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B.

1.

2.

3.

4.

Qualifications

Does the applicant own or partially own title to this residence?

(

) Yes

(

) No

If partially owned, explain how the ownership is legally held, and the applicant’s interest, and percentage.

Percentage of Ownership

%

Are you currently living in this residence? (

) Yes

(

) No

If not, please enter your current address and phone number and the reason you are not living in your home.

Has the applicant disposed of or transferred any assets or property to heirs within the last five years?

(

) Yes

(

) No

If so, please list to who, the dates, describe the transactions, and list value of properties, and/or assets below.

Has the applicant or co-owner been certified as disabled by the Social Security Administration, Railroad, or Veteran’s Administration or if such person is not eligible for the aforementioned, does applicant have a sworn affidavit by two medical doctors stating that applicant or co-owner is permanently and totally disabled?

(

) Yes

(

) No

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