Instructions For Form F-44614i - Aids/hiv Drug Assistance Program And Insurance Assistance Program Application/recertification Page 2
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3F-44614I (02/2017)
Page 2 of 3
This information is referenced within Section II, Financial Information. The current income guidelines are as follows:
2017 Income Guidelines
Family
Federal Poverty
300% of
Family
Federal Poverty
300% of Guideline
Size
Guideline
Guideline
Size
Guideline
1
$12,060
$36,180
5
$28,780
$86,340
2
$16,240
$48,720
6
$32,960
$98,880
3
$20,420
$61,260
7
$37,140
$111,420
4
$24,600
$73,800
8
$41,320
$123,960
*Note: For family units of more than 8 members, add $4,180 for each additional person.
SECTION III. INSURANCE INFORMATION
Check all boxes that describe your current health insurance status. At least one box must be checked. Answer the series
of questions about any health insurance policy you may have.
If you do not provide the insurance information necessary to process your payment (cost of monthly premium,
mailing address to send payment, etc.) it will delay payment and could result in loss of your insurance coverage.
If a payment is due before you receive written notice that your application has been approved, you are responsible for the
premium payment. Failure to pay premiums on time may result in loss of your insurance coverage.
Proof of income and proof of residency are both required to process your application.
Income Documentation
Any document from this list will be accepted if it reflects your current income:
▪
Social security or Veterans’ Administration Benefits award letter from current year
▪
Check stub from employer (within last 60 days)
▪
Unemployment award/benefits statement
▪
A written statement from your employer on company letterhead that indicates your rate of pay and average of hours
worked per pay period
▪
A written statement from your case manager that indicates your average income
If you have no income, you may provide:
▪
A written statement from the person or organization that supports you financially
If you are self-employed and have filed taxes, you may provide:
▪
Most recent Internal Revenue Service (IRS) form 1040
If you are self-employed and have not filed taxes, you may provide:
▪
Any documentation that shows the income you receive and expenses, such as a current bank statement
Residency Documentation
The documents below will only be accepted as proof of residency if they are:
1. Current (within the last six months) and not expired,
2. The same as the your stated physical address on the Application/Recertification, AND
3. Not a PO Box address. Residency documents with a PO Box will not be accepted
Any document from this will be accepted if it includes name and current address:
▪
Identification card such as a driver’s license, DMV issued identification or immigration identification
▪
Most recent check stub from employer
▪
Most recent bill in the applicant’s name
▪
Most recent rental agreement or lease
▪
Most recent bank statement
▪
Most recent unemployment award/benefits statement, social security or Veterans’ Administration Benefits award letter
▪
Written statement from your case manager indicating they have conducted a home visit at the address
If you have no current address or are homeless, you may provide:
▪
Written statement from a homeless service provider (shelter, clinic, food program, etc.) verifying homelessness
▪
Written statement from your case manager indicating homelessness
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