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*  Required Information

Step 1: Please complete this information about yourself or the applicant:
* First Name:	MI:	* Last Name:	* Date of Birth: (mm/dd/yyyy)	* Gender
				Male Female

* Address Line 1:	Address Line 2:

* City:	* State:	* Zip Code:
	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* Phone #: (999-999-9999)	Email Address:

Please Note - For applicants under age 60, please report annual or monthly income in all applicable spaces (1000.00). Please do not include dollar signs or commas. If there is no income, please enter a 0 for your income.

Income Type:	Income:	* Family Size:	* Language:
Monthly Annual			English Spanish

Step 2: Enter your family member information. If your dependents have no income, please enter a 0 for their income. If you are applying as an individual, please proceed to Step 3.
Relationship:	First Name:	MI:	Last Name:	Gender:	Date of Birth: (mm/dd/yyyy)	Income: (ex: 1000.00)
Spouse Child				Male Female
Child				Male Female
Child				Male Female
Child				Male Female
Child				Male Female
Child				Male Female
If you have additional dependents who need added to the program, please call 866-341-8894. TTY user may call 866-763-9630.

Step 3: Attest to this Application:
	I affirm that the information and any documentation provided in this application is true, complete, and accurate to the best of my knowledge and belief. If attesting on behalf of the applicant, I also affirm that I am authorized to do so.