Office Use Only Unit Size Requested Unit Number Targeted Move-In Date Date Received Time Received _C__o__k_a__t_o__P__a__r_k_v__i_e_w____________________________ _2__6_0___T__h_i_r_d__S__t_r_e__e_t__S__o__u_t_h__w__e__s_t_____________ _C__o__k_a__t_o_,__M___N___5_5__3_2__1_________________________ _P__h__:_(_3__2__0_)__9__0_5__-_2__8_7__4________________________ APPLICANT INFORMATION Applicant Name (Head of Household): Address: Social Security Number: Date of Birth: [ ] Male [ ] Female [ ] Decline Applicant Phone #: Applicant Email: Alternate Phone #: Alternate Email: Emergency Contact: List All Other Household Members First MI Last Relationship to Head Date of Birth Male/Female/ Decline to Answer Social Security Number [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline Primary Language: Do you require an interpreter? [ ] Yes [ ] No How did you hear about this housing? [ ] Online [ ] Newspaper [ ] Local Agency [ ] Drive By [ ] Resident Referral [ ] Other What is the combined gross monthly income of all household members? $ ADDITIONAL HOUSEHOLD MEMBERS CURRENT HOUSING STATUS How long have you lived at your current address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: Do all adult household members live at this address?........................................................................................................................ [ ] Yes [ ] No If NO, include additional adult household’s current address and contact information on a separate piece of paper. PREVIOUS HOUSING STATUS Your previous address: How long did you live at your previous address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: List every state in which each household member has lived: ELIGIBILITY INFORMATION
For Office Use Only Ref No )
Help Desk A help desk for Product support issues (the “Help Desk”) will be available to Customer. Unless specified in an Order, Customer should contact ▇▇▇.▇▇▇.▇▇▇▇ to receive a telephone number for the applicable supporting Solutions & Support Center. Customer will appoint one Product administrator and one backup administrator to serve as the primary point of contact regarding maintenance services.
Directory Assistance Service Updates 8.3.3.1 BellSouth shall update end user listings changes daily. These changes include: 8.3.3.1.1 New end user connections 3.3.1.2 End user disconnections
Service Areas HHSC authorizes the MA Dual SNP to add the MA Product to Texas service areas that are not identified in Attachment C, Proposed MA Product Service Areas, provided it receives prior CMS approval and complies with the notice requirements specified in this Agreement.
