Fillable Form 297 297 (Clark County Board of Commission)

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Form 297 297 (Clark County Board of Commission)

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The Form 297 297 (Clark County Board of Commission) form is 6 pages long and contains:

  • 0 signatures
  • 36 check-boxes
  • 175 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Clark County Board of Commission

BROWSE CLARK COUNTY BOARD OF COMMISSION (OH) FORMS

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FAMILY BACKROUND
Marital Status (Check one): ___Married ___ Single ___Divorced ___Separated
___
Engaged ___Widowed___ Common Law
Current Residence (Check one): ___House ___Apartment ___Mobile home ___Dormitory
___ Other:_____________________
What amount do you pay per month to live there?_________________________________
How long have you lived there? ______________________________________________
Prior Residence? ____________________________________________________________
Name
Age
Relationship
Who do you live with? _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Name
Age
Your children who do
NOT live with you? __________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
EDUCATION
Check last year completed: ___1 ___2 ___3 ___4 ___5 ___6
___7 ___8 ___9 ___10 ___11 ___12
College: ___1 ___2 ___3 ___4
Technical: ___1 ___2 ___3 ___4 Did you graduate? ___________
Name, address and dates of schools attended:
High School: _______________________________
From _____________
to _______________
College :___________________________________
From _____________to _______________
Other: _____________________________________
From _____________to _______________
List your present monthly expenses (car payments, housing, medical bills, loans, personal
debts, charge accounts, etc.)
Monthly bills Amount paid per month
_____________________________________ ___________________________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
Total: _________________________________
HEALTH
Rate your health (Check one): ___Excellent ___Good ___Fair ___Poor
Briefly describe any physical or emotional problems that you have: ________________________
_______________________________________________________________________________
_______________________________________________________________________________
Do you have a family physician? ___________
Are you under a doctor's care?_____________
Doctor's name and address: ________________________________________________________
Do you feel you may have a drug or alcohol problem? ____________________________________
Have you ever received counseling or treatment for the use of drugs or alcohol? _______________
If so, name of agency: ____________________________________________________________
Have you ever seen a psychiatrist or psychologist? _______________________________________
If so, when and where? ____________________________________________________________
Please list medications that you are currently taking: ______________________________________
__________________________________________________________________________
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Form 297 297 (Clark County Board of Commission)

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Completed 6 August 2020

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