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City

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Current Residence single level hometwo story structureapartmentcondominiummulti-level home

Age of occupants (check all that apply)

60-65

66-70

70-75

76-80

81-85

86-90

Over-90

Number of Rooms

Master bedroom with bathroom

Master bedroom

Guest bedroom with bath

Kitchen

Florida room

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Dining room

other

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Self

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Daughter

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other occupant

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