ATTACHMENT B
ELIGIBILITY FINANCIAL WORKSHEET AND ASSESSED CO-PAYMENT FORM ... NAME _____ MONTHLY INCOME INFORMATION - Fill in all sources received. Individual. Spouse. Total. a. Social Security (SSA), including Medicare premium $ $ $ 1 a). Supplemental Security Income (SSI) $ $ $ 2 a). Social Security Disability Insurance (SSDI) $ $ $ b. Veterans ... ................
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