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Household Size
1
2
3
4
5
6
7
8
Child Support (monthly gross) $
X 12 months is
$
Unemployment (monthly gross)
$
X 12 months is
$
Wages (monthly gross)
$
X 12 months is
$
Workers' Compensation (monthly gross)
$
X 12 months is
$
Other Income (monthly gross)
$
X 12 months is
$
Pension and Medical Premiums (monthly gross)
$
X 12 months is
$
TANF/EAEDC (monthly gross)
$
X 12 months is
$
Supplemental Security Income (monthly gross)
$
X 12 months is
$
Social Security and Medicare (monthly gross)
$
X 12 months is
$
Total Annual Income
$
Income Guidelines
Household Size
Max Annual Gross Income
1
$14,521.00
2
$19,669.00
3
$24,817.00
4
$29,965.00
5
$35,113.00
6
$40,261.00
7
$45,409.00
8
$50,557.00