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;+ /Tr or Nom. <br /> Harry Kim ' •]ut '�' Neil S.Gyotoku <br /> Mater <br /> • Housing Administrator <br /> Lance M..Nnmi <br /> County of Hawaii Assistant Housing <br /> Office of Housing and Community Development Administrator <br /> 1990 Kino'ole Street,Suite 105•Hilo,Hawaii 96720 <br /> VITT(808)959-4642•Fax(808)959-9308 <br /> KONA: 74-5044 Ane Keohokalole Highway • Kailua-Kona,Hawaii 96740 <br /> (808)323-4300 • Fax(808)323-4301 <br /> RESIDENTIAL REPAIR PROGRAM APPLICATION (RRP) <br /> Application must be filled out COMPLETELY. Please use BLACK Ink to complete application. If any question does NOT <br /> apply, please acknowledge by writing NONE or NOT APPLICABLE. Do not leave any section unanswered. Be reminded <br /> that Questions asked apply to ALL Household members. Please print or type. <br /> PART I: GENERAL INFORMATION: <br /> APPLICANT <br /> (Head of Household): Phone <br /> Legal M <br /> Last Name First <br /> Name M111 <br /> CO-APPLICANT <br /> (Spouse or Co-Head) _... Oilier Phone:waa <br /> I egal Last Name First Name MI <br /> Current Address.' Apt.No....,,...� <br /> try: tateC <br /> Zip' Yrs.at Residence: <br /> Previous address if less than 2 yrs,at above Yrs.at Residence <br /> Check here if mailing address is the same as current address. <br /> Mailing Address: Apt.No. <br /> City; State Zip:mm <br /> PART 2: HOUSEHOLD MEMBERS: <br /> Starting on first line for the:Head of Household,please supply the information for all adults and children that will live in the housing unit to be assisted. <br /> List the adults first,then children. Enter one of the following codes in the"Relation"box to identify the household relationship ofeach adult and child <br /> listed. II Head of Household K Co-Head(Not Married) Y Youth Under l8 L Live In Aide <br /> S Spouse(Married) F Foster Child/Adult E w Full Time Student Over 18 A Other Adult <br /> Last Name&Sr,Jr„etc. First Name Ml Date of Birth Sex Relation <br /> 1 H tHeasd sof Ho u s e he U Ilk <br /> Single Race(select one or more) Ithnicity(check one box) <br /> [ ] White [ ] Asian [ ]Black or African American ]; '[ Hispanic or Latino <br /> [ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino <br /> [ ] American Indian!Alaska Native <br /> Multi Race(select one or more) <br /> [ ] Asian and White [ ]Other Mulu.Racial <br /> [ ] Black or African Amencan and White <br /> [ ] American Indian t Alaska Native and White <br /> [ ] American Indian Alaska Native and Black <br /> EQUAL HOUSING OPPORTUNITY <br /> 'HAWArI COUNTY IS AN EQUAL OPPORTUNITY <br /> PROVIDER AND EMPLOYER' <br /> „ .O'9r'bia <br />