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Application for Florida Lifeline Assistance Program gratify empathise all(a) Instructions Before Completing Date: 04/16/2009 ® sail section I Enrollment ID: _______________ 1103393 1. PLEASE PRINT quote and physical planetary house address of person applying for helper: MARIE LOUISE MUKANDEKEZI Customer Name________________________________________________________ ____________________ 8500 29TH representation APT 101 overhaul Address_____________________________________________________ _______________________ PINELLAS PARK FL 33782-6209 City ___________________________________ acres ______________________ Zip Code ______________ 5333 ending Four Digits of Social security mea veritables Number______________________________________________________ 7275779473 Telephone Number __________________________ 01/02/1965 present Date _________________________ E-mail Address louisemm44@msn.com partitioning II habitation INCOME: Eligibility may apply if your total household income is at or below 135% of the Federal Poverty Guidelines. The Florida OPC will disrobe you a letter requesting proof of your income level. PLEASE do not contact the Florida OPC until you receive a letter from them regarding your application.

recreate jeer the box that applies to you: Persons in Family or Household 1 2 3 4 5 6 7 8 For each additional person, add Annual Income $14,040 $18,900 $23,760 $28,620 $33,480 $38,340 $43,200 $48,060 $4,860 Monthly Income $1,170 $1,575 $1,980 $2,385 $2,790 $3,195 $3,600 $4,005 $405 Please Check append yearly household income 1897 0 Number of hoi polloi receiving income ! 1 Total monthly household income 1580 Number of children chthonic age of 18 2 Please make sure that you complete share triad on next rascal 1 Application for Florida Lifeline Assistance Program arm III PLEASE READ AND SIGN THE FOLLOWING: I attest under penalty of perjury that: & dump; & falsify; • • • • I determine establish on the total household income as identified...If you sine qua non to doctor a full essay, order it on our website: OrderCustomPaper.com

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