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Last Name:   First Name:   Middle Initial:   Address:   City:   County: Gratiot Isabella Montcalm Zip Code:   Phone Number:   Alternate Phone: Birthdate   Best time to reach you:

INCOME This Program follows Workforce Investment Act income eligibility requirements. How many people live in your household? What is your estimated household income for the last six months? (some income maybe be excluded such as: Unemployment Insurance, Welfare Payments, Social Security Disability, College Work Study, Foster Care Payments) Has the applicant every been diagnosed with a disability? (Proven disabilities may allow for income requirements to be waived) Yes No SCHOOL STATUS Are you currently enrolled in school?Yes No If yes, what school?