SFN 1540, Part II, Annualized Income by Month 415-65-15-10

 

(Revised 10/00 ML #2629)

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Use the space in Part II to subtract any deductions on Line E of SFN 530 which must be considered before eligibility can be determined for that month. If the adjusted annualized income falls below the income guidelines, put a check in the "eligibility" column.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.