Medicaid And Kid Care Chip Renewal Form Page 7

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Tell us about other income
(continued)
Cross out any information that is not correct about members of your household. Write in the new information.
Alimony received
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
Farming or fishing (profit after business expenses)
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
Rental income or royalties (profit after business expens es)
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
Other income Type:
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Twice a month
Yearly
Other income Type:
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
If anyone in your household has deductions, tell us what kind.
Alimony paid to someone else
How much?
How often?
Name (first, middle, last & suffix):
Weekly
Every two weeks
Monthly
$
Twice a month
Yearly
How often?
Student loan interest paid
How much?
Name (first, middle, last & suffix):
Weekly
Every two weeks
Monthly
$
Twice a month
Yearly
Dependent care expenses
How much?
How often?
Name (first, middle, last & suffix):
Weekly
Every two weeks
Monthly
$
Twice a month
Yearly
List the names of anyone whose income changes from month to month. Also tell us
how much you think their income will be for the year.
1.
Name (first, middle, last & suffix):
$
What do you expect his or her income to be this year? Amount:
2.
Name (first, middle, last & suffix):
$
What do you expect his or her income to be this year? Amount:
?
7
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