We Counted __1__Resources To
Determine Your Subsidy
For __2__ and
Bank Accounts $___1___
Stocks, Bonds, or Other Investments
Cash Value of Life Insurance
(Burial Fund Money We Do Not Count) (___6___)
Your Resources That We Count $___7___
Resource Limit for Subsidy Eligibility $___8___
Amount Over The Resource Limit $___9___
We counted only the resources listed above. We do not count the value of your home,
your vehicles or your personal possessions.
NOTE: Use the following paragraph only when we have applied the $1500 burial exclusion.
Because you have set aside money for burial expenses, we also do not count $1,500.
Choice 1: your
Choice 2: your and your spouse’s
month and year of application using format “January 2006”
(date can be no earlier than January 2006)