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(DD-MM-YYYY) |
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(Include apartment number if applicable.) |
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Are you able to receive text messages? |
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(E-mail Address that is checked often) |
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(PDF, Doc, Docx files accepted) |
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Are you a disadvantaged local worker, currently experiencing at least one of the following?* |
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- History of prior arrest or conviction
- Homeless
- A custodial single parent
- Chronically unemployed
- Have been emancipated from the foster care system
- A veteran of the U.S. military
- Underemployed, meaning working less than 1,000
hours in the past year, or Unemployed, meaning
having no current source of income.
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Are you currently a recipient of, or eligible for public assistance within the last year provided by one or more programs, including food stamps, TANF, Section 8or LIHEAP?* |
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Are you a resident of a public housing development, such as those managed by HANO?* |
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During the last 3 years, has your family income been at or below the levels indicated in the chart below? * |
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Calendar Year |
1 person family |
2 person family |
3 person family |
4 person family |
5 person family |
6 person family |
7 person family |
8 person family |
2018 |
36,750 |
42,000 |
47,250 |
52,500 |
56,700 |
60,900 |
65,100 |
69,300 |
2017 |
35,500 |
40,550 |
45,600 |
50,650 |
54,750 |
58,800 |
62,850 |
66,900 |
2016 |
33,600 |
38,400 |
43,200 |
48,000 |
51,850 |
55,700 |
59,550 |
63,400 |
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(You may include prior experience, certifications, training or job skills) |
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Please enter today's date. |
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