Eligibility Checklist Template

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Eligibility Checklist
1) PHOTO identification
You need only ONE of the following:
 Driver’s License
 State ID
 Passport
 Current employment ID
2) Proof that you live or work in Walworth County
You need only ONE of the following:
 Utility bill
 Bank statement
 Piece of mail with your name and address on it
 Document verifying your place of employment with the workplace address on it
3) Income verification
You need ALL of the following that apply:
 Payroll check stubs from the last 30 days for you and/or your spouse
 If self employed, Schedule C Tax Form
 Unemployment verification
 Child support verification
 Rental assistance verification
 Social Security verification
 Verification of any other income
4) Additional Requirements
 Medical Assistance wait-list or denial letter
 If you filed taxes for 2011, you need either form 1040 or 1040EZ

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