INSTRUCTIONS: FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL)
Alabama public employees who are active or retired members of the state-administered PEEHIP health insurance plan use the form discussed in this article in order to apply for financial assistance related to having income that qualifies as federal poverty level. This document may be obtained from the website maintained by the Retirement Systems of Alabama.
Federal Poverty Level Assistance Application (FPL) Step 1: In the first box, enter your Social Security or PID number.
Federal Poverty Level Assistance Application (FPL) Step 2: In the second box, enter your first name.
Federal Poverty Level Assistance Application (FPL) Step 3: In the third box, enter your middle name or initial.
Federal Poverty Level Assistance Application (FPL) Step 4: In the fourth box, enter your last name.
Federal Poverty Level Assistance Application (FPL) Step 5: In the fifth box, enter your mailing street address.
Federal Poverty Level Assistance Application (FPL) Step 6: In the sixth box, enter your city.
Federal Poverty Level Assistance Application (FPL) Step 7: In the seventh box, enter your state.
Federal Poverty Level Assistance Application (FPL) Step 8: In the eighth box, enter your zip code.
Federal Poverty Level Assistance Application (FPL) Step 9: In the ninth box, enter your home phone number, including the area code.
Federal Poverty Level Assistance Application (FPL) Step 10: In the tenth box, enter your work phone number, including the area code.
Federal Poverty Level Assistance Application (FPL) Step 11: Do not fill in the eleventh box. This box is for internal use only.
Federal Poverty Level Assistance Application (FPL) Step 12: In the twelfth box, indicate with a check mark whether you are single, married, divorced, legally separated or widowed.
Federal Poverty Level Assistance Application (FPL) Step 13: In order to successfully submit this form, you must attach a copy of your federal 1040, 1040A or 1040EZ form from the previous year, as well as copies of all supporting 1099 and W-2 documentation. If you are married but did not file jointly, you must provide the same documentation for your spouse.
Federal Poverty Level Assistance Application (FPL) Step 14: Sign and date the form. Your spouse, if applicable, must do the same.
Federal Poverty Level Assistance Application (FPL) Step 15: To continue receiving this assistance, you must reapply every year using this form.
