Horizon Pathways

Path A: I receive means-tested benefits

Medicaid

SNAP (Food Stamps)

SSI (Supplemental Security Income)

TANF (Temporary Assistance for Needy Families)

State General Assistance

WIC (Women, Infants, and Children)

LIHEAP (Low Income Home Energy Assistance)

Section 8 Housing Assistance

Other

Path B: My household income is ≤ 150% of Federal Poverty Guidelines

Household Size

State

Annual AGI (from tax return)

OR Monthly Gross Income

Path C: I have an extraordinary expense or financial hardship

Describe your financial hardship

Monthly Expenses

I-912 Fee Waiver Request