Household Information 

#Filing Group:      Cat El: Yes       No
#Meet Citizen/Alien Req:      Elderly/Disabled: Yes       No
#NC1:      Utility Standard: FUA LUA TUA IUA None
#NC2:      Effective Date

 Income 

     NC1      NC2      Meets Citizen/Alien Requirements
Earned Income: Earned Income: Earned Income:

    Self Employment Income     Self Employment Income     Self Employment Income
SEC: SEC: SEC:
SEN: SEN: SEN:

Other Unearned Income: Other Unearned Income: Other Unearned Income:
TANF Grant Amount: TANF Grant Income: TANF Grant Income:

 Deductions 

Medical Costs: Medical Costs: Medical Costs:
Dependant Care: Dependant Care: Dependant Care:
Court Ordered Support: Court Ordered Support: Court Ordered Support:
Rent or Mortgage: Rent or Mortgage: Rent or Mortgage:
Responsible for Utility Costs: Responsible for Utility Costs: Responsible for Utility Costs: