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Date of Birth
/ / Invalid Input

Social security number
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Enrollment#
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School/Daycare
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Household Name 2
Invalid Input

Gender
Invalid Input

Date of Birth
/ / Invalid Input

Social security number
Invalid Input

Enrollment#
Invalid Input

School/Daycare
Invalid Input

Household Name 3
Invalid Input

Gender
Invalid Input

Date of Birth
/ / Invalid Input

Social security number
Invalid Input

Enrollment#
Invalid Input

School/Daycare
Invalid Input

Household Name 4
Invalid Input

Gender
Invalid Input

Date of Birth
/ / Invalid Input

Social security number
Invalid Input

Enrollment#
Invalid Input

School/Daycare
Invalid Input

Household Name 5
Invalid Input

Gender
Invalid Input

Date of Birth
/ / Invalid Input

Social security number
Invalid Input

Enrollment#
Invalid Input

School/Daycare
Invalid Input

Household Name 6
Invalid Input

Gender
Invalid Input

Date of Birth
/ / Invalid Input

Social security number
Invalid Input

Enrollment#
Invalid Input

School/Daycare
Invalid Input

If more than 6 household members please specify (add their information)
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