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1

ZIP/Email

2

PERSONAL INFO

3

QUALIFY

4

VERIFICATION

Zip Code, Email Address, Agent Email

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No

Temporary
Permanent

How do you qualify for LifeLine service in Illinois?


Medical Assistance (Medicaid)

Food Stamps (SNAP)

Income Requirements - 135% of Federal Poverty Level





In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below. Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Qualifying Annual Income Amounts - 135% FPG
Household Size Income
1 $17,226
2 $23,274
3 $29,322
4 $35,370
5 $41,418
6 $47,466
7 $53,514
8 $59,562
For each additional person add $6,048

Yes
No

AGREEMENT

You are almost done qualifying. Please initial next to each statement and sign this form to finish the process.

I agree, under penalty of perjury, to the following statements:



Your Signature