Benefits Paid
$
$
$
(Net Allotment + Overpayment Recovery)
Household Information
Use only if Household includes Ineligible Noncitizens
Income Information

Reminder: Is this Microenterprise income?

$
Enter Full Amount - Deduction will be calculated.
$
$
$
Retained By DHS as Current Reimbursement.
Adjustment Information
$
Including aged off benefits.
$
Comments
(Use only for Non-Citizen Calculation)
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