To help us figure out if you qualify for a discount, we need to know who is in your family and what your total household income is.

Use the guide below to see who should be included in your household when applying for a discount:

Do I include my children, even if they’re adopted or in foster care?
Yes. Include any children you plan to claim as tax dependents, no matter their age or if they are adopted or in foster care.

What about children under 18 who live with me but aren’t my legal dependents?
Yes. If they live with you and you take care of them, include them—even if you won’t claim them on your taxes.

Should I include my kids who are 19–26 and still in school?
Yes. If you support them and they are students, include them in your household.

Can I include my parents or other relatives?
Yes, but only if you plan to claim them as tax dependents. This applies even if they live in another country.

Do I list my spouse?
Yes. Always include your legally married spouse.

Should I include my partner if we’re not married?
Sometimes. Include them only if you have a child together or if you plan to claim them as a tax dependent.

Do I include my roommate?
No. Don’t include roommates or people you just live with, unless they are your legal or tax dependents.

You should include the following:

• Wages or salary before taxes are taken out
• Income from self-employment Social Security retirement
• Unemployment compensation
• Worker’s compensation
• Strike benefits
• Public assistance (like TANF or SSI)
• Training stipends, student loans, or grants used for personal costs
• Alimony or child support
• Regular support from someone not living with you
• Military family allotments
• Foster/guardian care subsidy (if the child is counted in your household)
• Pensions or retirement (private/government/railroad)
• Insurance or annuity payments
• Dividends, interest, rent, or payments from trusts or estates
• Veteran’s benefits

You do not need to include:

• Food or rent received instead of wages
• SNAP benefits (food stamps)
• Savings you’ve taken out of the bank
• Gifts
• Tax refunds
• WIC vouchers
• Lump-sum inheritance
• Student loans/grants used only for tuition
• Income from selling a car, house, or property
• One-time insurance payments
• Foster/guardian subsidy (if child is not included in your household size)
• Medicaid or public housing value

1. Download and print the application
2. Fill it out at home
3. Bring it to your clinic’s front desk with proof of income

Need help or have questions?
If you have questions or need help with your application, call your clinic, we’re here to help.