If you need help, click on the yellow question marks.

1. Elderly or disabled household members Yes No 2. Household size 3. Gross monthly earned income 4. Monthly unearned income 5. Expenses a). Monthly child support paid to non-household members b). If you answered Yes in question #1, enter any monthly medical costs for elderly/disabled household members 6. Monthly Child or Adult Care Costs Dependent # Under age 2 Care Costs Dependent # Under age 2 Care Costs 1 Yes No 2 Yes No 3 Yes No 4 Yes No 7. Shelter costs a). Rent or mortgage b). Monthly property tax and homeowners insurance c). Monthly utilities, standard utility allowance, or telephone standard