Government of New York

I certify that my documented 2019 or 2020 household income is at or below 500% of the poverty level for the number of family members residing in my household as documented in my 2019/2020 tax return. I certify that I have included ALL expenses I am seeking reimbursement for; I understand only one application is allowed per household. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download