SSN. 2. Description of the property with respect to which the election is being made: __________________(_____) shares of Common Stock, par value $0.0001 per share, of the Company.
SSN. 2. Family Size;
SSN. 2. The property with respect to which the election is being made is non-voting common stock of Xxxxxx Bancorp, Inc.
SSN. OR EIN: __ __ -- __ __ __ __ __ __ __ Check Appropriate box: Individual/Sole Prop. Other Print name as shown on your income tax return if different from «Payee»: ________________ Under penalties of perjury, I certify that:
SSN. The above application accepted this ............... day of ........................., ............
SSN. Relationship to Child/Youth: Mother Father Other Caregiver Self PLEASE LIST ALL OF THE ADULTS WHO RESIDE IN THE HOME: Last Name, First Name D.O.B. Relationship to Child PLEASE LIST ALL OF THE CHILDREN WHO RESIDE IN THE HOME, REGARDLESS OF DEPENDENCY STATUS Last Name, First Name D.O.B. Mother’s Name and Mother’s SSN Dependant Yes No If child/ren are receiving AFDC/FC, check one: 40 (non-federal) or 42 (federal) Is this an application for housing assistance or relocation? If yes, please complete below. Property Address: (Street, City, State, Zip Code) Property Owner: (Name) Must have one original form per vendor ************************************************************************************************************************************************************* Make Check Payable to: Vendor Landlord Telephone #: Tax ID #: Amount: $ Name of Payee Street Address City State Zip Code DISTRIBUTION METHOD: Mail to PAYEE Hold for pick-up at: OMO-000 Xxxxxxxx xxxxxxxxx, Xxxxxxx XXX 00000/ XXXX xxxxxxxxx, Xxxxxxx XXX 00000 ************************************************************************************************************************************************************** Relevant Waiver Goals (please check all that apply): To increase the number of children who can remain safely in their own homes. To increase the number of children and youth placed in least restrictive settings. To increase the number of children who safely and permanently reunify with their families within 12 months. To increase the percentage of timely adoptions and guardianships. To improve self-sufficiency and well-being for transition age youth emancipating from xxxxxx care. Is this an application for Kinship Emergency Funds? If yes, please complete below:
SSN. Please enter social security number for individuals or EIN number for business accounts. Please print or type clearly. And be sure the numbers are in sync with your W9.
SSN. It is critical that this information is correct so the money will be deposited in the correct account number at the appropriate bank. If you have questions about obtaining the correct transit or account numbers, please contact your financial institution.
SSN. If vehicle(s) is/are owned by a company, you must supply he Employer Identification Number (EIN): EIN:
SSN. 17 14. The Data Breach has subjected Plaintiff and the other Class Members to an 18 unauthorized access and exfiltration, theft, or disclosure of their nonencrypted and nonredacted 19 PII, including, but not limited to, PII that falls within the definition of subparagraph (A) of 20 paragraph (1) of subdivision (d) of Civil Code section 1798.81.5.
