Empower New York Program Application Checklist Page 4
Download a blank fillable Empower New York Program Application Checklist in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Empower New York Program Application Checklist with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8SECTION E: INCOME INFORMATION
Include the following information for each household member.
Name
Gender
Age
Student
Source(s)
Weekly
Monthly
Yearly
(Yes or No)
of income
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Income for the Household $
$
$
0.00
0.00
0.00
q Check here if you have received HEAP within the past 12 months.
SECTION F: INCOME DOCUMENTATION
A.
q Provide a copy of ONE of the following:
Copy of entire award letter for HEAP, SNAP (Food Stamps), TANF (Temporary Assistance for Needy Families)
or Supplemental Security Income dated within the past 12 months
B.
q Only if you cannot provide one of the documents listed under A, provide income documentation as follows:
• All household gross income for the last month: Pay stubs. To obtain monthly income total, if income is:
- Weekly - multiply weekly income representing 4 most recent weeks by 4.3
- Bi-weekly: multiply 2 most recent consecutive weeks by 2.15
- Twice a month: multiply by 2
• Social Security and Social Security Disability: copy of award letter
• Documentation of all forms of income including disability, worker’s compensation, unemployment, pension,
maintenance, child support, annuities, Veteran’s benefits and all other income.
• Self Employment: IRS Report of Quarterly earnings for the last three months
Page 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 14204 - Tax Counseling For The Elderly (tce) Program Application Checklist And Transmittal - 2011
Financial
Form 14204 - Tax Counseling For The Elderly (tce) Program Application Checklist And Contact Sheet
Financial
Form 14204 - Tax Counseling For The Elderly (tce) Program Application Checklist And Contact Sheet
Financial
Related Categories
Parent category: Business