Form Mc 175-5 - Sneede V. Kizer Federal Poverty Level (Fpl) Programs For Pregnant Women And Infants (Income Disregard, 200 Percent[%]), Children Ages 1 Through 5 (133 Percent [%]), And Children Ages 6 Through 18 (100 Percent [%]) Page 2

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B. ELIGIBILITY DETERMINATION
Number of persons in MFBU ___________
1. Name of potential percent (%)
program eligible
2. Potential percent (%) program
Income disregard
Income disregard
Income disregard
Income disregard
Income disregard
200 percent (%)
200 percent (%)
200 percent (%)
200 percent (%)
200 percent (%)
(check one)
133 percent (%)
133 percent (%)
133 percent (%)
133 percent (%)
133 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
3. Enter FPL for percent (%)
$
$
$
$
$
program shown in B.2. based on
the number of persons in MFBU.
4. Enter total net nonexempt
$
$
$
$
$
family income (from A.7.)
5. Is total net nonexempt family
Yes, eligible
Yes, eligible
Yes, eligible
Yes, eligible
Yes, eligible
(continue)
(continue)
(continue)
(continue)
(continue)
income (B.4.) less than or equal
to amount in B.3.?
No, deny FPL
No, deny FPL
No, deny FPL
No, deny FPL
No, deny FPL
Program
Program
Program
Program
Program
6. Person number (optional)
7. Aid code (optional)
8. MBU number (optional)
Eligibility Worker signature
Worker number
Computation date
MC 175-5 (05/07)

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