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PERSONAL INFORMATION

First Name:

Middle Name:

Last Name:

Street Address:

Lot Number:

City:

State:

Zip Code:

Phone Number

Alternate Number

Email:

Marital Status:

Birthday:

Gender:

US Resident?

Number of Household Members:

Household Income per year (USD):

Do you have prescription drugs coverage of any kind?

Are you enrolled in a Medicare Part D Prescription Drug Plan?

If “Yes”, when did you (or will you) enter the Donut Hole?

Do you have Health Insurance?

Medicare:

VA:

Private Insurance

Does this plan include prescription drug coverage?

Medications

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