Page 75

(a) (b) (c) (d) Family Size 100% of SMI($/Month) 85% of SMI ($/Month) [Multiply (a) by 0.85] (IF APPLICABLE) ($/Month) Maximum Initial or First Tier Income Limit (or Threshold) if Lower Than 85% of Current SMI IF APPLICABLE) (% of SMI) [Divide (c) by (a), multiply by 100] Income Level if Lower Than 85% of Current SMI 1 N/A N/A N/A N/A 2 $4,878 $4,146 $1,832 38% 3 $6,026 $5,122 $2,311 38% 4 $7,173 $6,097 $2,790 39% 5 $8,321 $7,073 $3,268 39%

c) If the income eligibility limits are not statewide, describe how many jurisdictions set their own income eligibility limits and provide the income limit ranges across the jurisdictions (e.g. range from [lowest limit] to [highest limit])( 98.16(i)(3)). N/A

Reminder: Income limits must be established and reported in terms of current SMI based on the most recent data published by the Bureau of the Census (98.20(a)(2)(i)) even if the federal poverty level is used in implementing the program. SMI guidelines are available at: https://www.acf.hhs.gov/ocs/resource/liheap-im2017-03.

d) SMI source and year. 2017 Federal Register e) Identify the most populous area of the State used to complete the chart above. N/A- Income limits are throughout the entire state.

f) What was the date (mm/dd/yyyy) that these eligibility limits in column (c) became effective? 07/01/2019

g) Provide the citation or link, if available, for the income eligibility limits. http://dhhs.ne.gov/Pages/Guidance-Documents.aspx

3.1.4 Lead Agencies are required to ensure that children receiving CCDF funds do not have family assets that exceed $1,000,000, as certified by a family member (98.20(a)(2)(ii)). Effective Date: 10/01/2018

Nebraska Page 75 of 314