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DocuSign Envelope ID: 9B3FAF99-0D78-49C7-B41E-F53AE7922E72 6

Self-Attestation of Household Income/Resources Electronic Data Source Reasonably Compatible Case Action Source of Income/Resource Used to Determine Eligibility At or Below Threshold for applicable household size Above Threshold for applicable household size Yes, if the self-attested amount is within 20% of electronic source amount. No further action necessary as the income/ resource meets the reasonable compatibility standard Applicant’s income/ resource self- attestation. No, if the self-attested amount is not within 20% of electronic source amount. Ask for reasonable explanation, or verification if needed. If reasonable explanation is provided, then use the applicant’s income/ resource self-attestation. If additional verification needs to be requested, then use the amount provided on the additional verification