Please answer the following questions so you, as an individual, can be couted in the plan of aging services for our community.  All of the information you provide is confidential and will be reported in group form only.
DEMOGRAPHIC INFORMATION

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* 1. My age is:

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* 2. My gender is:

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* 3. I live in the town, city, or area of:

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* 4. I have lived in this community:

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* 5. I am a veteran or a spouse of a veteran

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* 6. My martial status is:

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* 7. My sexual orientation is:

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* 8. I consider my race to be:

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* 9. I am of Hispanic, Latino, or Spanish origin.

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* 10. My primary language is:

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* 11. My highest level of education is:

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* 12. My employment status is:

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* 13. My monthly income is:

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