FINANCIAL ASSISTANCE PROGRAM TYPE B

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FINANCIAL ASSISTANCE PROGRAM TYPE B8221-071-1 (4/14)2720 Sunset Boulevard, West Columbia, south carolina , 29169 (803) 791-2000I. Applicant Identifying InformationName: ________________________________________ ________________________________________ ____Date of Birth: __________Social Security #: ____________Race: ____Sex: ____Marital Status: _______________ Mailing Address or current address: _______________________________ How long at this address? ____________City: ____________________________ State: ______ Zip Code: ________ County: ________________________Address where you live (if different or prior address if less than 4 months at current address): ________________________________________ ________________________________________ _________City: ____________________________ State: ______ Zip Code: ________ County: ________________________Telephone numbers: (H)_____________________(W)_____________ ________(C) _________________________US Citizen: Yes No Permanent Resident: Yes NoII.

FINANCIAL ASSISTANCE PROGRAM TYPE B 8221-071-1 (4/14) 2720 Sunset Boulevard, West Columbia, South Carolina, 29169 • (803) 791-2000 I. Applicant – Identifying Information

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