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Last Name&Sr,Jr,etc. First Name MI Date of Birth Sex Relation <br /> 2 <br /> Race(select one or more) Ethnicity(check one box) <br /> [ ] White [ ] Asian [ ]Black or African American [ ] Hispanic or Latino <br /> [ ] Native Hawaiian or Other Pacific Islander [ ] Not I lispanic or Latino <br /> I } Amencan Indian°Alaska Native <br /> Name&Sr,Jr,etc First Name MI Date of Birth Sex Relation <br /> 3 <br /> Race(select one or more) Ethnicity(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 r Alaska Native <br /> Last Name&Sr,Jr,etc. First Name Ml Date of Birth Sex Relation <br /> 4 <br /> Race(select one or more) Ethnicity(check one box) <br /> [ ] White [ ] Asian [ ]Black or African Amencan [ ] Hispanic or Latino <br /> [ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino <br /> [ ] American Indian%Alaska Native <br /> Last Name&Sr,Jr,etc. First Name MI Date of Birth Sex Relation <br /> 5 <br /> Race(select one ore more) Ethnicity(check one box) <br /> [ ] White [ ] Asian [ ]Black or African American [ ] I lispamc or Latino <br /> [ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino <br /> [ ] American Indian/Alaska Native <br /> Last Name&Sr,Jr,etc. first Name MI Date of Birth Sex Relation <br /> 6 <br /> Race(select one or more) Ethnicity(check one box) <br /> [ ] White [ ] Asian [ ]Black or African Amencan 9 } Ilrspanir_or Latino <br /> f ] Native Hawaiian or Other Pacific Islander [ '[ Nit I lrspanic or Latino <br /> [ ] Amencan Indian'Alaska Native <br /> PART 3: ASSET INFORMATION: Please list any checking,savings,stocks,bonds,annuities,savings bonds,credit <br /> union shares,trust accounts,retirement contributions,pension contributions,IRAs,certificates of deposit or other assets <br /> for everyone in your household. Also include assets that are held jointly with another person and include the joint <br /> holder's name. <br /> Family Member Bank/Credit Union/Financial Type of Account Estimated <br /> Name Institution Account Number Current Balance <br /> PART 4: REAL ESTATE INFORMATION: Please list all real estate owned for everyone for in your household. <br /> Family Member Tax Map Key Current Mortgage Monthly Mortgage Mortgagee Name <br /> Name Number Assessed Value Balance Payment Loan No. and Address <br /> A <br /> PART 5: LIABILITIES: Please list total monthly debt owed;credit cards,car loans,personal loans,etc,except previously <br /> listed mortgages. <br /> Family Member Account Type Balance Monthly Account No. Creditor Name <br /> Name Payment and Address <br />