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Occupancy - Number of Residents (select all that apply) Self Wife Husband Son Daughter Grandchild Caretaker other

Current Residence single level hometwo story structureapartmentcondominiummulti-level home

Age of Residents (select all that apply) 60-6566-7071-7576-8081-8586-9090+

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Room Types (select all that apply) Master bedroom w/bathroom accessMaster bedroomGuest bedroom w/bathroom accessKitchenFlorida roomLiving RoomFamily RoomDining roomother

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