HaoHan Technologies, LLC
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JHHNO: JH
First Name:
Last Name:
Determination Date:
Household income: $
(Integer) No. of persons in household supported by the income:
Housing Status:
Select one
Permanently housed
Non-permanently
housed Institution
Other
Unknown/unreported
EVS checked:
Select one
Yes
No
N/A
If other, state reason:
Medical assistance application pending:
Select one
Yes
No
Application(s) pending: (check all if apply)
MADAP
Pharmacy Assistance
MA
SSI
SSDI
DSS
MPAP
MPDP
TAP
Other
If other, specify:
Income verification:
Pay Stub
W4
SSA/SSI
TCA/CSS
Employer letter
Income tax form
None
Other
If other, specify:
Zip verification:
Select one
Utility bill (Land Line Phone, BGE, Cable, etc)
SSI letter
Drivers license or State ID
Letter from person finacially responsible for shared residence
Letter from shelter staff
Not yet verified
Lease
DSS Award Letter
Official Mail from Government Agency (Fed, State, Local government agency)
Incarcerated any time in last year:
Select one
Yes
No
Unknown
In the EMA?
Select one
Yes
No