Please take a photo of your ID and upload here.
Please take a photo of a current bill with your name and address and upload here.
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