Recipient Name* Recipient Phone Number* Monthly Income* Source of Income* Social Security Pension Disability SNAP Other Housing Costs* Housing Mortgage / Rent / Insurance Utilities* Gas/Electric/Water/Sewer/Trash Pick-up Connect to Others* Phone / TV (cable) / Internet Vehicle * Car Payment / Car Insurance / No vehicle expenses Medical* Out of pocket Prescription Costs /Monthly Medical Bills Medical Insurance* Insurance Premiums / Co-Pays / No Expenses Other Please list source and cost

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