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Health Savings Account deduction. Other. Total Monthly Tax Deductions Comparison of Household Income to Income Limit Use applicable annual FPL Household Size Gross Monthly Income -Tax Deductions Monthly Income After -5 FPL Disregard Net Income Income Limit Deduct 5 FPL only if income after tax deductions exceeds income limit for household size. Is the applicant eligible Yes No PE Begin Date date PE eligibility determined Estimated Date of Delivery pregnant woman PE Provider Name printed Staff...
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