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Please list each household member’s name, date of birth, and annual income. Include Applicants.
For individuals 18 years of age and over, please submit photocopies of the following to verify identity:
And one of the following:
For individuals who are under 18 years of age, please submit a photocopy of one of the following to verify identity:
INCOME DOCUMENTATION REQUIRED
Jefferson County Public Health c/o Amanda Christofferson 615 SheridanPort Townsend, WA 98368
*Open Mon-Fri, 9 am – 4:30 pm.
I/We hereby apply for the cost share described in this application. l/We certify that l/We made no misrepresentations in this application or in any related documents, that all information is true and complete, and that l/We did not omit any important information. l/We agree that any property undergoing repair will not be used for any illegal purpose. l/We understand that the Cost Share provider may retain this application and any other personal financial information Cost Share provider receives, even if no cost share is granted. These documents will be retained under secure procedures for the appropriate retention period.
By typing my name above, I agree to the terms listed above.
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