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Lifelong Dental Program Income Elibility

Acceptable eligibility documentation of the client’s total income should include one or more of the following:

  • 2 current, consecutive paystubs or earnings statements for ALL jobs
  • For self-employed clients, most recent tax returns (quarterly or annual) or business records for 3 consecutive months prior to verification
  • Unemployment compensation check stubs or benefit letter
  • Documentation from a financial institution showing income received from stocks, bonds, cash dividends, trust income, investment income, or royalties
  • Benefit award letter or official document showing amount received annually for alimony, child support, or foster care payments
  • Annual benefit statement of pension or retirement income
  • Annual benefit statement of Social Security retirement/survivor’s benefit, Social Security Income, or Social Security Disability Income (SSI/SSDI)
  • Veteran’s benefits award letter
  • Most recent payment statement of benefit notice for public assistance cash payments (does not include Low Income Home Energy Assistance Program)
  • Benefit award letter for worker’s compensation benefits
  • Benefit award letter for union benefits
  • Affidavit of self-disclosed income if no other documentation available (e.g., day labor income paid in cash)
  • Provider One (Medicaid) printout that documents income eligibility for Medicaid
  • Early Intervention Program (EIP) letter that documents income
  • No-income statement that includes declaration of no income and how the client/family get food, housing, and clothing