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Please fill in the information request form.

Be reassured that any information you submit will not be given out to any person or business unless you have given us permission. Portions may be used for statistical purposes only.

Information Packet Request Form for Jackson Affordable Housing
Your Full Name:
E-mail:
Head of Household:	Yes No
Co-Applicant:
Your Relationship:
Your Address:
City:
State:
Zip:
Phone:
Race:	Caucasian African-American Asian American Indian Pacific Islander Other I do not wish to furnish this information
Gender:	Female Male I do not wish to furnish this information
Are you disabled?	Yes No
Are You Employed:	Yes No
Co-Applicant Employed:	Yes No
Monthly Income Before Taxes:
Number of People in the House:

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