Eligibility Screening

Wage Calculator
$ × = $
Income Information
Type of Income Frequency Amount
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$
%%[income_type1,income_type]%% %%[income_freq1,income_freq,default=A]%%
$
%%[income_type2,income_type]%% %%[income_freq2,income_freq,default=A]%%
$
%%[income_type3,income_type]%% %%[income_freq3,income_freq,default=A]%%
$
%%[income_type4,income_type]%% %%[income_freq4,income_freq,default=A]%%
$
Gross Income $
Net Income $
Asset Information
Type of Asset Value
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$
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$
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$
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$
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$
Total Assets $
Poverty Information
%
%
Client Information
%%[veteran_household,yes_no,checkbox]%%
%%[referred_by,referred_by]%%
%%[referred_to,referred_to]%%
%%[citizen,citizen]%%
Demographics
%%[female_head_of_household,yes_no,checkbox]%%
%%[physical_disability,yes_no,checkbox]%%
%%[mental_disability,yes_no,checkbox]%%
%%[opp_info_opt_in,yes_no]%%
%%[case-elig.js,javascript,parse]%%