Please take a photo of the front of your driver’s license, state ID card, or passport photo page
Please take a photo of a CURRENT utility bill, tax bill, cell phone bill, lease agreement, etc. Your proof must be current (within the last six months) and show the patient’s name and address
Total number of people living in your household ages:
*This section to be completed by Dream Center Staff/Volunteer
Add patient’s income column with other member’s income column for total household income$_____________
Compare household total to the FPG chart at 250% to determine eligibility.
_____ YES - patient is eligible
_____ NO - the patient in not eligible