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Health Care Finance and Administration Section: Financial Eligibility Policy Manual Number: 010.035 Chapter: Reasonable Compatibility and Verification

• Business records • Bank deposit slip • Individual’s signed statement Farming or Fishing • IRS data from the Hub • Federal income tax return • Business Records • Bank deposit slips, receipts Unemployment • TDLWD • Written verification from the TDLWD • Written verification from state of issuance if unemployment benefits are received from another state. Retirement • IRS data from the Hub • State On-Line Query System (SOLQ), if individual had previous SSI connection • Written verification from the source of income • Copy of the most recent check and proof of deposit into the individual’s bank account with date of deposit Pension • IRS Data from the Hub • SOLQ, if individual had previous Supplemental Security Income (SSI) connection • Written verification from the source of income • Copy of the most recent check and proof of deposit into the individual’s bank account with date of deposit Social Security • SOLQ • Award letter from the Social Security Administration (SSA), Railroad Retirement Benefits Capital Gains

• Receipt from sale • Sale agreement • Proof of deposit into the individual’s bank account with amount and date of deposit Investment Income • IRS Data from the Hub • Copy of the most recent check and date of deposit Alimony Received • IRS Data from the Hub • Agreement awarding the individual alimony payments • Written statement from the individual paying the alimony and a copy of a recent alimony check or receipt Cancelled Debts

• Signed statement from the individual who forgave the debt Court Awards

• Court order or final judgment • Bank Statement Jury Duty Pay

• Copy of check(s) received • Proof of deposit into the individual’s June 4, 2015 HCFA 4