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Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 7. Office of Child Support Enforcement YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Other (specify in comments) This data source will be used for obtaining third-party liability information. It will also note the cooperation status with child support enforcement for beneficiaries required to cooperate with that office. This interface is expected to occur daily 8. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 9. Women, Infants and Children Program (WIC) NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 10. State Income Tax NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 11. Commercial database: (Please describe any commercial databases in the space below) 13. Other: (Please describe additional electronic data sources in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 8