SECTION C1:
COMPLETE THIS SECTION TO DETERMINE ELIGIBILITY FOR NET INCOME REQUIREMENT
If filing Joint Income Tax Return, Applicant must complete Column 1A only. If filing separately, both Columns 1A and 1B must be completed
INCOME FOR TAX YEAR ENDING DECEMBER 31, 20______
COLUMN 1A
COLUMN 1B
APPLICANT
SPOUSE
Line 1
Total Income from Public or Private retirement, disability or pension system
2
Line
Total Income from Social Security
Line 3
Total Income from both retirement and Social Security (Line 1 plus Line 2)
Line 4
Maximum Social Security amount (from Tax Receiver)
Line 5
Retirement Income over maximum Social Security (Line 3 less Line 4) - If less than 0, use 0
Line 6
Other income from all sources
Line 7
Adjusted Income (Line 5 plus Line 6)
Line
8
Standard or Itemized Deductions from Georgia Income Tax Return
Line 9
Personal Exemption amount from Georgia Income Tax Return
Line 10
Net Income (Line 7 less Lines 8 and 9)
If filing Joint Income Tax Return, Line 10, Column 1A must be less than $10,000. If filing Separately, Total of Line 10, Column 1A plus 1B must be less than $10,000
SECTION C2:
COMPLETE THIS SECTION TO DETERMINE ELIGIBILITY
FOR FEDERAL ADJUSTED GROSS INCOME REQUIREMENT
For each member residing in the household, complete the social security number & federal adjusted gross income in the spaces below
INCOME FOR TAX YEAR ENDING DECEMBER 31, 20______
FEDERAL
SOCIAL
SECURITY
ADJUSTED
NUMBER
GROSS INCOME
Line 1
Name of Household Member
2
Line
Name of Household Member
Line 3
Name of Household Member
Line 4
Name of Household Member
Line 5
Name of Household Member
Line 6
Name of Household Member
Line 7
Name of Household Member
ADJUSTED GROSS INCOME-TOTAL OF LINES 1 THRU 7 MUST BE LESS THAN $30,000>>>>>>>>>>>>>
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