Income Eligibility Chart

	Maximum Monthly Gross Income
Household Size	48 States and D.C.	Alaska	Hawaii
1	$2,268.75	$2,833.33	$2,612.50
2	$3,064.58	$3,829.17	$3,527.08
3	$3,860.42	$4,825.00	$4,441.67
4	$4,656.25	$5,820.83	$5,356.25
For each additional person, add	$795.83	$995.83	$914.58
Calculate your monthly income limit if you have more than 4 people in your household
Select a number 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 or more

Proof of household income for the past 30 days will be needed.

Proof of Household Income

Send in proof of current income and your completed and signed application. In addition, a prescription with refills, if medically appropriate, must be submitted to receive refills by mail order.

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:
• 1040 form including Schedule C from the most recent tax return

• 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
• Copy of most recent check
• Check stub

• Other:
• Benefits statement
• Award letter
• Bank statement from payer/source
• Copy of check(s)
• Judgment statement