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DocuSign Envelope ID: 9B3FAF99-0D78-49C7-B41E-F53AE7922E72 7

Self-Attestation of Household Income/Resources Electronic Data Source Reasonably Compatible Case Action Source of Income/Resource Used to Determine Eligibility Above Threshold for applicable household size At or Below the 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 The electronic source amount. 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 electronic source data. If additional verification needs to be requested, then use the amount provided on the additional verification.