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First Name
Last Name
Email
DOB
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North Dakota
Ohio
Oklahoma
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South Carolina
South Dakota
Tennessee
Texas
Utah
West Virginia
Wisconsin
Wyoming
Marital status
Single
Married
How many dependants do you claim?
0
1
2
3
4+
Estimated annual household income
$0 - $15,000
$15,000 - $25,000
$25,000 - $50,000
$50,000+
Do you have medicare?
Yes
No
Do you have medicaid?
Yes
No
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