(For proper evaluation please submit information from BOTH worksheets.)

FAMILY INFORMATION: Name: Mr. Mrs. Ms. Email: Address: City: State:      Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zipcode: Home Phone: How PAST DUE are you? Applicant's and Spouse's TOTAL NET Monthly Income: $ TOTAL MONTHLY HOUSEHOLD and LIVING EXPENSES: $ (Expenses to be itemized upon program enrollment) All information will be kept confidential. A counselour will contact you as soon as information is received and your accounts are verified and configured for our plan. Thank you for choosing CBC.