Are you or is your spouse, your parent (if you are under 21 or disabled), or your child living with you receiving any of the following benefits:

• Medi-Cal (Medicaid)
• Supplemental Nutrition Assistance Program (“SNAP” or formerly Food Stamps)
• Temporary Assistance to Needy Families (TANF)
• Supplemental Security Income (SSI)
• Other public assistance based on income and resources

My household income is at or below 150% of the Federal Poverty Guidelines, based on my household size.

Sponsor’s Household Size	150% of HHS Poverty Guidelines
1	$22,590
2	$30,660
3	$38,730
4	$46,800
5	$54,870
6	$62,940
7	$71,010
8	$79,080
	Add $8,070 For each additional person