Directions: Please enter MONTHLY amounts for each field. Leaving a field blank is the same as entering "0."
Number In House Hold *
Gross Monthly Earned Income (of total household) *
Unearned/Other Income (TANF, SSI, SSDI, Worker's Comp, Unemployment, Child Support received, etc.)
Is at least one member Elderly (over 60) or Disabled?	Yes
Recurring Medical Expenses For Elderly or Disabled Person(s) (enter total cost; leave blank if expenses are below $35)
Dependent Care Costs (day care, babysitter, etc.)
Child Support Payments (made to someone outside of the house)

Shelter Costs
Rent or Mortgage payment
Individual pays for Utilities AND that bill is separate from Rent/Mortgage (check "No" if the person either doesn't pay Utility costs OR if Utility costs are included in Rent/Mortgage)	Yes No
Homeless and paying for shelter?	Yes
Answer the next two questions ONLY if individual owns his/her home:
Homeowner's Insurance (if not included in Mortgage)
Property Tax (typically paid Yearly, so make sure to enter the Monthly amount)

* Required Fields

Last updated November 2, 2018