Low-Income Prescription Drug Subsidy Application
Applicant Information
First Name
Last Name
Date of Birth
Social Security Number
Address
City
State
Zip Code
Phone
Email
Household Information
Number of people in household
Total annual household income
Prescription Drug Coverage
Do you currently have prescription drug coverage?
Yes
No
If yes, list current plan(s):
Documentation
Proof of income (describe document provided)
Proof of residency (describe document provided)
Declaration
I certify that the information provided is true and correct to the best of my knowledge.
Applicant Signature
Date