Calculate your monthly income limit if you have more than 4 people in your household
Proof of income for the past 30 days will be needed.
Proof of Household Income
Send in proof of current income
and other requested documents along with the completed and signed application and a prescription with
refills if medically appropriate for mail order refills.
If the applicant filed income tax or was listed as a dependent on someone else's income tax
for the most recently filed tax year, attach a copy of page one of the tax form.
If no tax was filed or if the tax form does not represent current income, attach proof of income from
all sources for the most recent 30-day period for the applicant and all members of the household.
Please provide copies, not originals, of pay stubs, unemployment stubs, Social Security statements,
pension statements, and any other sources of income. The following are examples of acceptable
proof of income:
Income tax form:
A copy of page 1 of the most recently filed 1040, 1040A or 1040EZ tax return
Salary/wages:
One month consecutive salary/income documentation
A copy of a pay stub with year-to-date income
Letter indicating salary/wages on company letterhead
Notarized statement from employer
Bank statement showing salaries and wages deposited by employer
Self employment income:
1099 form including Schedule C from the most recent tax return
Copy of most recent check or check stub
Social Security Retirement:
Benefit statement for current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check or check stub
Supplemental Security Income:
Benefit statement for current year
Copy of most recent bank statement showing direct deposit
or copy of most recent check or check stub
Social Security Disability:
Benefit statement for current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check or check stub
Unemployment:
Unemployment award letter on company letterhead indicating amount and time period covered
Copy of most recent unemployment check or unemployment check stub
Alimony/Child support:
Court award letter indicating amount and time period covered
Child Support Enforcement Agency letter
Letter from attorney stating amount and time period covered
Copy of one month's check
Bank statement with amount indicated
Veterans Benefits:
Benefit statement or current year
Copy of most recent bank statement showing direct deposit
Copy of most recent check
Check stub
Pension/Retirement:
Benefit statement for current year
Copy of most recent bank statement showing direct deposit
